EmblemHealth provides member services through our Customer Service. Customer Service Advocates assist members with questions about services, benefits, enrollment and other issues. Our computerized Member Contact System enables same-day responses to most member requests. If a member's inquiry cannot be resolved during the initial call on the same day, then a Customer Service Advocate strives to call the member back within 48 hours.
Provider Customer Care Advocates are dedicated on a full-time basis to assist providers with questions about EmblemHealth, participation status, contract questions and to provide education and educational material.
We are committed to encouraging and rewarding superior service and recognize that cooperation is an essential component of the provision of quality medical care.
Glossary terms found on this page:
Services available to a member as defined in his or her contract. Benefit design includes the types of benefits offered, limits (e.g., number of visits, percentage paid or dollar maximums applied) and subscriber responsibility (cost sharing components).
A legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.
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.
Professional services rendered by a physician for the treatment or diagnosis of an illness or injury.
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.
The department responsible for helping members with problems and questions.
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.