Provider Pulse

Your lifeline to Essence news and resources

Do you have practice changes to report to Essence? Complete the Provider Demographic form if you’re changing an address (physical location or billing) or NPI number (adding or removing providers). Visit the Provider Portal to review all the details and to access the form.

NEW! Essence Provider Communications

We’re excited to introduce the Provider Pulse newsletter! It’s designed to keep you informed about the latest updates, resources and everything you need to know to work with us.

Be sure to bookmark this page to add it to your favorites and stay informed.

Enhanced Payment Process

We’re thrilled to inform you about a more efficient electronic payment process through our partnership with Zelis Payments. This collaboration provides you with access to the latest in secure electronic payment technology that expedites and streamlines the current claims process for Essence and its affiliates. 

To learn more log in to the Provider Portal, and from the "Forms & Resources" drop-down menu select "Forms and Resources." Scroll down the page and click on the "Claims" link.

Learn More

New Pharmacy Partner

Essence has partnered with Express Scripts® for administration of our pharmacy drug benefit services, including mail-order. For more information about this exciting change see the “Part D” section on this page.

Improved Coverage

Diabetic testing supplies including home glucose meters and test strips are now covered by our new preferred brands Abbott and LifeScan. For more information refer to the “Diabetic Testing Supplies at Network Pharmacies” document on the Provider Portal.
 

Learn More

New Vision Partner

EyeMed® is our new vision benefit partner. As a leader in vision benefits, we’re happy to partner with EyeMed to provide convenience and savings for our members. For more information about EyeMed and our vision benefit see the “Benefits” section on this page. 

New Home Delivery Service Specialized for GLP-1 Medications

Please be aware, starting June 15, 2025, Evernorth EnGuideSM Pharmacy will be the new home delivery pharmacy for GLP-1 medications.

To make the transition as simple as possible for our members:

  • Current patients using mail-order through Express Scripts™ Pharmacy to fill GLP-1 medications will receive communications about the change from Express Scripts beginning June 2.
  • GLP-1 medication prescriptions will automatically transfer to EnGuide Pharmacy by June 15, including remaining refills.
  • If no refills are available, EnGuide Pharmacy will contact the provider for a new prescription.

Review the “Benefits” section of this page for additional information.

New Programs to Support Claims Adjudication—Effective June 1, 2025

  1. We'll use ExlService.com, LLC (EXL) for post-payment reviews of outpatient claims concerning our Medicare Advantage plans.
  2. The Optum Emergency Department Claim (EDC) Analyzer tool will help with evaluating claim data elements.

For more information on these programs, review the "Claims" section on this page.

online-white-on-blue

Visit the Provider Portal to:

  • View member information.
  • Check claim status.
  • Manage referrals and authorizations.
  • Access the Lumeris technology suite.
  • So much more.
Provider Portal

Need help creating a Provider Portal account? See instructions.

Want to know if a corrected claim is needed?

Follow our flow chart.

Programs to Support Claims Adjudication—Effective June 1, 2025

EXL for Post-Payment Reviews
We'll use ExlService.com, LLC (EXL) for post—payment reviews of outpatient claims concerning our Medicare Advantage plans. Acting as a subcontractor under Essence Healthcare, EXL is fully compliant with HIPAA and HITECH Act requirements, ensuring the confidentiality and security of PHI shared for auditing purposes.

ED Outpatient Facility Reimbursement with Optum ED Claim Analyzer
We've made revisions to the Emergency Department (ED) outpatient facility Evaluation and Management (E/M) coding reimbursement for all plans. We will employ the Optum Emergency Department Claim (EDC) Analyzer tool, which evaluates appropriate E/M coding levels based on claim data elements such as the:

  • Patient’s presenting problem
  • Diagnostic services performed
  • Patient complicating conditions

Log in to your Provider Portal to access all the resources below.

Search for Referrals/Authorizations

Click on the “Referral and Authorization Inquiry” tab to use our search tool. You can search by referral or authorization number, or by member ID.

Create and Edit a Referral

For detailed instructions on how to create, edit or print an existing referral review the Referral Guide on the Referrals & Authorizations page.

Prior Authorizations

The Referrals & Authorizations page also includes helpful lists for our HMO and PPO plans to help you determine when a service requires prior authorization.

If you disagree with the amount Essence has paid on a claim or line, a provider dispute can be submitted in writing or through the Provider Portal. We don't accept fax submissions.

Send written pay disputes to:

Essence Correspondence or Claim
P.O. Box 5907
Troy, MI 48007

To submit your pay dispute electronically, log in to the Provider Portal and navigate to the Claims tab. Scroll to the bottom and complete the Provider Pay Dispute form.

Submitting Prescription Orders or Forms

Mail-Order

To submit Part D prescription drug orders, call Express Scripts mail-order pharmacy provider services at 1-888-327-9791. Direct Essence members to log in to their Essence Member Website to access the Express Scripts member portal.

Part D Determination/Exception

Submit forms to Express Scripts.
Fax: 1-877-251-5896
Phone: 1-800-935-6103
Call Essence Customer Service at 1-866-597-9560 to request a Part D coverage determination.

Real-Time Prescription Benefit Tool

Use the Real-Time Prescription Benefit Tool to check 2025 Part D formulary coverage and any applicable formulary Utilization Management requirements. This tool displays out-of-pocket drug cost estimates in the EMR to help the physician and patient decide on the best medication based on both medical necessity and cost-effectiveness.

To check provider credentialing status, please find your area in the list below and send an email.

Arkansas: littlerockcred@essencehealthcare.com

Kentucky: loulexcred@essencehealthcare.com

Missouri/Illinois: stlouiscred@essencehealthcare.com

Chicago: chicagocred@essencehealthcare.com

Ohio: cincinnaticred@essencehealthcare.com

MEMBER RESOURCES
BENEFITS

Benefit Information and Updates

Flexible Benefits Card: Medical copay coverage, OTC and More

What’s changed?
  • Medical copay coverage now possible via Flex Card (most plans).
  • Comprehensive dental covered primarily through Flex Card; no longer an embedded benefit on most plans.
  • OTC benefit removed from PPO plans and functions differently than in 2024 (see “How does the Flex Card Work?” section below). OTC is not available in Chicago.

For member-specific benefits, visit the “Eligibility” section of your Provider Portal. Members can check benefits by logging in to EverythingEssence.com.

Many Essence plans now offer the ability to use the Flex Card for certain medical copays.

Accepted Medicare-covered copay categories:

  • Doctor/provider visits (including telehealth, occupational, speech and physical therapy, substance abuse, mental health sessions, podiatry)
  • Urgent care
  • Diagnostic services (such as labs, X‑rays, CT scans, MRIs and therapeutic radiology)
  • Dental, eye exam, acupuncture and chiropractic visits

Declined Charges

For Flex Card use on medical copays, the card must be eligible and used for services in an accepted copay category (shown above). If the card has this benefit and is being declined, the member’s balance could be low. Members can check their card balance on the Essence Flex Spend app or on the Member Website.

Depending on the plan, Flex Cards can be used for non-Medicare-covered dental, vision and hearing items and services, medical copays and/or OTC items. Not all categories apply to all plans.

The allowance for dental, vision, hearing and medical copays (if applicable) is loaded annually at the start of membership.

Members in plans that include the OTC benefit will receive a quarterly allowance that’s separate from the allowance for other Flex Card categories (if available in their plan), but members will use the same Flex Card for all allowed categories. The OTC allowance is valid at eligible physical retail locations or the online Essence OTC store.

The Flex Card may be used with in- or out-of-network providers. HMO plan members using the card for medical copays must stay in the Essence network.

Oura Ring and Data Sharing

Select PPO members are eligible to receive a free Oura Ring as part of their plan benefits. This wearable health tracker provides real-time, reliable insights into key health metrics, like sleep quality, activity level, heart rate, average blood oxygen and more.

We’re encouraging members to share this data with their providers. Oura Ring data can help you assess wellness trends, identify health issues, develop intervention strategies and—overall—provide more personalized, proactive care for your patients.

Essence is working with Oura to automate data sharing and deliver it to you electronically. We will be communicating with you once this functionality is available.

  • The Oura Ring is the only research-validated wearable in market that directly measures from the arteries in your fingers.
  • Oura measures resting heart rate at 99.9% reliability compared to a medical-grade ECG and validated against the sleep lab golden standard—PSG.
  • Oura measures heart rate variability at 98.4% reliability compared to medical-grade ECG.
  • Oura’s temperature sensors match performance with research-grade sensors at >99 percent and are able to detect baseline deviations as small as 0.13 degrees Celsius.
  • Oura’s infrared PPG sensor matched performance with clinical-grade ECG and consistently outperformed other PPG tools relying on green light LEDs or the iPhone camera.
  • Oura’s new sleep staging algorithm was found to achieve 79 percent agreement with gold-standard PSG for 4-stage sleep classification (wake, light, deep, and rapid eye movement (REM) sleep).

For member-specific benefits, visit the “Eligibility” section of your Provider Portal. Eligible members can learn more about this benefit by visiting EverythingEssence.com/s/OuraRing.

New Vision Partner: EyeMed®

We’ve recently switched from EyeQuest® to EyeMed®—a leader in vision benefits, focusing on choice, convenience and savings. Members can find in-network providers by calling EyeMed at 1-833-918-0475 or visiting EyeDocLocator.EyeMedVisionCare.com/Essence/en-us.

Providers can see a list of vision providers by using our online search tool.

All plans, except Essence Advantage® Premier Plus (PPO) include routine vision benefits and an eyewear allowance. Most plans also include a preloaded Flex Card that can be used on vision services and eyewear.

For member-specific benefits, visit the “Eligibility” section of your Provider Portal. Eligible members can learn more about this benefit by logging in to EverythingEssence.com.

Prescription Drug Coverage

What’s changed:
  • No more Donut Hole, plus lower Part D out-of-pocket maximum
  • Most Essence plans now require a Part D deductible on tiers 3-5
  • New pharmacy benefit manager and mail-order pharmacy: Express Scripts
  • Expanded preferred pharmacy network
  • Preferred brand diabetic blood glucose meters for all plans now Abbott and LifeScan brand products
  • Changes to covered insulins

Initial coverage: Members pay $0 for preferred generics at preferred pharmacies and by mail order, and low copays for brand-name drugs.

Part D out-of-pocket max (end of initial coverage phase): $2,000

Catastrophic coverage: Members pay $0 for all covered Part D drugs

Members must meet their Part D deductible (if applicable) before standard cost-sharing applies.

For member-specific benefits, visit the “Eligibility” section of your Provider Portal. Members can learn more about this benefit by logging in to EverythingEssence.com.

Essence now partners with Express Scripts® for prescription drug benefits, including mail-order benefits.

New mail-order prescriptions should be sent to Express Scripts mail-order pharmacy. You can contact Express Scripts by phone: 1-888-327-9791.

Starting June 15, 2025, Evernorth EnGuideSM Pharmacy will be the new home delivery pharmacy for GLP-1 medications.

  • Current patients using mail-order through Express Scripts™ Pharmacy to fill GLP-1 medications will receive communications about the change from Express Scripts beginning June 2.
  • Patients can continue to fill GLP-1 medications at any in-network pharmacy.
  • GLP-1 medication prescriptions currently filled through mail order, including any remaining refills, will automatically transfer to EnGuide Pharmacy by June 15.
  • If no refills are available, EnGuide Pharmacy will contact the provider for a new prescription.
  • Express Scripts will notify high-volume prescribers (5+ GLP-1 scripts) about this change.
  • Non-GLP-1 medications will continue to be filled by Express Scripts Pharmacy for home delivery.

Preferred pharmacies include CVS, Sam‘s Club, Walmart and many others.

For a complete list of preferred pharmacies, use our online search tool. Members can view their plan’s provider directory on EverythingEssence.com.

Essence members can visit the “Pharmacy” section of EverythingEssence.com for a direct link to the Express Scripts member portal (for claims information, mail-order signup, formulary and more).

Preferred-brand diabetic blood glucose meters and test strips are Abbott and LifeScan brand products.

Members can learn how to get a new preferred-brand glucose meter or test strips free of charge by visiting the “Pharmacy” section of EverythingEssence.com. Once on the pharmacy page, members will click “Diabetic Testing Supplies at Network Pharmacies.” You can access this form here.

Certain insulins were removed from our formulary starting January 1, 2025. If none of the formulary insulin alternatives listed below are right for your patient, they, or you, can submit an exception request to our formulary. Refer Essence members to Chapter 5 of their Evidence of Coverage (“Using the plan’s coverage for Part D prescription drugs”) for more information.

You can also submit a Part D determination/exception request on your patient’s behalf. Download the form here. Submit forms to Express Scripts by phone at 1-800-935-6103 or by fax at 1-877-251-5896.

2024 Insulins (not covered in 2025 formulary) 2025 Formulary Insulin Alternatives
insulin aspart and Fiasp insulin insulin lispro, Humalog (vials and KwikPen)
aspart protamine insulin Humalog mix (KwikPen and vials)
Semglee Lantus and Toujeo insulins
Novolin 70/30, N and R insulins (vial and Flexpen) Humulin 70/30, Humulin N and R insulins (vials and KwikPen)

Flexible Benefits Card: Medical copay coverage, OTC and More

What’s changed?
  • Medical copay coverage now possible via Flex Card (most plans).
  • Comprehensive dental covered primarily through Flex Card; no longer an embedded benefit on most plans.
  • OTC benefit removed from PPO plans and functions differently than in 2024 (see “How does the Flex Card Work?” section below). OTC is not available in Chicago.

For member-specific benefits, visit the “Eligibility” section of your Provider Portal. Members can check benefits by logging in to EverythingEssence.com.

Many Essence plans now offer the ability to use the Flex Card for certain medical copays.

Accepted Medicare-covered copay categories:

  • Doctor/provider visits (including telehealth, occupational, speech and physical therapy, substance abuse, mental health sessions, podiatry)
  • Urgent care
  • Diagnostic services (such as labs, X‑rays, CT scans, MRIs and therapeutic radiology)
  • Dental, eye exam, acupuncture and chiropractic visits

Declined Charges

For Flex Card use on medical copays, the card must be eligible and used for services in an accepted copay category (shown above). If the card has this benefit and is being declined, the member’s balance could be low. Members can check their card balance on the Essence Flex Spend app or on the Member Website.

Depending on the plan, Flex Cards can be used for non-Medicare-covered dental, vision and hearing items and services, medical copays and/or OTC items. Not all categories apply to all plans.

The allowance for dental, vision, hearing and medical copays (if applicable) is loaded annually at the start of membership.

Members in plans that include the OTC benefit will receive a quarterly allowance that’s separate from the allowance for other Flex Card categories (if available in their plan), but members will use the same Flex Card for all allowed categories. The OTC allowance is valid at eligible physical retail locations or the online Essence OTC store.

The Flex Card may be used with in- or out-of-network providers. HMO plan members using the card for medical copays must stay in the Essence network.

Oura Ring and Data Sharing

Select PPO members are eligible to receive a free Oura Ring as part of their plan benefits. This wearable health tracker provides real-time, reliable insights into key health metrics, like sleep quality, activity level, heart rate, average blood oxygen and more.

We’re encouraging members to share this data with their providers. Oura Ring data can help you assess wellness trends, identify health issues, develop intervention strategies and—overall—provide more personalized, proactive care for your patients.

Essence is working with Oura to automate data sharing and deliver it to you electronically. We will be communicating with you once this functionality is available.

  • The Oura Ring is the only research-validated wearable in market that directly measures from the arteries in your fingers.
  • Oura measures resting heart rate at 99.9% reliability compared to a medical-grade ECG and validated against the sleep lab golden standard—PSG.
  • Oura measures heart rate variability at 98.4% reliability compared to medical-grade ECG.
  • Oura’s temperature sensors match performance with research-grade sensors at >99 percent and are able to detect baseline deviations as small as 0.13 degrees Celsius.
  • Oura’s infrared PPG sensor matched performance with clinical-grade ECG and consistently outperformed other PPG tools relying on green light LEDs or the iPhone camera.
  • Oura’s new sleep staging algorithm was found to achieve 79 percent agreement with gold-standard PSG for 4-stage sleep classification (wake, light, deep, and rapid eye movement (REM) sleep).

For member-specific benefits, visit the “Eligibility” section of your Provider Portal. Eligible members can learn more about this benefit by visiting EverythingEssence.com/s/OuraRing.

New Vision Partner: EyeMed®

We’ve recently switched from EyeQuest® to EyeMed®—a leader in vision benefits, focusing on choice, convenience and savings. Members can find in-network providers by calling EyeMed at 1-833-918-0475 or visiting EyeDocLocator.EyeMedVisionCare.com/Essence/en-us.

Providers can see a list of vision providers by using our online search tool.

All plans, except Essence Advantage® Premier Plus (PPO) include routine vision benefits and an eyewear allowance. Most plans also include a preloaded Flex Card that can be used on vision services and eyewear.

For member-specific benefits, visit the “Eligibility” section of your Provider Portal. Eligible members can learn more about this benefit by logging in to EverythingEssence.com.

Prescription Drug Coverage

What’s changed:
  • No more Donut Hole, plus lower Part D out-of-pocket maximum
  • Most Essence plans now require a Part D deductible on tiers 3-5
  • New pharmacy benefit manager and mail-order pharmacy: Express Scripts
  • Expanded preferred pharmacy network
  • Preferred brand diabetic blood glucose meters for all plans now Abbott and LifeScan brand products
  • Changes to covered insulins

Initial coverage: Members pay $0 for preferred generics at preferred pharmacies and by mail order, and low copays for brand-name drugs.

Part D out-of-pocket max (end of initial coverage phase): $2,000

Catastrophic coverage: Members pay $0 for all covered Part D drugs

Members must meet their Part D deductible (if applicable) before standard cost-sharing applies.

For member-specific benefits, visit the “Eligibility” section of your Provider Portal. Members can learn more about this benefit by logging in to EverythingEssence.com.

Essence now partners with Express Scripts® for prescription drug benefits, including mail-order benefits.

New mail-order prescriptions should be sent to Express Scripts mail-order pharmacy. You can contact Express Scripts by phone: 1-888-327-9791.

Starting June 15, 2025, Evernorth EnGuideSM Pharmacy will be the new home delivery pharmacy for GLP-1 medications.

  • Current patients using mail-order through Express Scripts™ Pharmacy to fill GLP-1 medications will receive communications about the change from Express Scripts beginning June 2.
  • Patients can continue to fill GLP-1 medications at any in-network pharmacy.
  • GLP-1 medication prescriptions currently filled through mail order, including any remaining refills, will automatically transfer to EnGuide Pharmacy by June 15.
  • If no refills are available, EnGuide Pharmacy will contact the provider for a new prescription.
  • Express Scripts will notify high-volume prescribers (5+ GLP-1 scripts) about this change.
  • Non-GLP-1 medications will continue to be filled by Express Scripts Pharmacy for home delivery.

Preferred pharmacies include CVS, Sam‘s Club, Walmart and many others.

For a complete list of preferred pharmacies, use our online search tool. Members can view their plan’s provider directory on EverythingEssence.com.

Essence members can visit the “Pharmacy” section of EverythingEssence.com for a direct link to the Express Scripts member portal (for claims information, mail-order signup, formulary and more).

Preferred-brand diabetic blood glucose meters and test strips are Abbott and LifeScan brand products.

Members can learn how to get a new preferred-brand glucose meter or test strips free of charge by visiting the “Pharmacy” section of EverythingEssence.com. Once on the pharmacy page, members will click “Diabetic Testing Supplies at Network Pharmacies.” You can access this form here.

Certain insulins were removed from our formulary starting January 1, 2025. If none of the formulary insulin alternatives listed below are right for your patient, they, or you, can submit an exception request to our formulary. Refer Essence members to Chapter 5 of their Evidence of Coverage (“Using the plan’s coverage for Part D prescription drugs”) for more information.

You can also submit a Part D determination/exception request on your patient’s behalf. Download the form here. Submit forms to Express Scripts by phone at 1-800-935-6103 or by fax at 1-877-251-5896.

2024 Insulins (not covered in 2025 formulary) 2025 Formulary Insulin Alternatives
insulin aspart and Fiasp insulin insulin lispro, Humalog (vials and KwikPen)
aspart protamine insulin Humalog mix (KwikPen and vials)
Semglee Lantus and Toujeo insulins
Novolin 70/30, N and R insulins (vial and Flexpen) Humulin 70/30, Humulin N and R insulins (vials and KwikPen)
MARK YOUR CALENDAR
Events Coming Soon!
REGULATORY CHANGES
April 1, 2025
The Qualified Medicare Beneficiary (QMB) Program
All Medicare providers, even those that do not accept Medicaid, are prohibited under federal law from billing members in the QMB Program for their cost-share of covered Parts A and B services, including Part B-covered prescription drugs, and are prohibited from discriminating against QMBs by refusing service because of this cost-share protection. Essence encourages providers to establish processes to routinely identify the QMB status of members. Essence offers several options to help identify QMB status:
  • Contact the Plan’s customer service team
  • Review the member profile on the Provider Portal
  • Submit a 270-transaction set to inquire about Medicare eligibility. Medicare providers can seek payment for Medicare cost-sharing for QMB-eligible members from the member’s state Medicaid program. Please consult the applicable state Medicaid program for information on billing processes that apply to seeking payment from Medicaid.
 
April 30, 2025
Balance Billing
In accordance with CMS rules, as an Essence network provider, network providers are not permitted to balance bill Essence members. The term “balance billing” refers to billing a member for more than the plan-allowed cost-sharing for a covered service or billing a member for a covered service Essence denied. The Essence member is held harmless for payment beyond the Essence cost-share (copayment or coinsurance). The provider’s remit notice indicates whether an amount is owed by the member and that’s what the provider should follow when billing the member. If a member qualifies for state assistance you may see codes on your remittance notice which limit the ability to balance bill.
 
FREQUENTLY ASKED QUESTIONS

When a member disagrees with a decision made by their health plan regarding the services or benefits covered under Part C or Part D, they can appeal. The member has the right to ask for this decision to be reviewed if they think it's wrong. This can include if the health plan is taking too long to approve or arrange the care or drugs needed, or if the member thinks they should pay less for a service or drug.

Contracted providers have the right to a pay dispute rather than an appeal. If you disagree with the amount Essence has paid on a claim or line a provider dispute can be submitted in writing or through the Provider Portal. We don’t accept fax submissions.

Send written pay disputes to:
Essence Correspondence or Claim
P.O. Box 5907
Troy, MI 48007

To submit your pay dispute electronically, log in to the Provider Portal and navigate to the Claims tab. Scroll to the bottom and complete the Provider Pay Dispute form.

Many Essence plans offer the ability to use the Flex Card for certain medical copays.

Accepted Medicare-covered copay categories:

  • Doctor/provider visits (including telehealth, occupational, speech and physical therapy, substance abuse, mental health sessions, podiatry)
  • Urgent care
  • Diagnostic services (such as labs, X-rays, CT scans, MRIs and therapeutic radiology)
  • Dental, eye exam, acupuncture and chiropractic visits

Declined Charges

For Flex Card use on medical copays, the card must be eligible and used for services in an accepted copay category (see above list). If the card has this benefit and is declined, the member’s balance could be low. Members can check their card balance on the Essence Flex Spend app or on the Member Website (EverythingEssence.com).

For more information on the Flex Card, see the “Benefit Information and Updates” section on this page.

Mail-Order

Pharmacy provider services

Phone: 1-888-327-9791

Part D Determination/Exception

Submit forms to Express Scripts.

Fax: 1-877-251-5896

Phone: 1-800-935-6103

Essence members can call Express Scripts at 1-800-282-2881 (TTY: 1-800-759-1089) to get help with their prescriptions.

For general provider questions or to get more information about an event send an email to: providerservices@lumeris.com.

If you're in the Chicago area, please send an email to: chicagomarket@lumeris.com.