Glossary

 
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NCQA National Committee for Quality Assurance

A not-for-profit organization that performs quality-orientated accreditation reviews of HMOs and similar types of managed care plans.

Need Info

An indicator on a claim that identifies that additional information is required before the claim can be finalized.

Network

The group of physicians, hospital, and other medial care providers that a specific plan has contracted with to deliver medical services to its members.

Network Provider

A doctor, hospital or other healthcare provider who has entered into an agreement with EmblemHealth to provide healthcare services to members for a negotiated rate of reimbursement.

New York State Department of Health

The state regulatory agency that certifies reimbursement methods, rates to hospitals and reviews HMO activities in the state of New York.

New York State Department of Insurance

A state regulatory agency which has the responsibility to review and oversee health insurance companies' contracts and rates in the state of New York.

No Fault

A law in several states including New York State requiring all registered motor vehicles to be covered by personal injury protection insurance. Under this law, a person's own motor vehicle insurance company pays for expenses relating to an accident regardless of who caused the accident.

Non-Certification

A determination by a utilization management organization that an admission, extension of stay, or other health care service has been reviewed and, based on the information provided, does not meet the clinical requirements for medical necessity, appropriateness, level of care, or effectiveness under the auspices of the applicable health benefit plan.

Non-Participating Hospital/Facility

A hospital/facility that does not have a participation agreement with EmblemHealth or another EmblemHealth plan to provide hospital/facility services to persons covered under EmblemHealth.

Non-Participating Provider

A healthcare provider such as a physician, skilled nursing facility, home health agency, laboratory etc, who does not have an agreement with the EmblemHealth to provide covered services to members.