CommercialReimbursementHigh impact
Reimbursement Policies
EmblemHealth·Provider News
Effective date
Nov 14, 2024
We identified it
Jun 20, 2026
Summary
EmblemHealth is expanding ConnectiCare's observation stay policy starting Nov 14, 2024, restricting reimbursement to observation stays between 8-48 hours only. Additional updates include ASC grouper payment methodology changes and clarifications on facility fees for E&M services with new G0463 reporting requirements.
Action Required
By November 14, 2024: Billing team must update systems to flag observation stays under 8 hours or over 48 hours for EmblemHealth (except NYC plans) as these will not be reimbursed. Update ASC billing to use revenue codes 360 or 490 for surgical services to ensure proper grouper payment rates. Review all outpatient facility claims using CPT G0463 to ensure compliance with CMS off-campus provider-based department reporting requirements. Claims outside the 8-48 hour observation window will be denied.