Provider Toolkit
Whether you’re a new provider or a long-standing member of our network, you can find here basic information and tools you need for efficient service of your CHOICE clients and patients.
Welcome From CHOICE Provider Relations
VNSNY CHOICE Orientation Training (All Health Plans) – COMING SOON
This Provider Orientation Training presentation contains an introductory overview of all VNSNY CHOICE health plans. The presentation features a brief overview of benefits, eligibility, and goals for each health plan. It also features documents that will help you with the on-boarding process. Please reach out to your assigned account manager with any further questions.
About Our Plans Find out more about our long term care and special needs plans.
Provider Reference Guide (All Plans)
A convenient resource when you have questions about claims, member services, medical management, utilization, compliance, pharmacy, or participating labs.
Clinical Practice and Preventive Health Guidelines (All Plans)
VNSNY CHOICE HEDIS QARR Provider Reference Guide
Comfort Care Options
Comfort Care Options for VNSNY CHOICE Medicare Patients
VNSNY CHOICE Medicare comfort care programs for members include palliative care and hospice care. These programs address the medical and social needs of patients living with a serious or end-of-life illness. Learn more.
Improving Patient Experience and Quality of Care
Highlights CAHPS survey questions and gives tips on actions to take to meet quality standards.
CAHPS and Health Outcomes Survey Checklist
Tracks annual HEDIS quality measures and recommends how to discuss them with patients.
Medicare Hospice Care FAQs for Hospice Providers
The Hospice Care Benefit program is designed to increase patient access to hospice services and improve coordination between hospice providers and other clinicians at the patient’s end of life.
References for SelectHealth Providers
SelectHealth Provider Reference Guide
Quickly find out who to contact for specific plan information.
SelectHealth Advantage Fact Sheet
Learn more about SelectHealth, including special initiatives and program offerings.
Treatment of Gender-Dysphoric Persons Quick Reference Guide
This guide provides a summary of recommended medication therapies along with their VNSNY CHOICE SelectHealth formulary coverage status.
Prescriber Billing Codes
Sarepta Prescriber Billing Codes
- Amondys 45 (casimersen) Prescriber Billing
- Exondys 51 (eteplirsen) Prescriber Billing
- Vyondys 53 (golodirsen) Prescriber Billing
Genentech Prescriber Billing Codes
- Avastin (bevacizumab) Prescriber Billing
- Herceptin (trastuzumab) Prescriber Billing
- Perjeta (pertuzumab) Prescriber Billing
- Xolair (omalizumab) Prescriber Billing
For assistance with billing questions, please call 1-866-783-0222.
PrEP Prescribers Directory
Please use this online directory from the AIDS Institute to find providers offering the services listed below: https://providerdirectory.aidsinstituteny.org/.
- HIV
- HCV
- PrEP
- PEP
- Buprenorphine
- STI Services
- Opioid Overdose Prevention Program
If you’d like to register to be featured in the directory, visit https://providerdirectory.aidsinstituteny.org/Register/RegisterCreate.
Diagnosing and Treating Opioid Use Disorder (OUD) During COVID-19
Pharmacy Vaccine Coverage and Billing Notice
Please download the Pharmacy Vaccine Coverage and Billing Notice, effective 5/1/2019.
Opioid Safety Edits Update
Effective October 1, 2019, opioid analgesics prescribed to members of SelectHealth are subject to certain safety edits. Please read these SelectHealth Opioid Coverage Updates for more information.
Beacon Health Provider Reference Tools
Beacon Health Options Provider Reference Tool – Alcohol and Other Drug Dependence Treatment
This provider reference tool offers information about the initiation and engagement of treatment for alcohol and other drug dependence.
Beacon Health Options Provider Reference Tool – Follow-Up After Mental Illness Hospitalization
This provider reference tool offers information about the follow-up process after hospitalization for mental illness.
Special Topics
Medicaid Fee for Service (FFS) Mosquito Repellent Coverage
NYS FFS Medicaid will provide coverage for mosquito repellent when prescribed to enrollees who intend to travel to or return from a Centers of Disease Control (CDC) recognized area of localized Zika transmission. Read the Department of Health notice for more information.
ICD-10 FAQ
The ICD-10 FAQ document is intended to provide a general overview of what can be expected with the transition from ICD-9 to ICD-10 as it impacts VNSNY CHOICE providers. Read the ICD-10 FAQ document.
JNC8: Recommendations: Changes in Diagnosis and Treatment of Hypertension
Hypertension is one of the most important preventable contributors to disease and death in the United States, leading to myocardial infarction, stroke, and renal failure when it is not detected early and treated appropriately. The Eighth Joint National Committee (JNC8) recently released evidence-based recommendations on treatment thresholds, goals, and medications in the management of hypertension in adults. Read JNC8 Recommendations: Changes in Diagnosis and Treatment of Hypertension.
Access and Availability Standards for Medicare Patients
According to CMS, all health plans are required to maintain and monitor a network of appropriate providers, supported by written arrangements, that is sufficient to provide adequate access to covered services to meet the needs of the population served. This is a regulatory requirement that involves standards that must ensure that the hours of operation of the plan’s providers are convenient to, and do not discriminate against, enrollees. The plan must also ensure that, when medically necessary, services are available 24 hours a day, 7 days a week. This includes requiring primary care physicians to have appropriate backup for absences. The standards should consider the enrollee’s need and common waiting times for comparable services in the community. Please download this PDF for more information: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/mc86c04.pdf
High Risk Medications in the Elderly
At VNSNY CHOICE, we know that effective medication management — especially among the elderly population — is one of the key strategies for improving quality of patient care and reducing avoidable ED visits and hospitalizations. The Pharmacy Quality Alliance (PQA) has developed a list of High Risk Medications, including their potential risks and safer treatment options.
Pain Assessment, BMI/ Functional Status Chart
This chart is available in case you do not have a way to document the result of a member’s Pain Assessment, BMI, or Functional Status in your EMR system. VNSNY CHOICE created this sheet to keep in the member’s chart to make it easier for you to document the member’s health vitals accurately.
In 2022, VNSNY CHOICE will be offering three provider education webinars: Minding the Gaps, Documentation, and Surveys and the Provider Role. Learn more and register here.
2022 Webinars
Minding the Gaps
This webinar is designed to help you understand:
- The role providers play in Medicare Risk Adjustment
- How the annual wellness visit can impact payment rates in coming years
- How to ensure you’re using the right billing codes to close HEDIS gaps
- How to improve workflows to ensure the accuracy of your billing and coding process
Documentation
This webinar covers:
- Documentation standards for accurate Medicare risk adjustment, including:
- Checklist for medical record review audit programs
- Documentation integrity issues
- Documentation and coding for transitions of care
- Office workflows to ensure coding and documentation standards for the four HEDIS Transitions of Care measures are met
- Program to inform you via daily notifications about your patients with inpatient admissions
Resumption of Prior Authorization Activities 7/7/2020:
Given the importance of medical review activities to CMS’ program integrity efforts, CMS will discontinue exercising enforcement discretion for the Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items beginning on August 3, 2020, regardless of the status of the public health emergency. For Power Mobility Devices and Pressure Reducing Support Surfaces that require prior authorization as a condition of payment, claims with an initial date of service on or after August 3, 2020 must be associated with an affirmative prior authorization decision to be eligible for payment.
Additionally, prior authorization will be required for certain Lower Limb Prosthetics (L5856, L5857, L5858, L5973, L5980, and L5987), with dates of service on or after December 1, 2020.
Please see more information here (PDF). The Required Prior Authorization list can be found here (PDF).
Health Information Exchange Facts and Forms
Information in Spanish and English to share with your CHOICE patients explaining how the Health Information Exchange works. Includes an FAQ. (English and Spanish)
Authorization for Access to Patient/Member Information Through Health Information Exchanges (English and Spanish)
Advanced Care Planning Form
Health Care organizations such as VNSNY CHOICE are required by New York State Department of Health regulations to provide information about Advanced Directives to all of our members.
The New York Health Care Proxy Law allows patients to appoint someone they trust, for example, a family member or close friend, to make health care decisions for them if they lose the ability to make decisions for themselves.
As sensitive as it can be, a proactive discussion of end-of-life issues with patients is extremely important to avoid confusion and potential discord regarding their preferences for care. VNSNY CHOICE has developed this downloadable one-page overview of Advance Care Planning that contains helpful suggestions and information about various forms of advance directives. We are also providing a basic Advance Care Planning Checklist to make it easier for you and your patients to assess needs.
Additional forms include the following:
Appointing Your Health Care Proxy (English and Spanish)
New York Advance Directive Planning Guide
CHOICE Medications Adherence Tip Sheet
VNSNY CHOICE knows the importance of medication adherence. This Medication Adherence tip sheet makes it easy for providers to help CHOICE members take the right meds at the right time — no matter how complex their medication regimens. In addition, the tip sheet will help empower members and caregivers to easily see what medications to take and when to take them. Read the CHOICE Medications Adherence Tip Sheet.
What Is Medicaid?
VNSNY CHOICE offers helpful information about this important government program and How to Apply for Medicaid that may be useful for both you and your patients or clients.
Provider EMR Data-Sharing – Provider Information Packet
The Provider Information Packet is a comprehensive guide to all aspects of VNSNY CHOICE’s EMR flat file sharing initiative. In addition to the links below, it contains high-level summaries, timelines, initial and ongoing workflows, file format information, and FAQs. Providers and staff are encouraged to review this guide when sharing data with VNSNY CHOICE via EMR flat file, as it contains important information to ensure successful submission.
Provider EMR Data-Sharing – Measure Definitions
This guide lists the measures providers may be asked to document details for in the VNSNY CHOICE member medical record. Definitions, applicable lines of business, and sample procedure codes are also included.
Provider EMR Data-Sharing – Measure Dictionary
The EMR data-sharing measure dictionary details the approaches providers may use to achieve measure compliance and close gaps. By utilizing these guidelines, providers will be able to assist VNSNY CHOICE in achieving and reporting total quality of care for our members. Specifications, key elements, and timelines are also presented for reference.
Here are some resources that may be helpful to those living with HIV/AIDS, and their families.
VNSNY CHOICE SelectHealth supports the HIV Treatment Works (HTW) Campaign sponsored by the Centers for Disease Control and Prevention (CDC). The HTW campaign features people who are living with HIV talking about how sticking with care and treatment helps them stay healthy, protect other, and live longer, healthier lives.
- HIV Treatment Works (HTW) website
- Watch videos of people living well with HIV
- Read profiles of people living well with HIV
- Resources for people living well with HIV
HIV Tobacco Cessation Improvement Campaign The New York State Department of Health AIDS Institute is excited to announce the launch of the HIV Tobacco Cessation Improvement Campaign. Antiretroviral therapy is extending the lives of people living with HIV (PLWH); yet, in the US, PLWH who smoke lose over six years of life expectancy compared to PLWH who do not smoke.
Please let your patients know about the NYSDOH campaign to help improve the health of PLWH across New York State. Have them visit www.hivtobaccofreeny.org to enroll and learn more about the campaign.
New York State Policies and Guidelines
- New York State Department of Health HIV Testing Policies and Procedures
- New York State Department of Health Updates and Changes to HIV Treatment Guidelines
- New York State HIV Testing Law – FAQs
Additional Resources