Cardiology Imaging Program > Members Exempt From the EmblemHealth Cardiology Imaging Program
While most of our members' covered cardiology imaging services are managed through this program, the following exceptions apply.
Members whose care is managed by Montefiore (CMO) or HealthCare Partners (HCP) must contact the applicable organization for prior approval. See the member's ID card or eligibility information at www.emblemhealth.com to determine whether HIP, CMO or HCP is the managing entity responsible for managing a member's care. If HIP is the managing entity, then the instructions in this chapter apply.
Members who selected a PCP affiliated with AdvantageCare Physicians or St. Barnabas Hospital (see member's ID card) are excluded from this program. AdvantageCare Physicians and St. Barnabas Hospital PCPs must enter a prior approval request at www.emblemhealth.com.
The Cardiology Imaging Prior Approval Code List For EmblemHealth CompreHealth EPO, EmblemHealth Medicare HMO/PPO, GHI HMO, Vytra and HIP Benefit Plans chart later in this chapter applies to the members listed above as well. Only the managing entity varies. Please refer to the Care Management chapter for information on how to obtain prior approval for these members.
Vytra HMO and Vytra ASO plans prior to January 1, 2016 covered cardiology imaging services for their members and were excluded from the EmblemHealth Cardiology Imaging Program. As of January 1, 2016 members with the Vytra Premium Network follow the procedures in this chapter.
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.
A determination of whether or not a person meets the requirements to participate in the plan and receive coverage under the plan.
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 organization that provides comprehensive health care coverage to its members through a network of doctors, hospitals and other health care providers. Also called a Health Maintenance 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.
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 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 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
- 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.