Practitioners are expected to adhere to EmblemHealth's appointment availability and 24-hour access standards for primary care physicians, OB/GYNs, specialists and mental health and substance abuse practitioners (as appropriate). These standards are based on industry, Centers for Medicare and Medicaid Services (CMS) and New York State Department of Health (NYSDOH) access standards.
Appointment Availability Standards
Practitioner offices will schedule appointments in a timely and efficient manner. Member visits to see a practitioner shall be scheduled based on EmblemHealth's Appointment Availability Standards During Office Hours & After Office Hours Access Standards, which is available at the end of this chapter.
Customer Service will maintain and monitor standards for customer telephone access.
EmblemHealth conducts semi-annual appointment availability surveys by calling practitioner offices to determine the next available appointment for a given type of service. This determines both individual practitioner and overall network compliance with these standards as part of our Quality Management program. Noncompliant practitioners are notified and resurveyed approximately six months after the initial survey. Practitioners that are not compliant with these standards upon resurvey will be forwarded to our Recredentialing Committee for review and action.
24-hour Access Standards
All practitioners will provide access to medical advice or treatment when not in the office in the form of 24-hour coverage, seven days a week, 365 days a year. This 24-hour access will include:
- An answering service or machine with an appropriate message explaining:
- That patients should go to the emergency room if they reasonably believe that their health is in serious jeopardy if they do not seek immediate medical treatment.
- How to access medical attention outside of an ER for conditions that are not life- or limb-threatening.
- Coverage by another practitioner in the event the practitioner is unavailable. Please see the Claims chapter for details on covering practitioners.
- A method to communicate issues, calls and advice from covering practitioners to the PCP and the member's file.
Covering practitioners should be contracted and credentialed by EmblemHealth's companies. Practitioners must provide EmblemHealth with a list of the covering physicians and notify us of any changes. If the covering practitioner in the coverage group does not participate with the EmblemHealth plan, the network practice must inform that practitioner of our policies and procedures. Out-of-network practitioners are prohibited from balance billing and they must clearly identify the name of the practice/practitioner for whom they are covering.
Patients should be instructed by the covering physician to follow up with their PCP. Only one visit will be approved for the covering practitioner's services, unless the office is closed for more than 24 hours. If a practice is closed for an extended period of time, the practice must notify the Provider Relations department and any members that may be affected by the closure.
Members also have access to urgent care centers. See the Care Management chapter for more information.
EmblemHealth conducts semi-annual surveys of 24-hour access by calling after-hours telephone numbers to determine whether members can reach a live voice and be connected either directly to their practitioner or to an answering machine/voice-mail system that asks the caller to leave a name and phone number so the call can be returned immediately. Noncompliant practitioners are notified and resurveyed approximately six months after the initial survey. Practitioners that are not compliant with these standards upon resurvey will be forwarded to our Recredentailing Committee for review and action.
Glossary terms found on this page:
An activity of EmblemHealth or its subcontractor that results in:
- Denial or limited authorization of a service authorization request, including the type or level of service
- Reduction, suspension or termination of a previously authorized service
- Denial, in whole or in part, of payment for a service
- Failure to provide services in a timely manner
- Failure of EmblemHealth to act within the time frames for resolution and notification of determinations regarding complaints, action appeals and complaint appeals
Billing a member or other responsible party for the difference between the insurer's payment and the actual charge.
An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.
The government agency responsible for administering the Medicare and Medicaid programs.
A legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.
A licensed doctor of medicine or osteopathy who has an agreement with a network provider to provide covered services to members when the network provider is not available.
Means a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (a) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy; (b) serious impairment to such person’s bodily functions; (c) serious dysfunction of any bodily organ or part of such person; or (d) serious disfigurement of such person.
An organization comprised of individual physicians or physicians in group practices that contracts with the managed care organization on behalf of its member physicians to provide health care services. Also called an Independent Practice Association.
Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.
A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.
A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.
An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.
Conditions that affect thinking and the ability to figure things out that affect perception, mood and behavior.
The group of physicians, hospital, and other medical care providers that a specific plan has contracted with to deliver medical services to its members.
The state regulatory agency that certifies reimbursement methods and rates to hospitals and reviews HMO activities in the state of New York. Also called NYSDOH.
The state regulatory agency that certifies reimbursement methods and rates to hospitals and reviews HMO activities in the state of New York. Also called the New York State Department of Health.
The use of health care providers who have not contracted with the health plan to provide services. Depending on the member's contract, out-of-network services may not be covered.
A family physician, family practitioner, general practitioner, internist or pediatrician who is responsible for delivering or coordinating care. Also called a primary care physician.
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. Also called a Preferred Provider Organization.
A family physician, family practitioner, general practitioner, internist or pediatrician who is responsible for delivering or coordinating care. Also called a PCP.
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:
- Doctor of medicine
- Doctor of osteopathy
- Doctor of podiatric medicine
- Physical therapist
- Nurse midwife
- Certified and registered psychologist
- Certified and qualified social worker
- Nurse anesthetist
- Speech-language pathologist
- Clinical laboratory
- Screening center
- General hospital
- Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance 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.
New York State Department of Health. This agency provides information for consumers, doctors, researchers and health care providers.
The use of one or more drugs for purposes other than those for which they are prescribed or recommended.
Services received for an unexpected illness or injury that is not life threatening but requires immediate outpatient medical care that cannot be postponed. An urgent situation requires prompt medical attention to avoid complications and unnecessary suffering or severe pain, such as a high fever.