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  • Care Management > Referral Procedures - Practitioners

    All services for members enrolled in benefit plans that require referrals must be provided through network practitioners and ordered by the PCP, OB/GYN, primary caregiver (qualified advanced nurse practitioner) or participating specialist to whom the member was referred for testing and treatment by the PCP or OB/GYN, with the exception of the following services. (These services do not require a referral.)

    1. Direct-access (self referral) services.
    2. Services for which members can self-refer to network providers, in accordance with their benefit plan. See Provider Networks and Member Benefit Plans chapter for more details regarding what plans require referrals.
    3. Services for which Medicaid members can self-refer to network providers, County Department of Health clinics or providers who accept their Medicaid card.
    4. Services for which members have and are using their out-of-network benefits.
    5. Services for which the applicable managing entity's prior approval is required for a member to use out-of-network providers. (For more information, please go to the Use of Out-of-Network Providers section in this chapter.)

    Referral requirements may be different depending on the member's benefit package, so please contact the managing entity listed on the member's ID card if clarification is needed.

    How To Make a Referral

    Referrals must be made to a network specialist who participates in the member's benefit plan and must include the number of recommended visits to the specialist. Specialist participation can be validated using the Provider Directory or the provider search feature, Find A Doctor, at www.vytra.com or www.emblemhealth.com, as applicable.

    How To Make a Referral for Specialty Services
    Plan/Managing Entity Instructions

    CompreHealth EPO, GHI HMO, HIP and Medicare HMO

    Enter referral request by signing in to www.emblemhealth.com.

    EmblemHealth EPO/PPO and GHI EPO/PPO

    No referral required.

    Vytra HMO

    Enter your referral request by signing in to www.vytra.com or call 1-888-288-9872.

    Referring to Physical and Occupational Therapy Practitioners

    Refer to the Physical and Occupational Therapy Program chapter.

    OB/GYNs Referring to Specialists

    Except for the types of specialists listed below, only the member's PCP may issue a referral for a specialist. OB/GYNs (e.g., gynecologists, obstetricians, obstetrician/gynecologists and nurse midwives) may refer to the following specialists:

    • Diagnostic mammography (Screening mammography does not require a referral or prior approval.*)
    • Diagnostic radiology and imaging (includes diagnostic imaging, diagnostic radiology, radiology and magnetic resonance imaging**)
    • Gynecologic oncology
    • General surgery
    • Infertility specialists
    • Lamaze (No referral is necessary for Medicaid members.)
    • Maternal and fetal medicine
    • Neonatal/perinatal medicine
    • Pediatric cardiology for fetal studies
    • Radiation oncology (includes diagnostic radiological physics, radiation oncology and therapeutic radiology)
    • Reproductive endocrinology

    *Screening mammography appointments may be made with network radiologists without a referral or prescription. Members may call participants directly to make an appointment. Go to www.emblemhealth.com/~/media/Files/PDF/Providers/Mammography_Sites.pdf to view the list of network mammography sites available to HIP and CompreHealth EPO members.

    ** Requires prior approval. Please see the How to Obtain a Prior Approval section of the Radiology Program chapter for additional information on how to obtain prior approval.

    Specialists Referring to Specialists

    When a PCP creates a referral to a specialist that includes specialty services in addition to consultation, the specialist has the authorization to refer the member for additional in network testing and services that are within the guidelines of their specialty including:

    • Chemotherapy
    • Dialysis
    • Laboratory services
    • Radiation therapy
    • Radiology*
    • Rehabilitation services (PT**/OT**/ST)
    • In the case of an emergency, as determined by the immediate treating physician.
    • If the member is an EPO or PPO plan member who can self-refer for any services within their plan's network.
    • If the member is a VIP HMO, Access I or Access II member.

    *Please see the Prior Approval Procedures section of the Radiology Program chapter for a list of services and CPT codes that require prior approval and for additional information on applicable members and managing entities.

    ** For GHI HMO members after the first six visits, and for certain HIP members after the first initial consultation visit, the servicing provider will be required to obtain a prior approval from www.palladianhealth.com. For more information, see the Physical and Occupational Therapy Program chapter.

    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.

    Referral Duration

    A referral is only valid for the specific time frame designated for the referral type requested or until the number of visits/units has been exhausted. See the following table for details.

    Referral Type Maximum # Units/Visits Duration
    EmblemHealth Medicare HMO and HIP Plans

    Allergy Testing

    12

    90 days*

    Chemotherapy

    20

    90 days*

    Consultation

    1

    180 days

    Consultation, Follow-up, Testing

    6

    180 days

    Consultation, Follow-up, Testing, Treatment

    6

    180 days

    Consultation, Follow-up, Treatment

    6

    180 days

    Diagnostic Lab/X-Ray

    1

    45 days*

    Dialysis

    13

    30 days*

    Radiation Therapy (see the Radiation Therapy Program chapter for more information)

    Varies by treatment

    Varies by treatment

    Speech Therapy

    10

    10 visits within 30 days

    GHI HMO Plans

    Most Services


    1 year

    Rehabilitation (Outpatient PT/OT)

    6 visits

    1 year

    HIP and Medicare HMO Plans in Palladian program

    Rehabilitation (Outpatient PT/OT) and Chiropractic Services

    1

    1 visit within 30 days

    HIP Plan Excluded from Palladian Program

    Rehabilitation (Outpatient PT/OT)

    8

    8 visit within 90 days

    Vytra Plans

    Most Services

    1-14 visits depending on the specialty care provider

    1 year

    Rehabilitation (PT/OT/ST)

    Determined on a case-by-case basis

    Determined on a case-by-case basis

    *Or until number of approved visits/units is exhausted.

    Consultation Reports

    All specialists are reminded to provide referring physicians with timely and informative consultation reports. This will contribute to improving the quality of care provided to our members.

    All consultation reports should be sent to the referring physician as determined by the member's physical status:

    • If emergent: A consultation report will be issued immediately following the visit by means of telephone or fax communication with the written summary mailed to the referring physician within 24 hours of the visit.
    • If urgent: A consultation report will be issued within 24 hours of the visit.
    • If routine: A consultation report will be issued within five to seven business days after the visit.

    All consultation reports will contain at least the following information:

    • Consultant's name, address and phone number
    • Specialty of consultant
    • PCP's name, address and phone number
    • Name, address and phone number of referring physician
    • Date of request and date of consultation
    • Member's demographic data (including plan ID number)
    • Urgency of the referral: emergent, urgent or routine
    • Documentation of the reason for the requested consultation
    • Complete history and physical as it pertains to the consultation
    • Documentation of all pertinent laboratory and radiographic results
    • Assessment of identified problems specific to the consultant expertise and any others included in the referring physician's report including differential diagnoses
    • Documentation of recommended plan for the completion of the consultation, if applicable
    • Documentation of recommended treatment/diagnostic plan
    • Recommendations for follow-up by the consultant if applicable

    The consultation report will be faxed back to the referring clinician at the completion of the service.

    Second Opinions

    EmblemHealth members are entitled to second opinions with network physicians as part of their covered benefit. The PCP or OB/GYN (when required by the member's plan) should provide a referral to another network physician when a second opinion is requested and deemed appropriate.

    In the event of a positive/negative diagnosis of cancer, the treating provider should coordinate with the managing entity listed on the member's ID card. Coverage for cancer care second opinions to out-of-network specialists is:

    • Limited to usual and customary charges only (For Medicare members, reimbursement is limited to the Medicare fee schedule for out-of-network specialists.)
    • Requires the specialist's agreement to accept the reimbursement rate
    • Necessitates a prior approval from the managing entity to ensure appropriate claims payment.

    Second opinion referrals are for consultation only and do not imply referral for ongoing treatment. In the event that the second opinion differs from the first, the member may opt for a third opinion. Second and third opinions are arranged in the same manner as the original referral.

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    Glossary terms found on this page:

    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.

    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).

    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.

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

    The amount customarily charged for the service by other physicians in the area (often defined as a specific percentile of all charges in the community), and the reasonable cost of services for a given patient after medical review of the case. Also called customary and reasonable (C&R) or usual, customary and reasonable (UCR).

    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.

    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 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.

    The fee determined by the insurer to be acceptable for a procedure or service that the physician agrees to accept as payment in full.

    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.

    A card which allows the subscriber to identify himself or his covered dependents to a provider for health care services.

    A unique number which identifies the member's enrollment with EmblemHealth. EmblemHealth's claims are processed by this number. Also known as Member ID Number.

    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.

    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.

    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.

    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 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.

    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.

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

    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.

    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.

    The voluntary option or mandatory requirement to visit another physician or surgeon regarding diagnosis, course of treatment or having specific types of elective surgery performed.

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

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