Partial Day Treatment

A program offered by appropriately-licensed psychiatric facilities that includes either a day or evening treatment program for mental health or substance abuse. Such care is an alternative to inpatient treatment.

Participating Hospital/Facility

A hospital or facility that is part of EmblemHealth's provider network and has signed an agreement to provide covered services to its members.

Participating Provider/Network Provider

A participating provider is a physician or other Provider who has agreed to accept EmblemHealth's scheduled or negotiated rates as payment in full or covered services (except for any applicable copayments, coinsurance or deductibles). A Participating Provider is a member of the EmblemHealth network of Participating Providers applicable to your Certificate. Therefore, they are sometimes referred to as "Network Providers." Payment is made directly to a Participating Provider. Please consult your EmblemHealth Directory to search for Participating Providers. 

Patient Protection and Affordable Care Act

The recent health care reforms were mostly enacted under the Patient Protection and Affordable Care Act (PPACA), which is usually called the Affordable Care Act.


See 'Primary Care Physician'

A doctor who specializes in caring for infants, children and adolescents.
Physical Therapy

Treatment involving physical movement to relieve pain, restore function and prevent disability following disease, injury, or loss of limb.

Plan Benefit Maximum

Dollar amount set by the insurer that limits the amount members have to pay out of their own pocket for particular covered healthcare services during a specified time period.

Point of Service (POS)

A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do.


See 'Point Of Service'.


See 'Preferred Provider Organization'.

Pre-Authorization or Pre-Certification

A procedure used to review and assess the medical necessity and appropriateness of elective hospital admissions and non-emergency outpatient services before the services are provided.

Pre-Authorized or Pre-Certified Services

Services that must be coordinated and approved by EmblemHealth's medical or behavioral healthcare management programs to be fully covered by your plan. Examples may include: planned inpatient surgeries, and medical tests such as MRIs and MRAs.


See 'Pre-Certification'

Pre-Determination of Dental Benefits Request

A treatment plan or pre-determination is a detailed statement of the proposed services (by ADA code) to be rendered.

Pre-Existing Condition

A pre-existing condition is any disease, symptom or condition that was present on the first day of coverage and for which medical advice or treatment was recommended or received during the six-month period prior to the enrollment date. Please check your benefits chart. It will indicate if your group's plan imposes a limitation on coverage of pre-existing conditions. Note that, upon a member's renewal date on or after October 1, 2010, pre-existing condition limitations will be waived for enrollees under age 19.

Preferred Provider

A Preferred Provider is any physician or other Provider who has agreed with EmblemHealth to accept EmblemHealth's payment as payment in full for covered services and to adhere to all applicable EmblemHealth managed care protocols.

Preferred Provider Organization (PPO)

A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time.


A prepaid payment or series of payments made to a health plan by purchasers and often plan members for health insurance coverage.


A written order or refill notice issued by a licensed medical professional for drugs which are only available through a pharmacy.

Prescription Drugs

Drugs and medications that are required by law to be dispensed by written prescriptions from a licensed physician.

Prevailing Fee Schedule

A listing that sets forth the most a plan will pay for covered medical services to either a member or provider.

Preventive Care

Comprehensive care emphasizing priorities for prevention, early detection, and early treatment of conditions, and generally including routine physical examinations and immunization.

Primary Care Physician (PCP)

A PCP is a family physician - family practitioner, general practitioner, internist or pediatrician - who is responsible for delivering or coordinating care.

Primary Carrier

A term used when administering the COB program, which defines the insurance company called upon first to consider payment.

Prior Authorization

The process of obtaining advanced approval of coverage for a health care service or medication. Also called Pre-Authorization or Pre-Certification.

Professional Provider Number

An identification number that identifies a doctor or provider with the insurance company.

Prosthetic Device

A device which replaces all or portion of a part of the human body.


A Provider is a medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A Provider may be any of the following, subject to the conditions listed in this paragraph:

  • A doctor of medicine
  • A doctor of osteopathy
  • A dentist
  • A chiropractor
  • A doctor of podiatric medicine
  • A physical therapist
  • A nurse midwife
  • A certified and registered psychologist
  • A certified and qualified social worker
  • An optometrist
  • A nurse anesthetist
  • A speech therapist
  • An audiologist
  • A clinical laboratory
  • A screening center
  • A general hospital
  • Any other type of practitioner or facility specifically listed in your Certificate of Insurance or this brochure as a practitioner or facility recognized by EmblemHealth for reimbursement purposes

A Provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.

Provider Network

A set of providers contracted with a health plan to provide services to the enrollees.

Provider Number

This is the seven digit identification number issued to the provider by EmblemHealth. This is the tax identification number issued to the provider by the Internal Revenue Service.