Your practice information appears in our network directories (including our online Find a Doctor tool) and is used in claims processing. Keeping your information current helps ensure that patients can locate your practice and that we process your claims accurately. Please use our secure provider website (rather than sending a paper form) to report updates to your practice information, unless you're part of a group that has arranged to submit changes via a spreadsheet/ dataset process, as instructed below, whenever one of the following occurs:
- Your practice address changes
- Your practice phone number changes
- You need to add or delete a provider from your practice
- Your IRS taxpayer identification number (TIN) changes
- Your National Provider Identifier (NPI) number is assigned
- Your Medicare Number is assigned
Providers, and their staff, can access their practice records on our secure provider website by following the directions below:
- Go to www.emblemhealth.com/providers
- Enter your GHI or HIP User ID and password
- Select Sign In
- Select "Provider Profile" or "Practice Profile" from the left navigation panel
- If you maintain multiple office locations select the specific location you wish to review
- Select “Update” to make changes
- Don’t have an account? Select Register for access and fill in the required fields to obtain a user ID and password.
- Forgotten your User ID or password, select Forgot your User ID or Password? and enter your tax ID or provider number, your first and last name, and your email address. Your account will be reset and the information emailed to you at the email address you provided.
For changes that cannot be processed on-line, mail or fax your changes to our Provider Modifications team:
Provider Modifications Team
55 Water Street, 6th Floor
New York, New York, 10041-8190
Providers must inform EmblemHealth of any change to specialty, languages spoken, hospital affiliation, addition or termination of an individual provider in a medical group as soon as possible or within (5) days. Subject to any applicable reconsideration or hearing rights required by state or federal law, EmblemHealth may terminate a provider if he/she fails to notify EmblemHealth of any location changes in a timely manner. Updates to your practice information will be posted to the EmblemHealth website within fifteen (15) days. In general, some updates, such as to your license number, specialty or school, will be verified by our Credentialing department and may take longer to appear.
Note: Removing an individual provider from a service location will not affect previously submitted claims. EmblemHealth will continue to process claims with a Date of Service on or before the provider’s termination date for that location.
Keeping your directory information will help our members, your future patients, locate you. EmblemHealth encourages new members to contact their primary care physicians (PCP) within 90 days of enrollment for an initial evaluation. Accuracy is essential. If any information provided is inaccurate, we may be required to withhold a percent from all payments to your account and forward this amount to the IRS. In addition, your practice would be subject to a penalty by the IRS for failure to provide your correct name/TIN combination. To avoid unnecessary withholding, please be sure to contact us when your records require updates.
Change of Ownership
A change of ownership (CHOW) cannot be performed online; a CHOW is treated like a new enrollment. When a change of ownership occurs, providers must contact EmblemHealth. The appropriate contact information can be located in the EmblemHealth Contact Information section of the Directory chapter.
Know Your Network Participation
The provider profile also lists your network affiliations. If the network information on the member's ID card matches your network affiliations, then you are in-network for that member's benefit plan. See the Provider Networks and Member Benefit Plans chapter for a listing of all networks and plans.
Note: Some government program cards don’t have network names; however, they are easily identified by the plan name. Digital representations of our most common member ID cards are located in the Member Identification Cards section of the Your Plan Members chapter.
Ask to see a member’s ID card at each appointment, emergency visit or inpatient stay. However, the provision of service should not be conditioned solely on the presentation of a member ID card because a member’s enrollment status can change due to various reasons. Sign in to our secure provider website to check your patients’ eligibility status.
Keeping your information current ensures we send your claims payments and other important correspondence to the correct address. It also helps our members contact you at your current location. We recommend that you periodically review the information we have on file for you and encourage you to share your network participation and any changes with your staff on a regular basis.
Glossary terms found on this page:
A health insurance product offered by a health plan company that is defined by the benefit contract and represents a set of covered services. Also called a health benefit plan.
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.
The date on which a service was rendered.
A determination of whether or not a person meets the requirements to participate in the plan and receive coverage under the plan.
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.
A form sent to the enrollee after a claim for payment has been processed by the health plan. The form explains the action taken on that claim. This explanation usually includes the amount paid, the benefits available, reasons for denying payment and the claims appeal process. Also called Explanation of Benefits.
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 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
A card which allows the subscriber to identify himself or his covered dependents to a provider for health care services.
A card that allows the subscriber to identify himself or his covered dependents to a provider for health care services.
A unique number that identifies the member's enrollment with EmblemHealth. EmblemHealth's claims are processed by this number. Also known as Member ID Number.
The group of individuals who provide person-centered care coordination and care management to participants in a FIDA plan. Each participant will have an interdisciplinary team (IDT). Each IDT will be comprised, first and foremost, of the participant and/or his or her designee, and the participant’s designated care manager, primary care physician, behavioral health professional, home care aide, and other providers either as requested by the participant or his or her designee or as recommended by the care manager or primary care physician and approved by the participant and/or his or her designee. The IDT facilitates timely and thorough coordination between a FIDA plan and the IDT, primary care physician and other providers. The IDT makes coverage determinations. Accordingly, the IDT’s decisions serve as service authorizations, may not be modified by a FIDA plan outside of the IDT, and are appealable by the participant, their providers and their representatives. IDT service planning, coverage determinations, care coordination and care management are delineated in the participant’s person-centered service plan and are based on the assessed needs and articulated preferences of the participant.
The use of providers who participate in the health plan's provider network. Many benefit plans encourage enrollees to use network providers to reduce the enrollee's out-of-pocket expense.
Service provided after the patient is admitted to the hospital. Inpatient stays are those lasting 24 hours or more.
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.
A permit (or equivalent) to practice medicine or a health profession that is: 1) issued by any state or jurisdiction in the United States and 2) required for the performance of job functions.
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 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.
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 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.
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 set of providers contracted with a health plan to provide services to the enrollees.
This is the seven digit identification number issued to the provider by EmblemHealth. This is the tax identification number issued to the provider by the Internal Revenue Service.
A request for inpatient review, made while the member is still in the facility, of a case that was denied on the basis of medical necessity.