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  • Care Management > Prior Approval Procedures - Practitioners and Facilities

    The physician or organization providing or requesting the service is responsible for obtaining prior approvals. As part of an ongoing effort to decrease physicians' administrative burden and ensure prompt access to care for our members, we regularly review and update our prior approval policies. Please subscribe to this chapter and its sections to receive email notification of updates.

    The following require prior approval for all members, unless noted otherwise:

    Standing Referrals

    A PCP may refer members with chronic, disabling or degenerative conditions or diseases to a specialist for a set number of visits within a specified time period. An EmblemHealth or managing entity medical director must approve standing referrals via the prior approval process.

    Specialists as PCPs

    A specialist may substitute as a PCP for a member with a life-threatening condition or disease or degenerative and disabling condition or disease, either of which requires specialized medical care over a prolonged period of time, when authorized by the managing entity's medical director. Whenever possible, the specialist who will be acting as a PCP should be dually board-certified. A treatment plan must be agreed upon among the PCP, the managing entity's medical director and the specialist.

    Specialty Care Centers

    A member with a life-threatening condition or disease or degenerative and disabling condition or disease, either of which requires specialized medical care over a prolonged period of time, may request a referral to a specialty care center. Such referral will require prior approval by the managing entity's medical director. A treatment plan must be agreed upon among the PCP, the managing entity's medical director and the provider.

    Use of Out-of-Network Providers

    All requests to see out-of-network providers are reviewed against the member's benefits, the plan's provider network and the medical necessity of treatment by an out-of-network provider. Members with a Point of Service, PPO or Access II contract may elect to receive specialty care from an out-of-network specialist without a PCP referral if they elect to use their out-of-network benefits (including appropriate out-of-pocket expenses). If the service requires prior approval, the member is responsible for obtaining prior approval from the managing entity.

    For more details regarding when out-of-network providers can be used, please see the Commercial Networks, Medicaid Network and Medicare Networks sections of the Provider Networks and Member Benefit Plans chapter.

    Prior approval is required for members who do not have out-of-network benefits. See the How to Obtain a Prior Approval section of this chapter for more information on how to request prior approval. If a specialist is not available in the network and prior approval has been granted by the managing entity listed on the member's ID card, the member may receive care from an out-of-network specialist at no additional cost to the member.

    Submitting an ICD-10 Compliant Prior Approval or Referral Request

    When submitting a prior approval or referral request, use the date that you are entering the prior approval or referral request (NOT the date of service) to determine whether to use ICD-9 or ICD-10 codes. Unless there are any new CMS guidelines, the following requirements apply with no exceptions.
    • For prior approval or referral requests entered before October 1, 2015, use ICD-9 codes only. Those submitted with ICD-10 codes will not be accepted and must be modified to use ICD-9 codes.
    • For prior approval or referral requests entered on or after October 1, 2015, use ICD-10 codes only. Those submitted with ICD-9 codes will not be accepted and must be modified to use ICD-10 codes.
    • Prior approval or referral requests submitted with a combination of ICD-9 and ICD-10 codes will not be accepted and must be modified to use either ICD-9 or ICD-10 codes (based on date of entry of prior approval request).

    For more information on submitting ICD-10 compliant claims, please see the Claims chapter.

    Continuity/Transition of Care - New Members

    Upon enrollment, the member shall select a PCP from whom the member may request continuation of care. When appropriate, EmblemHealth will permit new members to continue seeing their current out-of-network practitioner for up to 60 days.

    If on the effective date of enrollment a member has a life-threatening disease or condition or a degenerative and disabling disease or condition, the member may continue to see their current out-of-network practitioner for up to 60 days. In the case of pregnancy, if the member has entered into her second trimester, she may continue to see the nonparticipating practitioner through delivery and postpartum care for up to 60 days for care related to the delivery for Medicaid members. All transitions of care and continuity of services must be reviewed and approved by EmblemHealth or the member's assigned managing entity (see back of member ID card) prior to the services continuing. For the request to be considered, the member must have at least one of the following health conditions:

    1. A condition in the midst of ongoing course of treatment with an out-of-network provider
    2. Second and third trimester of pregnancy (up to 60 days postpartum directly related to the delivery for Medicaid members)

    If transitions of care and/or continuity of care is approved, it will be for a period of up to 60 days from the effective date of enrollment when the eligibility criteria are met. A single case agreement for continued services with an out-of-network health care provider must be agreed upon by EmblemHealth and the provider. The provider must do all of the following:

    • Accept our reimbursement rates as payment in full
    • Adhere to our Quality Improvement program
    • Provide medical information related to the enrollee's care
    • Otherwise adhere to our policies and procedures including those regarding referrals and obtaining prior approvals and a treatment plan approved by our applicable Prior Authorization department. (See the How to Obtain Prior Approval section in this chapter.)

      This transitional method does not require EmblemHealth to provide coverage for benefits not otherwise covered or diminish or impair pre-existing condition limitations contained in the member agreement.

      Continuity/Transition of Care - Benefits Exhausted or Ended

      We collaborate with the members and their providers and practitioners to assure that members receive the services needed, within the benefit limitations of their contracts. When benefits end for members, the Utilization Management department will assist, if applicable, in the transition of their care.

      Continuity of Care - When Providers Leave the Network

      When a member's health care practitioner leaves EmblemHealth, the member will be given the option of continuing an ongoing course of treatment with his or her current practitioner for a transitional period of up to 90 days. If the member has entered the second trimester of pregnancy, the transitional period includes the provision of postpartum care through 60 days postpartum directly related to the delivery. Members who wish to continue seeing their current health care practitioner for a limited time must contact or have their provider contact the appropriate Anticipated Care department (see the How to Obtain Prior Approval section in this chapter).

      EmblemHealth will permit a member to continue with their current practitioner as long as the reason for leaving is not related to imminent harm to patients, to a determination of fraud or to a final disciplinary action by a state licensing board that impairs the health professional's ability to practice. The practitioner must agree to all of the following:

      1. Continue to accept reimbursement at the rates applicable prior to the start of the transitional period as payment in full
      2. Adhere to EmblemHealth's quality assurance requirements and provide us with necessary medical information related to such care
      3. Otherwise adhere to our policies, which include but are not limited to, procedures regarding referrals, obtaining prior approval for services and obtaining an approved treatment plan

      Services That Require Approval for HIP Network Plans

      On July 1, 2016, a revised prior approval list went into effect for benefit plans in the following networks:

      • Enhanced Care Prime Network
      • HIP Premium Network
      • HIP Prime Network
      • NY Metro Network
      • Select Care Network
      • VIP Prime Network
      • Vytra Network

        What requires prior approval?
        Services that require prior approval are now consistent for the networks listed above, unless the service is not covered by the member’s benefit plan. When submitting a prior approval request, there may be minor exceptions in timing, for example, the number of referral visits allowed before a prior approval request must be made. A Prior Approval Look-up Tool to simplify determination of what procedures need pre-service review and approval became operational on January 22, 2014. Sign in to our secure website to access the Look-up Tool.

        Who conducts the pre-service review?
        Pre-service reviews are administered by the managing entity on the member ID card or by the vendor managing a utilization program on our behalf. The following services require prior approval in accordance with the member’s benefit plan:

        • All inpatient confinements:
          • Emergency admissions*
          • Elective hospital admissions
          • Skilled nursing facility admissions
          • Rehabilitation facility admissions
          • Inpatient hospice admission
        • Services and procedures provided in an ambulatory or outpatient surgery center. For exceptions, effective June 15, 2014, see Services That Do Not Require Prior Approval.
        • All procedures (outpatient, ambulatory surgery and inpatient) that require an assistant surgeon or co-surgeon
        • Reconstructive surgery or other procedures that may be considered cosmetic, including but not limited to:
          • Blepharoplasty/canthopexy/canthoplasty
          • Breast reconstruction/breast enlargement
          • Breast reduction/mammoplasty
          • Cervicoplasty
          • Chemical peels
          • Cosmetic procedures (see EmblemHealth’s cosmetic surgery procedures medical policy located in Clinical Corner under Provider Resources)
          • Excision of excessive skin due to weight loss
          • Gastroplasty/gastric bypass
          • Gender reassignment surgery
          • Hair transplant
          • Injection of filling material
          • Lipectomy or excess fat removal
          • Otoplasty
          • Pectus excavatum repair
          • Rhinoplasty/rhytidectomy
          • Surgical treatment of gynecomastia
          • Sclerotherapy or surgery for varicose veins
        • Outpatient cardiac and pulmonary rehabilitation
        • Nonemergent services when rendered by nonparticipating providers in accordance with the member’s benefit plan
        • All procedures considered experimental and investigational (see the EmblemHealth Medical Technologies Database located in Clinical Corner under Provider Resources)
        • All home health care services, including home uterine monitoring, home hospice and home sleep study services
        • Home infusion therapy
        • Some types of durable medical equipment (DME; see code list for services that require prior approval).
        • Dental implants and oral appliances
        • Elective (nonemergent) transportation by ambulance, ambulette or medical van, and all transfers via air ambulance (see the Medical Transportation Procedures chapter)
        • Genetic testing, including:
          • BRCA 1 and BRCA 2 Genetic/BRAC Analysis Rearrangement Testing (BART)
          • Genetic testing for colorectal cancer
          • Genetic testing for long QT syndrome
          • Genetic testing - BRAC Analysis Rearrangement Testing (BART)
          • Genetic testing - comparative genomic hybridization (CGH) microarray for chromosomal imbalance (various manufacturers)
          • Genetic testing - cystic fibrosis
          • Genetic testing - familial hypertrophic cardiomyopathy
          • Genetic testing - KRAS sequence variant analysis for predicting response to colorectal cancer drug therapy
        • Assisted reproductive infertility treatments, including pre-implantation genetic testing
        • All major organ transplant evaluations and transplants, including but not limited to kidney, liver, heart, lung and pancreas and bone marrow replacement, and stem cell transfer after high-dose chemotherapy
        • Services covered by vendor-administered utilization programs, which may require prior approval. See Prior Approval Requests for Vendor-Administered Utilization Management Programs for services and entities responsible for authorizing services.

        * Prior approval is not required for emergency admissions. However, EmblemHealth must be notified within 24 hours. The services will be reviewed for medical necessity following notification and submission of clinical information.

        Services That Require Prior Approval for EmblemHealth EPO/PPO

        • All non-emergency inpatient hospital admissions (acute, rehabilitation, behavioral health and skilled nursing facility care)
        • Assistant surgeon (does not apply to Medicare members). Prior approval should be requested at the time the surgery is authorized to determine the necessity of the request.
        • Services and procedures provided in an ambulatory or outpatient surgery center. For exceptions, effective July 1, 2016, see Services That Do Not Require Prior Approval.
        • Air ambulance
        • Land ambulance (non-emergent)
        • Ambulette
        • Diagnostic heart catheterization (contact eviCore at 1-800-835-7064)
        • Durable medical equipment (customized1 or rental2 ) (See the Durable Medical Equipment chapter for more information.) Note: Prior approval required only for DME in excess of $2,000 ($500 for Medicare Advantage)
        • Home health care (nursing, PT, OT, ST, home infusion therapy)
        • Hospice (covered under Medicaid Managed Care and traditional Medicare). Prior approval requirement does not apply to Medicare Advantage.
        • Hyperbaric oxygen therapy
        • Lymphedema therapy
        • Midwifery services
        • Neuropsychological and psychological testing
        • Outpatient cardiac and pulmonary rehabilitation
        • Podiatry procedures (hammer toe repair, hallux valgas correction, excision of Morton's neuroma, resection of calcaneal spur/plantar fasciotomy, resection of Haglunds deformity)
        • Radiation therapy (see the Radiation Therapy Program chapter for more information)
        • Skilled nursing facility admissions
        • Sleep studies
        • Sub-acute behavioral health services (partial hospitalization, ambulatory detoxification, outpatient electroconvulsive therapy)
        • Transplant evaluation and services
        • Services covered by vendor-administered utilization programs, which may require prior approval. See Prior Approval Requests for Vendor-Administered Utilization Management Programs for services and entities responsible for authorizing services.

        1Any prosthetic, orthotic or equipment that must be designed and built to meet the specific needs of a patient (e.g., power wheelchairs, braces, prosthetic limbs). Please note that mastectomy supplies (HCPCS codes L8000, L8001, L8010 and L8030) do not require prior approval.

        2Any equipment intended for short-term home use (e.g., oxygen and its delivery devices, hospital beds, wheelchairs and scooters). In general, Medicare coverage rules apply.

         

        Prior Approval Requests for Vendor-Administered Utilization Management Programs

        EmblemHealth has engaged a number of vendors to conduct utilization management for certain segments of our member populations. Full descriptions may be found in the following chapters:

        If a member is not covered by the vendor program, prior approval must be obtained from the managing entity indicated on the member’s ID card or on our website.

        Prior Approval for Procedures, Supplies and Drugs for Erectile Dysfunction Treatment

        In May 2005, the NYSDOH suspended all coverage for erectile dysfunction (ED) prescription drugs for the Medicaid and Healthy New York programs, as well as for direct pay members.

        Effective February 1, 2006, health plans were required to employ procedures attendant to legislation to exclude from coverage procedures and supplies for the treatment of ED for sex offenders enrolled in Medicaid. No guidance has been received from the New York State Department of Financial Services (NYSDFS) on how the ED ban will be implemented for the Healthy New York program or direct pay members.

        Medicaid members may be prescribed ED drugs approved by the FDA for the treatment of non-ED-related conditions. In these cases, use of ED drugs may be approved, but only if:

        1. The member is not on the Sex Offender Registry
        2. The Prior Approval Request outlined below is followed

        The NYSDOH created a prior approval program for Medicaid members for the provision of ED procedures and supplies, so that the member's eligibility can be confirmed. The physician must submit a prior approval request to EmblemHealth or to the entity listed on the back of the member's ID card for the excluded ED services. A prior approval clinical manager or a designated prior approval nurse will send an inquiry to the NYSDOH for confirmation of the member's eligibility to receive the requested procedures and supplies.

        If the NYSDOH response acknowledges the member's eligibility, the request will be reviewed for medical necessity. If appropriate, a physician's prior approval (PPA) number is issued. Once the physician has obtained prior approval, the member can obtain the service requested. If the request is denied because it is deemed medically unnecessary, a medical necessity denial letter will be sent to the physician/member.

        If the NYSDOH response acknowledges that the member is not eligible for coverage, the case will be denied as "not a covered benefit" and the physician/member will receive a benefit denial letter. The practitioner/member has the right to appeal and the right to request a fair hearing and an external appeal if the service request is denied for any reason.

        Go to the NYSDOH's website to obtain more information regarding the procedures that require prior approval.

        Prior Approval for Anticipated Care of Maternity Patients

        The OB/GYN physician's office must notify EmblemHealth's Prior Authorization department or the managing entity listed on the member's ID card of the estimated date of confinement (EDC) of maternity patients after the first prenatal visit so a prior approval can be recorded. This notification is the responsibility of the OB/GYN physician's office. Once the member has delivered, it is the facility's responsibility to notify the plan or the managing entity of the actual delivery.

        It is the responsibility of the admitting facility to notify the plan of all emergency admissions.

        Prior Approval for Midwifery Services

        The services of a midwife are covered for all our benefit plans. Prior approval is required for all HIP, CompreHealth EPO, Medicare HMO and GHI HMO lines of business. For GHI PPO, EmblemHealth EPO/PPO, ConsumerDirect and InBalance plans, Vytra ASO plans and the Vytra plan for the City of New York, prior approval is only required if the midwife is not a plan participant.

        Note: If a provider and a midwife bill for the same services on the same date(s), only the first claim submitted will be adjudicated and the second claim will be treated as a duplicate submission. See Midwifery Services in the Credentialing chapter.

        Additional Prior Approval Procedures for GHI Practitioners

        Where possible, prior approval requests should be made on the secure provider website at www.emblemhealth.com; otherwise, the written request must document needed identification information. Depending on the complexity of the request, clinical information sufficient to make a medical necessity determination should be documented. In most cases, a copy of a recent office note or consultation summarizing the medical needs of your patient will help us rapidly process the request. Information that can facilitate prior approval determinations includes the following elements, as relevant to each individual case:

        • Patient characteristics such as age, gender, height, weight, vital signs or other historical and physical findings pertinent to the condition proposed for treatment
        • Precise information confirming the diagnosis or indication for the proposed medical service
        • Details of treatment for the index condition, or any related condition, including names, doses and duration of treatment for pharmacotherapy, and/or detailed surgical notes for surgical therapy
        • Appropriate laboratory or radiology results
        • Office or consultation notes related to the proposed medical service
        • Peer-reviewed medical literature, national guidelines or consensus statements of relevant expert panels
        • Applicable CPT-4 and ICD diagnosis codes
        • Complete facility and service information

        Note: ICD-10 diagnosis codes were implemented in our systems effective October 1, 2015.

        Services That Do Not Require Prior Approval - Effective July 1, 2016

        CPT Codes That Do Not Require Prior Approval - Effective July 1, 2016
        CPT Code CPT Description Place of Service (POS)*
        01992  anesth n block/inj prone  11, 22, 24 
        10021  fna w/o image  22, 24 
        11980 implant hormone pellet(s) 11
        14040  tis trnfr f/c/c/m/n/a/g/h/f  22, 24 
        14041 tis trnfr f/c/c/m/n/a/g/h/f  21, 22, 24
        17311  mohs 1 stage h/n/hf/g  22, 24 
        19120 removal of breast lesion  22, 24
        19301 partial mastectomy  21, 22, 24 
        19302  p-mastectomy w/ln removal  21, 22, 24
        19303  mast simple complete  21, 22, 24  
        21556  exc neck tum deep < 5 cm  22, 24 
        25111  remove wrist tendon lesion  22, 24
        26055  incise finger tendon sheath  22, 24 
        29540  strapping of ankle and/or ft  11, 22, 24 
        29806  shoulder arthroscopy/surgery  22, 24 
        29807  shoulder arthroscopy/surgery  22, 24 
        29823  shoulder arthroscopy/surgery  22, 24 
        29824  shoulder arthroscopy/surgery  22, 24 
        29826  shoulder arthroscopy/surgery  22, 24 
        29827  arthroscop rotator cuff repr  22, 24 
        29866  autgrft implnt knee w/scope  22, 24 
        29877  knee arthroscopy/surgery  22, 24 
        29880  knee arthroscopy/surgery  22, 24 
        29888  knee arthroscopy/surgery  22, 24 
        30140  resect inferior turbinate  22, 24 
        30802  ablate inf turbinate submuc  22, 24 
        31255  removal of ethmoid sinus  22, 24 
        31541  larynscop w/tumr exc + scope  11, 22, 24 
        31575  diagnostic laryngoscopy  11, 22, 24 
        31620  endobronchial us add-on  21, 22, 24 
        31622  dx bronchoscope/wash  22, 24 
        31625  bronchoscopy w/biopsy(s)  11, 22, 24 
        31628  bronchoscopy/lung bx each  22, 24 
        32405  percut bx lung/mediastinum  21, 22, 24
        36216 place catheter in artery  22, 24 
        36245  ins cath abd/l-ext art 1st  22, 24 
        36247  ins cath abd/l-ext art 3rd  22, 24 
        36415  routine venipuncture  11, 22, 24 
        36569  insert picc cath  22, 24 
        36589  removal tunneled cv cath  22, 24 
        36590  removal tunneled cv cath 22, 24 
        37210  embolization uterine fibroid  22, 24
        37221  iliac revasc w/stent  22, 24
        37224  fem/popl revas w/tla  22, 24
        37225  fem/popl revas w/ather  22, 24
        37226  fem/popl revasc w/stent  22, 24
        37227  fem/popl revasc stnt & ather  22, 24
        38220  bone marrow aspiration  11, 22, 24 
        38221  bone marrow biopsy 11, 22, 24 
        38510  biopsy/removal lymph nodes  22, 24
        38525  biopsy/removal lymph nodes  22, 24 
        38792  ra tracer id of sentinl node  22, 24 
        38900  io map of sent lymph node  22, 24
        42826  removal of tonsils  22, 24 
        42830  removal of adenoids  22, 24 
        43774  lap rmvl gastr adj all parts  22, 24
        45990  surg dx exam anorectal  11, 22, 24 
        46260  remove in/ex hem groups 2+  22, 24 
        47000  needle biopsy of liver  22, 24 
        47562  laparoscopic cholecystectomy  22, 24 
        47563  laparo cholecystectomy/graph  22, 24 
        49320  diag laparo separate proc  22, 24 
        49505  prp i/hern init reduc >5 yr  22, 24 
        49560  rpr ventral hern init reduc  22, 24 
        49568  hernia repair w/mesh  22, 24 
        49585  rpr umbil hern reduc > 5 yr  22, 24 
        49650  lap ing hernia repair init  22, 24 
        49652  lap vent/abd hernia repair  22, 24
        50200  renal biopsy perq  22, 24 
        50590  fragmenting of kidney stone  22, 24 
        51600  injection for bladder x-ray  22, 24 
        51701  insert bladder catheter  22, 24
        51728  cystometrogram w/vp  22, 24 
        51729  cystometrogram w/vp&up  22, 24 
        51741  electro-uroflowmetry first  22, 24 
        51798  us urine capacity measure  11, 22, 24 
        52000  cystoscopy  22, 24 
        52005  cystoscopy & ureter catheter  22, 24 
        52204  cystoscopy w/biopsy(s)  22, 24 
        52240  cystoscopy and treatment  22, 24 
        52310  cystoscopy and treatment  22, 24 
        52332  cystoscopy and treatment  22, 24 
        52351  cystouretero & or pyeloscope  22, 24 
        52353  cystouretero w/lithotripsy   22, 24
        54161  circum 28 days or older  22, 24 
        54512  excise lesion testis  22, 24
        54640  suspension of testis  22, 24
        55040  removal of hydrocele  22, 24
        55250  removal of sperm duct(s) 22, 24 
        55530  revise spermatic cord veins  22, 24 
        55700  biopsy of prostate  22, 24
        56820  exam of vulva w/scope  11, 22, 24 
        57288 repair bladder defect 22, 24
        57454  bx/curett of cervix w/scope  11, 22, 24 
        57505  endocervical curettage  11, 22, 24 
        57522  conization of cervix  11, 22, 24 
        58100  biopsy of uterus lining  11, 22, 24 
        58120  dilation and curettage  22, 24 
        58340  catheter for hysterography  22, 24 
        58350 reopen fallopian tube 22, 24
        58353  endometr ablate thermal  22, 24 
        58558  hysteroscopy biopsy  22, 24 
        58561  hysteroscopy remove myoma  22, 24 
        58563  hysteroscopy ablation  22, 24 
        58565  hysteroscopy sterilization  22, 24 
        58661  laparoscopy remove adnexa  22, 24 
        58662  laparoscopy excise lesions  22, 24
        58670  laparoscopy tubal cautery  22, 24
        58671  laparoscopy tubal block  22, 24
        58925  removal of ovarian cyst(s)  22, 24
        59015  chorion biopsy  22, 24 
        59400  obstetrical care  11 
        59840  abortion  22, 24 
        59841  abortion  22, 24 
        60100  biopsy of thyroid  22, 24 
        60240  removal of thyroid  22, 24 
        61782  scan proc cranial extra  22, 24 
        62270  spinal fluid tap diagnostic  22, 24 
        63030  low back disk surgery  22, 24 
        64613  destroy nerve neck muscle  22, 24
        64708  revise arm/leg nerve  22, 24
        64721  carpal tunnel surgery  22, 24
        64727  internal nerve revision  22, 24
        65756  corneal trnspl endothelial  22, 24
        65757  prep corneal endo allograft  22, 24
        65875  incise inner eye adhesions  22, 24
        66180  implant eye shunt  22, 24
        66821  after cataract laser surgery  22, 24 
        66830  removal of lens lesion  22, 24 
        66982  cataract surgery complex  22, 24 
        67255  reinforce/graft eye wall  22, 24
        67312  revise two eye muscles  22, 24
        67314  revise eye muscle  22, 24
        67318  revise eye muscle(s)  22, 24
        67320  revise eye muscle(s) add-on  22, 24
        68700  repair tear ducts  22, 24
        68815  probe nasolacrimal duct  11, 22, 24
        69436  create eardrum opening  11, 22, 24 
        69990  microsurgery add-on  21, 22, 24
        92018 new eye exam & treatment  11, 22 
        92133  cmptr ophth img optic nerve  11, 22 
        92134  cptr ophth dx img post segmt  11, 22 
        92526  oral function therapy  11, 22 
        92550  tympanometry & reflex thresh  11, 22 
        92570  acoustic immitance testing  11, 22 
        92626  eval aud rehab status  11, 22
        92960  cardioversion electric ext  22, 24 
        92980  insert intracoronary stent  22, 24 
        93000  electrocardiogram complete  11, 22, 24 
        93015  cardiovascular stress test  11, 22, 24 
        93227  ecg monit/reprt up to 48 hrs  11, 22, 24 
        93451 right heart cath  22, 24 
        93452  left hrt cath w/ventrclgrphy  22, 24 
        93459  l hrt art/grft angio  22, 24 
        93460  r&l hrt art/ventricle angio  22, 24 
        93650  ablate heart dysrhythm focus  22, 24
        93651  ablate heart dysrhythm focus  22, 24 
        93652  ablate heart dysrhythm focus  22, 24
        93660  tilt table evaluation  22, 24 
        93662  intracardiac ecg (ice)  22, 24
        93886  intracranial complete study  11 ,22, 24 
        93926  lower extremity study  11, 22, 24 
        93976  vascular study  11, 22, 24 
        93978  vascular study  11, 22, 24 
        93980  penile vascular study  11, 22, 24 
        94375  respiratory flow volume loop  11, 22, 24 
        94690  exhaled air analysis  11, 12 
        94727  pulm function test by gas  11, 22, 24
        96365  ther/proph/diag iv inf init  11, 22, 24 
        96415  chemo iv infusion addl hr  11, 22, 24 
        97010  hot or cold packs therapy  11, 22, 24 
        G0108  Diab manage trn  per indiv  11 
        G0268  Removal of impacted wax md  11, 22, 24 
        G0289 Arthro, loose body + chondro  22, 24 

        *POS 11 = Office; POS 12 = Home; POS 21 = Inpatient hospital; POS 22 = Outpatient hospital; POS 24 = Ambulatory surgical center

        Other Services That Do Not Require Prior Approval

        • Mastectomy supplies

        The following services performed in a provider office or outpatient facility. (Place of Service: Office [11], outpatient [22] and ambulatory surgery center [24]). Referral rules for initial specialty care office visits still apply for those members whose plan requires a referral:

        • Endoscopy (CPT codes 43200-43232; 43234-43272; 44360-45392).
          Note: Capsule endoscopy (CPT code 91110) does require prior approval.
        • Colonoscopy (CPT codes 44391-44393; 45378-45380; 45382-45385).
          Note: Virtual colonoscopy HCPCS codes 0066T and 0067T do require prior approval.
        • Dilated eye exam for EmblemHealth Medicaid members.
          Note: Effective January 1, 2009, Medicaid members diagnosed with diabetes may self-refer (i.e., no prior approval or referral is required) to any network provider of vision services (an optometrist or ophthalmologist) for a dilated eye (retinal) exam once in any 12-month period.
        • Emergency hospital admissions.
        • Emergency services.
        • Services provided when EmblemHealth is the secondary insurer.
        • Pulmonary perfusion imaging.
        • Services that do not require prior approval but may require a referral from the member's PCP (e.g., basic X-rays, mammograms and bone density tests).
        • Office/outpatient physical and occupational therapy initial visit(s). For GHI HMO members, an initial physical therapy referral for the first six visits from the PCP is required. For HIP fee-for-service members, a referral is needed for the initial evaluation visit. All additional visit requests for these services should be faxed to Palladian at 1-716-712-2817.

          How To Obtain a Prior Approval

          All providers must verify member eligibility and benefits prior to rendering non-emergency services. 
          How to Obtain Prior Approval
          Plan/Managing Entity Instructions

          HIP

          Requests may be submitted via the EmblemHealth website, www.emblemhealth.com, or faxed to 1-866-426-1509 for DME requests or 1-866-215-2928 for all other requests.

          Call 1-866-447-9717 for more information or to use the IVR system.

          Hospitals and skilled nursing facilities can verify prior approval status by reviewing their concurrent review status reports.

          EmblemHealth EPO/PPO (GHI)

          Requests may be submitted via the EmblemHealth website, www.emblemhealth.com, faxed to 1-212-563-8391, or by calling the Coordinated Care Intake department at 1-800-223-9870.

          See Additional Prior Approval Procedures for GHI Practitioners for more information.

          Medicare PPO (GHI)

          Requests may be submitted via the EmblemHealth website, www.emblemhealth.com or faxed to 1-877-508-2643.

          Call 1-866-557-7300 for more information or to use the IVR system.

          For questions regarding the status of a request submitted or the prior approval process, call Customer Service at 1-877-244-4466.

          See Additional Prior Approval Procedures for GHI Practitioners for more information.

          HealthCare Partners

          Call 1-800-877-7587 or fax your request to 1-888-746-6433.

          Montefiore CMO

          Call 1-888-666-8326.

          For behavioral health services, call 1-800-401-4822.

          Vytra Health Plan

          Call 1-888-288-9872.

          Prior approval requirements and procedures may be different for Vytra ASO accounts, so please contact the administrator listed on the Vytra member's ID card for more information.

          Behavioral Health Services

          Emblem Behavioral Health Services Program (For members in plans underwritten by HIP or HIPIC or administered by VHMS)

          Requests may be submitted via the ValueOptions Provider Connect website, https://www.valueoptions.com/pc/eProvider/providerLogin.do or by calling ValueOptions at 1-888-447-2526.

          EmblemHealth Behavioral Management Program (For members in plans underwritten by GHI)

          Requests may be submitted via the ValueOptions Provider Connect website, https://www.valueoptions.com/pc/eProvider/providerLogin.do or by calling ValueOptions at 1-800-692-2489.

          Montefiore (For members who have the Montefiore logo on the lower left corner of their ID card)

          Requests may be submitted by calling University Behavioral Associates (UBA) at 1-800-401-4822.

          Cardiology and Radiology Services

          eviCore

          Radiology

          Cardiology

          Requests may be submitted via the eviCore National website, www.evicore.com, or by calling 1-866-417-2345 (for HIP and CompreHealth EPO members) or 1-800-835-7064 (for GHI HMO and EmblemHealth EPO/PPO members)
          Chiropractic Services

          All EmblemHealth plans

          Requests may be submitted via the Palladian website, www.palladianhealth.com, by calling 1-877-774-7693 or faxed to 1-716-809-8324.

          Outpatient Physical and Occupational Therapy

          HIP

          Requests may be sumbitted via the Palladian website, www.palladianhealth.com, by calling 1-877-774-7693, or faxed to 1-716-809-8324.

          Pharmacy Services
          EmblemHealth Pharmacy Benefit Services

          Call 1-877-362-5670, Monday through Friday, 8 am to 6 pm.

          ICORE

          Requests may be submitted by calling 1-888-447-0295.

          EmblemHealth Injectable Drug Utilization Management Program - began June 1, 2012

          Requests may be submitted via the ICORE website, www.icorehealthcare.com, by calling 1-800-424-4084, Monday through Friday, 8 am to 6 pm, or faxed to 1-716-809-8324.

          Submit both the prior approval request and the replacement drug order from ICORE by using the appropriate fax form available at www.emblemhealth.com/~/media/Files/PDF/ICORE_FaxOrderFrms_COMBO1.pdf.

          Specialty Pharmacy Program

          Requests may be submitted by calling 1-888-447-0295, Monday through Friday, 8:30 am to 5 pm or faxed to 1-877-243-4812.

          Radiology Services

          See the Radiology Program and Cardiology Imaging Program chapters.


          Referrals and Elective Hospital Prior Approvals By Plan

          The following table indicates which types of benefit plans require referrals and hospital prior approvals, except in emergency situations:

          Referrals and Elective Hospital Prior Approvals by Plan
          Type of Plan Benefits Available Referral Required? Elective Hospital Prior Approval Required?

          Access I

          Network only

          No

          Yes

          Access II

          Network and out-of-network

          No, No

          Yes, Yes

          Prime POS

          Network and out-of- network

          Yes, No

          Yes, Yes

          EPO (i.e., Prime EPO/ Select EPO, CompreHealth EPO)

          Network only

          No

          Yes

          Prime HMO/ GHI HMO/ Select Care (HMO Plans)

          Network only

          Yes

          Yes

          Medicaid (Including Child Health Plus)

          Network only

          Yes

          Yes

          Medicare HMO

          Network only

          Yes

          Yes

          Medicare PPO

          Network and out-of-network

          No, No

          Yes, Yes

          GHI PPO

          Network and out-of-network

          No, No

          Yes, Yes

          Prime PPO/ Select PPO

          Network and out-of-network

          No, No

          Yes, Yes

          Vytra ASO clients

          Network and out-of-network

          Check with ASO administrator

          Check with ASO administrator

          Out-of-network services that receive prior approval may be subject to a deductible and coinsurance, depending on the member's contract or benefit plan. If a prior approval is not obtained, there may also be a penalty reduction of benefits up to 50 percent depending on the member's contract or benefit plan.

          Services Requiring Pre-Certification for GHI PPO City of New York Employee and Non-Medicare Eligible Retirees with GHI PPO Benefits

          Beginning January 1, 2016, many services provided on an inpatient and outpatient basis will now require precertification. This can be done by calling the NYC Healthline at 1-800-521-9574. This is the same number you have always called for inpatient precertification and is on your ID card.

          Services Requiring Pre-Certification
          Services Precertification
          Required
          Yes / No

          Inpatient Facility

          Yes
          Contact Beacon Health at
          1-800-692-2489

          Inpatient Psychiatric & Substance Abuse Facility

          Yes

          Maternity-Pregnancy & Delivery

          • Stays under 48 hours normal delivery, 96 hours C-Section requires notification only
          • Over 48/96 hours requires pre-certification

          Yes

          NICU Admission

          Yes

          Acute Inpatient Rehabilitation

          NOTE: This benefit is part of the Skilled Nursing Facility (SNF) benefit. 1 day in an acute inpatient rehabilitation bed = 2 days in a SNF. 30 days in an acute inpatient rehab is equal to 60 SNF days. Therefore, the SNF benefit remaining would only be 30.

          Yes

          Skilled Nursing Facility (SNF)

          NOTE: NYC Healthline can choose to substitute outpatient benefits for SNF days. The formula used is 2 ½ outpatient visits = 1 inpatient SNF day. Only NYC Healthline can authorize substitution of benefits. No outpatient benefits are available under this benefit if no pre-certification is received.

          Yes

          Outpatient hospital or free-standing ambulatory surgery facility (not in a doctor's office)

          • Includes possible/cosmetic procedures, reconstruction, outpatient transplants, optical/vision related procedures, breast reconstruction, cochlear implants, functional endoscopy/nasal surgery, joint replacements, experimental/investigational procedures, hyperbaric O2 chamber, infertility with underlying condition, pain management, spinal stimulatory implants, wound vac, bariatric surgery and spinal surgery
          • See list of all codes requiring precertification for Ambulatory Surgery

          Yes

          Infertility services, including artificial insemination and IVF

          • Precertification required when in the MD office, outpatient facility or free standing facility

          Yes

          Physical Therapy Outpatient

          NOTE: after 16 visits, needs authorization

          Yes

          Outpatient speech therapy

          NOTE: after 16 visits, needs authorization

          Yes

          Occupational Therapy Outpatient

          Not covered, except as part of the home care services benefit

          DME (Par and Non-Par)
          Examples-Not limited to the following:

          • Electric Beds
          • Wheelchairs

          Yes
          When the charge for DME equals or exceeds $2,000

          Prosthetics (Par and Non-Par)

          Yes

          Specialty Drugs (non-self injectables) in office or outpatient facility

          • See list of all codes requiring precertification for Non-Self-Injectables

          Yes

          Dialysis

          Pre-cert for network status and place of service only as dialysis is a NYS Mandate

          Radiation Therapy

          Yes

          Cardiac Rehabilitation Outpatient

          Yes

          Air Ambulance (scheduled only)

          Yes

          Genetic Testing

          Yes

          The following services continue to require precertification by EmblemHealth.
          Providers should call 1-800-223-9870 for precertification.

          Home Health Care

          Yes

          Home Infusion Therapy (billed by a home infusion specialist)

          Yes

          MRI/MRA/PET/CAT/
          NUCLEAR CARDIOLOGY/

          Yes

          Nutritional Supplements and Enteral Formulas

          Yes

          My Subscriptions

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

          Submit
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          Glossary terms found on this page:

          An activity of EmblemHealth or its subcontractor that results in:

          • Denial or limited authorization of a service authorization request, including the type or level of service
          • Reduction, suspension or termination of a previously authorized service
          • Denial, in whole or in part, of payment for a service
          • Failure to provide services in a timely manner
          • Failure of EmblemHealth to act within the time frames for resolution and notification of determinations regarding complaints, action appeals and complaint appeals

          Formal acceptance as an inpatient by an institution, hospital or health care facility.

          Surgical procedures performed that do not require an overnight hospital stay. Procedures can be performed in a hospital or a licensed surgical center. Also called Outpatient Surgery.

          Oral or written request from a member or their designee for EmblemHealth to review or reconsider a decision made by the plan.

          An agreement in which a patient assigns to another party, usually a physician or hospital, the right to receive payment from a public or private insurance program for the service the patient has received.

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

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

          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).

          When the maximum number of visits for a specific service is reached, further benefits will not be considered.

          A process in which an individual, an institution or educational program is evaluated and recognized as meeting certain predetermined standards. Certification usually applies to individuals; accreditation usually applies to institutions.

          Treatment of malignant disease by chemical or biological antineoplastic agents.

          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.

          A percentage of the allowed charge that is payable by the member, not EmblemHealth, for covered services rendered by an out-of-network provider. After the member has met his or her deductible, EmblemHealth will pay a percentage of the allowed charge for those covered services in accordance with the member's benefit program. The member is responsible to pay the remaining percentage of the allowed charge. This remaining percentage is the coinsurance charge.

          Services rendered by a physician whose opinion or advice is requested by another physician for further evaluation or management of the patient.

          An individual person who is the direct or indirect recipient of the services of the organization. Depending on the context, consumers may be identified by different names, such as "member," "enrollee," "beneficiary" or "patient." A consumer relationship may exist even in cases where there is not a direct relationship between the consumer and the organization. For example, if an individual is a member of a health plan that relies on the services of a utilization management organization, then the individual is a consumer of the utilization management organization.

          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.

          The date on which a service was rendered.

          A portion of eligible expenses that an individual or family must pay during a calendar year before EmblemHealth will begin to pay benefits for covered services.

          Any medically determinable physical or mental impairment that can be expected to result in death or that has lasted or can be expected to last for a continuous period of not less than 12 months and renders the member unable to engage in any substantial gainful activities.

          Any medically determinable physical or mental impairment that can be expected to result in death or has lasted or can be expected to last for a continuous period of not less than 12 months and renders the member unable to engage in any substantial gainful activities.

          Medical equipment, goods, implements and prosthetics that are prescribed for patient care, usually in an outpatient setting. Examples of such equipment include hospital beds, wheelchairs and walkers.

          Medical equipment, goods, implements and prosthetics that are prescribed for patient care, usually in an outpatient setting. Examples of such equipment include hospital beds, wheelchairs and walkers.

          The date on which the coverage of an insurance policy goes into effect at 12:01 am.

          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.

          An individual who is enrolled and eligible for coverage under a health plan contract. Also called a member.

          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.

          Treatment, procedure, drug, biological product or medical device that has not been of proven benefit for the particular diagnosis or treatment of the particular condition or is not generally recognized by the medical community, as reflected in the published peer-reviewed medical literature, as effective or appropriate for the particular diagnosis or treatment of the particular condition.

          Written request for an independent entity that has been certified by the State to conduct a review of a denial of coverage, based on lack of medical necessity or that the service requested is experimental and investigational.

          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 payment method in which the insurer will reimburse the member or provider directly for each covered medical expense.

          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 individual who: (1) has undergone formal training in a health care field; (2) holds an associate or higher degree in a health care field, or holds a state license or state certificate in a health care field; and (3) has professional experience in providing direct patient care.

          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.

          Health care services rendered to a member in their home in lieu of confinement in a hospital or skilled nursing facility. Care must be under the supervision of a registered professional nurse. This type of care may include physical, occupational or speech therapy, medical supplies and medication prescribed by a doctor.

          The administration of intravenous drug therapy in the home. Home infusion therapy includes the following services: solutions and pharmaceutical additives; pharmacy compounding and dispensing services; durable medical equipment; ancillary medical supplies; and nursing services.

          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 inability to conceive or an inability to carry a pregnancy to a live birth after a year or more of regular sexual relations without the use of contraception.

          Treatment accomplished by placing therapeutic agents into the vein, including intravenous feeding. Such therapy also includes enteral nutrition that is the delivery of nutrients into the gastrointestinal tract by tube.

          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 condition or disease that has a high probability of death, according to the current diagnosis of the attending physician.

          Specific circumstances or services listed in the contract for which benefits will be limited.

          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.

          Any form of health plan that uses selective provider contracting to have patients seen by a network of contracted providers and that requires prior approval of certain services.

          A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.

          Professional services rendered by a physician for the treatment or diagnosis of an illness or injury.

          A doctor of medicine or doctor of osteopathic medicine who is duly licensed to practice medicine and is an employee of, or party to a contract with, a utilization management organization, and has responsibility for clinical oversight of the utilization management organization's utilization management, credentialing, quality management and other clinical functions.

          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 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. Also known as MA.

          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 network provider is a member of the EmblemHealth network of network providers applicable to the member's certificate. Therefore, they are sometimes referred to as participating providers. Payment is made directly to a network provider. Please consult the EmblemHealth Directory or go online to search for network providers.

          The state regulatory agency that certifies reimbursement methods and rates to hospitals and reviews HMO activities in the state of New York. Also called the New York State Department of Health.

          Treatment to restore a physically disabled person's ability to perform activities such as walking, eating, drinking, dressing, toileting and bathing (activities of daily living).

          The use of health care providers who have not contracted with the health plan to provide services. Depending on the member's contract, out-of-network services may not be covered.

          Reimbursement for covered services provided by out-of-network providers and suppliers. Out-of-network benefits are generally subject to a deductible and coinsurance and, therefore, have higher out-of-pocket costs. Depending on the member's contract, out-of-network services may not be covered.

          A health care provider, such as a physician, skilled nursing facility, home health agency or laboratory, that does not have an agreement with EmblemHealth plans to provide covered services to members. Also called a Non-Participating Provider.

          Surgical procedures performed that do not require an overnight stay in the hospital or ambulatory surgery facility. Such surgery can be performed in the hospital, a surgery center or physician office.

          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.

          Treatment involving physical movement to relieve pain, restore function and prevent disability following disease, injury or loss of limb.

          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 pre-existing condition is any disease, symptom or condition that was present on the first day of coverage and for which medical advice or treatment was recommended or received during the six-month period prior to the enrollment date.

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

          A written order or refill notice issued by a licensed medical professional for drugs available only through a pharmacy.

          Drugs and medications that are required by law to be dispensed by written prescriptions from a licensed physician.

          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 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.

          Treatment of disease by X-ray, radium, cobalt or high energy particle sources.

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

          New York State Department of Health. This agency provides information for consumers, doctors, researchers and health care providers.

          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.

          Treatment of the correction of a speech impairment which resulted from birth, disease, injury or prior medical treatment

          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.

          Provides managed mental health and substance abuse (MHSA) programs, workplace services, employee assistance programs (EAP), psychiatric disability management, Medicaid behavioral health management and child welfare programs for over 23 million lives. Visit the ValueOptions Web site at www.valueoptions.com.

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