Table of Contents
How Do I...

Search Tips

Table of Contents Search

  • For more specific results, select both a chapter and section.
  • To move from section to section within a chapter, use the left navigation bar.

Keyword Search

  • For best results, select a recommended search term if one appears in the search box.
  • To narrow your search, use the Filter By and Additional Keywords features in the left navigation bar.
  • To find an exact phrase, use quotes (e.g., “prior approval”).
  • To find all search terms, use the word AND in capital letters between search terms.
  • To find at least one search term, use the word OR in capital letters between search terms.
  • Care Management > Overview

    The purpose of the Care Management program is to create an alliance among our network practitioners, clinicians, hospitals, facilities and ancillary services in order to meet our members' health care needs.

    This chapter explains the philosophy, policies and procedures used to coordinate optimal, cost effective, quality care for our members. We provide prior approval, concurrent management, discharge planning and case management services. These processes are reviewed by our Quality Improvement/Utilization Management Committee on an annual basis.

    EmblemHealth will provide the clinical review criteria used to make such determinations upon written request to the plan's Care Management program. Please forward all requests to:

    Clinical Review Criteria
    PO Box 2824
    New York, NY 10116-2824

    We invite comments and suggestions from our providers to assure these policies support the quality and value of the health care that our members receive. Please submit comments using our Message Center by signing in to

    Help for Providing Care Through a Continuum of Services

    Qualified clinical professionals in the Care Management program use utilization management tools to help practitioners guide their patients' care through the continuum of services. This includes care provided for all conditions, both acute and chronic, physical and behavioral, in the offices of participating clinicians and in hospitals, skilled nursing facilities and other settings.

    We strive to facilitate the primary care physician's (PCP's) or designated health care practitioner's role through careful structuring of our network of specialty providers and facilities. Our referral and authorization processes focus on member eligibility, identification of participating providers and review of member benefits. Some services might require prior approval to help the member select the right care, in the right setting with the right provider. Nurse case managers provide concurrent review and case management when members are hospitalized, receiving skilled nursing facility (SNF) care, rehabilitation, home care or hospice services. Where the complexity of a particular member's needs requires services by multiple providers across different health care systems, our nurse case managers will assist the practitioner and member to support the care needs. Care for FIDA members will be coordinated in their IDTs and Medicaid and HARP members through their Health Homes.

    The procedures and practices discussed in this chapter apply to all of our plans; however, certain variations in referral requirements, authorization requirements and coverage exist depending on the plan and benefit package. Please see the applicable subsections for further information.

    Note: EmblemHealth conducts care management and also delegates this function to certain utilization review agents. Whether the care management for a particular member is delegated depends on the PCP that member has selected. Follow the instructions on the back of each plan member's ID card to contact the managing entity responsible for that member's care management, or contact the member's plan if you have any questions. For HIP members, managing entity may also be identified on the Eligibility Details page after signing into the secure provider website:

    My Subscriptions

    Enter your e-mail address to receive a link to your subscriptions.


    Glossary terms found on this page:

    Auxiliary or supplemental services (i.e., diagnostic services, physical therapy and medications) used to support diagnosis and treatment of a patient's condition.

    Services that have been approved for payment based on a review of EmblemHealth's policies.

    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.

    A doctor, nurse or other health care professional.

    Occurs when a clinical professional reviews information about a patient's health.

    The written screens, decision rules, medical protocols or guidelines used by the utilization management agent as an element in the evaluation of medical necessity and appropriateness of requested admissions, procedures and services under the auspices of the applicable health benefit plan.

    An entity contracted with EmblemHealth to perform various services including utilization review, credentialing and claims processing. Also called managing entities and carve outs.

    A determination of whether or not a person meets the requirements to participate in the plan and receive coverage under the plan.

    A hospital, ambulatory surgical facility, birthing center, dialysis center, rehabilitation facility, skilled nursing facility or other provider certified under New York Public Health Law. A hospice is a facility. An institutional provider of mental health substance abuse treatment operating under New York Mental Hygiene Law and/or approved by the Office of Alcoholism and Substance Abuse Services is a facility.

    A facility or service that provides care for the terminally ill patient and support to the family. The care, primarily for pain control and symptom relief, can be provided in the home or in an inpatient setting.

    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 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.

    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.

    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 physician, hospital or other provider who has signed an agreement to covered services to EmblemHealth plan members. A participating provider is a member of the EmblemHealth network of providers applicable to the member's certificate. Therefore, they are more commonly referred to as network providers. Payment is made directly to a participating provider. Please consult the EmblemHealth Directory or go online to search for participating providers.

    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.

    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.

    The process to objectively and systematically monitor and evaluate the quality, timeliness and appropriateness of covered services, including both clinical and administrative functions, to pursue opportunities to improve health care and resolve identified problems in any of these services.

    A recommendation by a physician that an enrollee receive care from a specialty physician or facility.

    A licensed institution (or a distinct part of a hospital) that is primarily engaged in providing continuous skilled nursing care and related services for patients who require medical care, nursing care or rehabilitation services. Also called a SNF.

    A licensed institution (or a distinct part of a hospital) that is primarily engaged in providing continuous skilled nursing care and related services for patients who require medical care, nursing care or rehabilitation services. Also called a skilled nursing facility.

    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.

    A formal evaluation (prospective, concurrent or retrospective) of the coverage, medical necessity, efficiency or appropriateness of health services and treatment plans. Also called Coordinated Care.


You are now leaving the Medicare section of the EmblemHealth website.

Click to Continue ×

Your member ID # is on the front of your ID card.