EmblemHealth-contracted Primary Care Practitioners (PCPs) are responsible for supervising and coordinating medically necessary health care of their patients including, but not limited to:
- Providing health counseling and advice
- Baseline and periodic health examinations
- Diagnosing and treating conditions not requiring the services of a specialist
- Arranging inpatient care, specialist consults and laboratory/radiological services when medically necessary and in a timely manner
- Coordinating the findings of consultants and laboratories and interpreting such findings to the member and the member's family (subject to HIPAA Privacy Rules)
- Maintaining a current medical record for each patient
PCPs are required to follow the standards of care contained in this manual and the administrative guidelines posted to our website, which are reflective of professional and generally accepted standards of medical practice. One of the first and most important decisions any member makes is the selection of a PCP. It is equally important for PCPs to establish a meaningful professional and lasting relationship with their patients. A PCP cannot be his/her own or his/her family's primary care physician.
If a member is using a behavioral health clinic that also provides primary care services, the member may select the lead provider to be their PCP.
Credentialed advanced nurse practitioners (ANPs) may act as primary caregivers, maintaining their own panel of EmblemHealth members and issuing referrals for specialty care. All ANPs functioning as primary caregivers must maintain a current collaborative relationship with an EmblemHealth physician who is participating in the same networks and coverage arrangement for hospital admissions at an EmblemHealth contracted hospital. ANPs may submit to EmblemHealth either a written collaborative agreement or the NYS Education Department Collaborative Relationships Attestation Form (NP-CR). See the Credentialing Chapter for more information. In general, NPs and PAs are paid for covered services at 85 percent of what a physician is paid.
For more information on how to become credentialed with EmblemHealth as a primary caregiver, please sign in to our secure provider website at www.emblemhealth.com/providers and send us an email via our Message Center.
EmblemHealth encourages new members to contact their PCP within 90 days of enrollment for an initial evaluation. If the initial contact with the practitioner is for an acute visit, the practitioner should recommend that the member return for a general health assessment based on age, state of health and the member's last health assessment.
Each time a member needs to see a specialist, it is the PCP's/primary caregiver's responsibility to identify and refer the member to a participating practitioner and to give the member an appropriate referral, either for a consult only or for specific medical services. If the PCP or primary caregiver anticipates the need to refer a member for services that require a referral, prior approval, or the use of a non-participating provider, the request must be approved by EmblemHealth in advance.
All members have direct access to OB/GYN care without a referral or prior approval, as required by New York State law.
Primary Care Practitioner Responsibilities
Primary care practitioners (PCPs) are responsible for providing primary care services and managing all necessary health care services for the members assigned to them. Coordinating all care and maintaining an overall picture of member health is key to helping members stay healthy while effectively managing appropriate use of health care resources.
When providing primary health care services and coordination of care, the PCP must:
- Provide for all primary health care services that do not require specialized care. These include, but are not limited to:
- Routine preventive health screenings.
- Physical examinations.
- Routine immunizations.
- Child/Teen Health Plan Services (C/THP) screenings for children and adolescents (required for Medicaid members; as appropriate for other members).
- Reporting communicable and other diseases as required by Public Health Law.
- Behavioral health screening (as appropriate).
- Routine/urgent/emergent office visits for illnesses or injuries.
- Clinical management of chronic conditions not requiring a specialist.
- Hospital medical visits (when applicable).
- Maintain appropriate coverage for members 24 hours a day, seven days a week, three hundred and sixty-five days a year as noted in the above section on 24-hour access.
- Refer all members for services in accordance with EmblemHealth's referral policies and procedures. See the Care Management chapter of this manual for more details.
- Provide services of available allied health professionals and support staff in your office.
- Provide supplies, laboratory services and specialized or diagnostic tests that can be performed in the office.
- Assure members understand the scope of referred specialty or ancillary services and how/where the member should access the care.
- Communicate conditions, treatment plans and approved authorizations for services to member and appropriate specialists.
- Consult and coordinate with members regarding specialist recommendations.
- Comply with the New York State "Vaccine for Children Program," as appropriate, and with New York State and New York City requirements for reporting communicable diseases.
EmblemHealth Medicaid and Child Health Plus Participating Practitioners
Practitioners treating members enrolled in Medicaid or Child Health Plus shall have no more than 1,500 members on their panel or 2,400 for a physician practicing in combination with a registered physician assistant or certified nurse practitioner. Advanced nurse practitioners credentialed as primary caregivers shall have no more than 1,000 members on their panel.
These member-to-practitioner ratios are based on the assumption that the practitioner works 40 hours per week and therefore must be prorated for practitioners working less than 40 hours per week. The ratios apply to practitioners, not to each of their practice locations.
Glossary terms found on this page:
Formal acceptance as an inpatient by an institution, hospital or health care facility.
Auxiliary or supplemental services (i.e., diagnostic services, physical therapy and medications) used to support diagnosis and treatment of a patient's condition.
Services that have been approved for payment based on a review of EmblemHealth's policies.
Conditions that affect thinking and the ability to figure things out that affect perception, mood and behavior.
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 medically necessary service for which a member is entitled to receive partial or complete coverage under the terms and conditions of the benefit program, is within the scope of the practitioner's practice and the practitioner is authorized to render pursuant to the terms of the agreement.
A test or procedure ordered by a physician to determine if the patient has a certain condition or disease based upon specific signs or symptoms demonstrated by the patient. Such diagnostic tools include radiology, ultrasound, nuclear medicine, laboratory and pathology services.
A health care benefit arrangement that is similar to a preferred provider organization in administration, structure and operation but does not cover out-of-network care. Also called an Exclusive Provider Organization.
An individual who: (1) has undergone formal training in a health care field; (2) holds an associate or higher degree in a health care field, or holds a state license or state certificate in a health care field; and (3) has professional experience in providing direct patient care.
A federal act that protects people who change jobs, are self-employed or have pre-existing medical conditions. The act standardizes an approach to the continuation of health care benefits for individuals and members of small group health plans and establishes parity between the benefits extended to these individuals and those offered to employees in large group plans. The act also contains provisions to ensure that prospective or current enrollees in a group health plan are not discriminated against based on health status and protects the confidentiality of protected health information of members. Also known as the Health Insurance Portability and Accountability Act.
An institution which provides inpatient services under the supervision of a physician, and meets the following requirements:
- Provides diagnostic and therapeutic services for medical diagnosis, treatment and care of injured and sick persons and has, as a minimum, laboratory and radiology services and organized departments of medicine and surgery
- Has an organized medical staff which may include, in addition to doctors of medicine, doctors of osteopathy and dentistry
- Has bylaws, rules and regulations pertaining to standards of medical care and service rendered by its medical staff
- Maintains medical records for all patients
- Has a requirement that every patient be under the care of a member of the medical staff
- Provides 24-hour patient services
- Has in effect agreements with a home health agency for referral and transfer of patients to home health agency care when such service is appropriate to meet the patient's requirements
Service provided after the patient is admitted to the hospital. Inpatient stays are those lasting 24 hours or more.
Treatment provided to a patient who stays overnight (24 hours or more) in a hospital or other facility.
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.
Health care that is rendered by a hospital or a licensed or certified provider and is determined by EmblemHealth to meet all of the criteria listed below:
- It is provided for the diagnosis or direct care or treatment of the condition, illness, disease, injury or ailment.
- It is consistent with the symptoms or proper diagnosis and treatment of the medical condition, disease, injury or ailment.
- It is in accordance with accepted standards of good medical practice in the community.
- It is furnished in a setting commensurate with the member's medical needs and condition.
- It cannot be omitted under the standards referenced above.
- It is not in excess of the care indicated by generally accepted standards of good medical practice in the community.
- It is not furnished primarily for the convenience of the member, the member's family or the provider.
- In the case of a hospitalization, the care cannot be rendered safely or adequately on an outpatient basis or in a less intensive treatment setting and, therefore, requires the member receive acute care as a bed patient.
The fact that a provider has prescribed a service or supplies care does not automatically mean the service or supply will qualify for reimbursement under the EmblemHealth plan. To be eligible for reimbursement by EmblemHealth, all covered services must meet EmblemHealth's medical necessity criteria, described above.
Medically necessary with respect to Medicaid and Family Health Plus members means health care and services that are necessary to prevent, diagnose, manage or treat conditions that cause acute suffering, endanger life, result in illness or infirmity, interfere with a person's capacity for normal activity or threaten some significant handicap.
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 group of physicians, hospital, and other medical care providers that a specific plan has contracted with to deliver medical services to its members.
A health care provider, such as a physician, skilled nursing facility, home health agency or laboratory, that does not have an agreement with EmblemHealth plans to provide covered services to members. Also called an Out-of-Network Provider.
A physician, hospital or other provider who has signed an agreement to covered services to EmblemHealth plan members. A participating provider is a member of the EmblemHealth network of providers applicable to the member's certificate. Therefore, they are more commonly referred to as network providers. Payment is made directly to a participating provider. Please consult the EmblemHealth Directory or go online to search for participating providers.
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 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. Also called Point of Service.
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.
The process of obtaining advanced approval of coverage for a health care service or medication. The request for services is reviewed to assess medical necessity and appropriateness of elective hospital admissions and non-emergency outpatient services before the services are provided. Also called pre-authorization or pre-certification or pre-determination.
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.
A recommendation by a physician that an enrollee receive care from a specialty physician or facility.