Members of EPO and PPO plans underwritten by GHI have their behavioral health services administered by Beacon Health Options under the Behavioral Management Program (BMP).
Provider Networks served by BMP include:
- CBP Network, National Network, Tristate Network
- Network Access Network
- Medicare Choice PPO Network
Under BMP, Beacon Health Options manages covered inpatient, outpatient and ambulatory behavioral health services, including provider network and care management services such as utilization management and case management. Provider claims should be submitted to EmblemHealth, except those for Medicare members; these claims should be submitted to Beacon Health Options. Appeals and grievances should be submitted to Beacon Health Options, except for those of Medicare members; these appeals and grievances should be submitted to EmblemHealth.
Contracting with Beacon Health Options: Emblem Behavioral Health Services Program
To care for GHI members served by the BMP, providers are only required to have a Beacon Health Options practitioner agreement.
For more information about contracting with Beacon Health Options, please call the Beacon Health Options National Provider Line at 1-800-397-1630 from 8 a.m. to 5 p.m. and ask to speak with the Credentialing department.
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.
Conditions that affect thinking and the ability to figure things out that affect perception, mood and behavior.
A program that assists the patient in determining the most appropriate and cost-effective treatment plan, including coordinating and monitoring the care with the ultimate goal of achieving the optimum health care outcome.
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.
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 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.
A request to change an adverse determination that was based on administrative policies, procedures or guidelines.
Service provided after the patient is admitted to the hospital. Inpatient stays are those lasting 24 hours or more.
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 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 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.
A review to determine whether covered services that have been provided or are proposed to be provided to a member, whether undertaken prior to, concurrent with or subsequent to the delivery of such services are medically necessary. Also called Coordinated Care.