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  • Behavioral Health Services > Emblem Behavioral Health Services Program

    Behavioral health services for members in plans underwritten by HIP or in ASO plans administered by VHMS are administered by Beacon Health Options under the Emblem Behavioral Health Services Program.

    Provider Networks served by EBHSP include:

    • Associated Dual Assurance Network
    • EmblemHealth Dual Assurance Network
    • Enhanced Care Prime Network
    • Medicare Essential Network
    • NY Metro Network
    • Premium Network
    • Prime Network
    • Select Care Network
    • VIP Prime Network

    Under EBHSP, Beacon Health Options administers covered inpatient, outpatient and ambulatory behavioral health services including provider network and care management services such as utilization management and case management. Beacon Health Options also manages credentialing, claims processing, claims payment and grievances and appeals (except for Medicare plans), as well as other provider service issues related to Behavioral health.

    Members may call 1-888-447-2526 or use our online Find a Doctor tool to find a mental health or substance abuse practitioner.

    Montefiore members can access behavioral health providers in the Montefiore network. They also may use the Beacon Health Options network if they choose. For providers who are not Montefiore network participants, claims for members who have the Montefiore logo on their ID card must be submitted to Beacon Health Options. Utilization management functions for behavioral health services for these members, including prior approvals, are performed by Montefiore. Please call 1-800-401-4822 for help finding a Montefiore network mental health or substance abuse practitioner.

    Note: EmblemHealth administers disease management, including the Depression Disease Management program, for all members except for Medicare plans which will be administered by Beacon Health Options effective August 1, 2015. For more information on Serious and Persistent Mental Illness Disease Management Services, visit the PATH Programs section of the Health Promotion and Disease Management chapter.

    Health and Recovery Plan (HARP)

    Our Health and Recovery Plan (HARP), Enhanced Care Plus, is designed to meet the unique needs of members living with serious mental illness and/or substance use disorder. For more information on HARP and other Medicaid services, please see the Medicaid section of the Provider Network and Member Benefit Plans chapter.

    Medicaid Health Homes

    All HARP members and qualifying Medicaid members will be assigned to Health Homes that will be responsible for coordinating all of their care. It is especially important for there to be coordinated care between a member’s medical and behavioral health care providers. The Health Home will facilitate the development of a plan of care that encompasses both aspects of the member’s health.


    A Health Home is a care management service model whereby all of an individual's caregivers communicate with one another so that all of a patient's needs are addressed in a comprehensive manner. This is done primarily through a "care manager" who oversees and provides access to all of the services an individual needs to assure that they receive everything necessary to stay healthy, out of the emergency room and out of the hospital. Health records are shared among providers so that services are not duplicated or neglected. Health Home services are provided through a network of organizations – providers, health plans and community-based organizations. When all the services are considered collectively they become a virtual "Health Home."

    For information on MMC and HARP covered services, please see the Medicaid section of the Provider Network and Member Benefits Plans chapter.

    Contracting with Beacon Health Options: Emblem Behavioral Health Services Program

    To care for all members served by the EBHSP, providers are required to participate in both of the Beacon Health Options practitioner networks and must have a Beacon Health Options practitioner agreement and a CHCS IPA agreement (collectively referred to as "Beacon Health Options Agreements").

    Providers who only have a CHCS IPA agreement will only be permitted to provide in-network care to Health Insurance Plan of New York (HIP) members.

    Providers who only have a Beacon Health Options practitioner agreement will only be permitted to provide in-network care to HIPIC-underwritten members and members of ASO plans administered by VHMS.

    For patients in an active course of treatment prior to January 1, 2012, please see Continuity of Care During Program Implementation.

     

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    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 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.

    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 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.

    The evaluation of the medical necessity, appropriateness and efficiency of the use of health care services, procedures and facilities under the provisions of the applicable health benefit plan. It is sometimes called utilization review or utilization management.

    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 coordinated system of preventive, diagnostic and therapeutic measures intended to provide cost-effective, quality health care for a patient population who have or are at risk for a specific chronic illness or medical condition.

    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 request to change an adverse determination that was based on administrative policies, procedures or guidelines.

    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 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.

    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.

    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.

    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.

    Conditions that affect thinking and the ability to figure things out that affect perception, mood and behavior.

    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 prepaid payment or series of payments made to a health plan by purchasers and often plan members for health insurance coverage.

    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
    • Dentist
    • Chiropractor
    • Doctor of podiatric medicine
    • Physical therapist
    • Nurse midwife
    • Certified and registered psychologist
    • Certified and qualified social worker
    • Optometrist
    • Nurse anesthetist
    • Speech-language pathologist
    • Audiologist
    • 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.

    The use of one or more drugs for purposes other than those for which they are prescribed or recommended.

    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.

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