Access to Care and Delivery System > Transitional Care When Practitioners Leave the EmblemHealth Network
Upon a practitioner's termination from EmblemHealth, EmblemHealth shall:
- Make a good faith effort to notify affected enrollees of a practitioner's termination 30 days prior to the effective date
- Provide the affected practitioner with a written notice explaining the reasons for the termination or suspension as well as the right to a notice and hearing (See the Termination and Appeal section of the Credentialing chapter.)
We make every effort to assist members whose physicians end their participation with one of our plans. Members who wish to continue seeing their current health care provider for a limited time must contact or have their provider contact their plan/managing entity. See the Continuity of Care - When Providers Leave the Network subsection of the Care Management chapter on transitional care.
If the physician is a PCP and the member opts to stay with the PCP, the member must notify Customer Service of the new PCP who will manage their care following the 90-day transition period. If the physician leaving the network is a specialist and the member opts to stay with the specialist for the 90-day transition period, the member should obtain a referral to a new specialist for care following the 90-day transition period.
Glossary terms found on this page:
Oral or written request from a member or their designee for EmblemHealth to review or reconsider a decision made by the plan.
The date on which the coverage of an insurance policy goes into effect at 12:01 am.
An individual who is enrolled and eligible for coverage under a health plan contract. Also called a member.
A professionally licensed individual, facility or entity giving health-related care to patients. Physicians, hospitals, skilled nursing facilities, pharmacies, chiropractors, nurses, nurse-midwives, physical therapists, speech pathologist and laboratories are providers. All network providers are health care providers, but not all providers are network providers.
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.
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 family physician, family practitioner, general practitioner, internist or pediatrician who is responsible for delivering or coordinating care. Also called a primary care physician.
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.