CommercialCoverageHigh impact
Starting Aug. 1: New Commercial Plan Site of Service Coverage Rules for Maintenance Infusions
EmblemHealth·Oncology, Rheumatology, Gastroenterology +3 more·Provider News
Effective date
Aug 1, 2024
We identified it
Jun 20, 2026
Summary
Starting August 1st, EmblemHealth and ConnectiCare commercial plans will only cover maintenance infusion services for adults 21+ in specific outpatient settings: home, office, or ambulatory infusion suites. Hospital outpatient infusion coverage will be limited to initial doses or medically justified exceptions.
Action Required
By August 1, 2024: Billing team must verify maintenance infusion services for commercial plan members 21+ are performed in covered settings (POS 11-office, POS 12-home, POS 24/49-ambulatory infusion suites, or POS 12 with modifier SS). Update scheduling staff to direct patients to appropriate infusion locations. Contact HomeInfusionteam@emblemhealth.com for assistance finding optimal infusion settings. Claims for hospital outpatient maintenance infusions will be denied unless medical necessity is documented.