City of New York GRS Alliance Program (Updated 12/3/21)
Empire and EmblemHealth network arrangement is applicable in the following 13 downstate New York counties: New York, Bronx, Kings, Queens, Richmond, Nassau, Suffolk, Westchester, Orange, Rockland, Putnam, Dutchess, and Sullivan. Medicare Advantage PPO professional and facility providers outside of the counties listed above will be considered participating. NYC Medicare Advantage Plus members have access to Medicare Advantage PPO providers contracted with Blue Cross Blue Shield Association plans across the nation.
Members do not need referrals for any providers, specialists, or hospitals in or out of the network. Actual benefit payments are subject to eligibility and coverage limitations at the time services are rendered. Claims should be submitted electronically using payer ID CONY1 or paper submission (via UB-04 or CMS-1500 form) to Empire (the local Blue plan).
The following grid illustrates which insurer has claims rate responsibility for NYC Medicare Advantage Plus plan benefits. Notably, all claims for NYC Medicare Advantage Plus plan members must be submitted to Empire (the local Blue plan) for both the hospital (facility) and medical (professional) benefits, regardless of services rendered or health plan claims rate responsibility, to ensure a seamless claims process and experience for providers and facilities alike.
Under no circumstances should claims be submitted directly to EmblemHealth for NYC Medicare Advantage Plus plan members.
Empire (the local Blue plan) will process and adjudicate all claims for NYC Medicare Advantage Plus plan benefits.
Empire rate applies to facility-based services, including but not limited to those listed below, in all geographies, including within the 13 downstate New York counties. All claims must be submitted to Empire (the local Blue plan):
• Air/ground ambulance
• Ambulatory infusions
• Audiology (hearing aids)
• Behavioral health (professional/facility)
• Diabetic supplies
• Durable medical equipment
• Emergency care
• Facility hospitals
• Home health
• Home infusion therapy
• Nutrition (registered dietitians)
• Orthotics and prosthetics
• Pharmacy (Part B drugs covered under medical plan)
• Private duty nursing
• Reference labs
• Skilled nursing facilities (SNFs)
• Urgent care
EmblemHealth rate applies to directly contracted professional/traditional services, including but not limited to those listed below, only within the 13 downstate New York counties. All claims must be submitted to Empire (the local Blue plan):
• Professional and specialist providers
• Occupational therapy
• Physical therapy
• Speech therapy
December 2021 Newsletter