SPRING 2013

 

Come Take a Look!

Member Satisfaction

Utilization Review Criteria Update

Medical Director Availability After an Adverse Determination

EmblemHealth Neighborhood Care Success Stories

EmblemHealth Introduces National Diabetes Prevention Program

Appointment Availability and Access Surveys

Claims Corner

Submit Claims with Accurate Pay To Information

CareCore Manages Accreditation and Privileging for SRPP

Changes to Look Back Period for Medicare

Behind the Scenes

Help Your Patients Understand

Member Rights and Responsibilities

Correctly Coding HIV Care

Healthy Beginnings PATH Updates

Healthy Discounts for Members

EmblemHealth Resources for Managing Your Patients With HIV/AIDS

Brochure for Teens Now Available!

Low Dose Aspirin Therapy

Managing and Treating LDL Levels

Dental Hygiene Is Important

Clinical Corner

News&Notes Archive

  

Medical Director Availability After an Adverse Determination

Our medical directors use established evidence-based criteria to evaluate requests for procedures and services, including but not limited to surgery, testing or inpatient admissions, continued hospital stays, care in skilled nursing or rehabilitation facilities, and requests for home care and durable medical equipment. They also use eligibility, benefits, medical necessity, and appropriateness of the type, level and setting of care criteria to make their determinations.

In the event that a medical director issues an adverse determination after evaluating a request, verbal and written communications required by regulatory guidelines are delivered to the provider and member. Medical directors may rescind the adverse determination if additional information establishes medical necessity. If the adverse determination relates to a continued hospital stay, a reconsideration will be conducted only if the patient has not been discharged. If the patient has been discharged, a formal appeal must be filed with the Grievance and Appeals department as outlined for the specific member in the Dispute Resolution section of the Provider Manual:

 

   
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