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  • Care Management > Utilization Management Process and Policy

    Utilization Management Decision Making

    For clinical decision making, we utilize nationally recognized criteria (including InterQual) and evidence-based guidelines, such as our medical policies (provided in Clinical Corner at www.emblemhealth.com/providers/provider-resources/clinical-corner) and CMS guidelines. The Quality Improvement/Utilization Management Committee (QIUMC) reviews our utilization management criteria and medical policies annually. Guidelines and policies are available for review upon request.

    Utilization review determinations for medical appropriateness are made by evaluating information from the requesting physician, the member's medical record, consultations and relevant laboratory and radiological information. All adverse determinations are made by a medical director. When applicable, the reviewing medical director will consult with another physician who is in the same or similar specialty as the health care provider who would typically manage the medical condition, procedure or treatment that is under review.

    Medical Appropriateness Review

    The purpose of medical appropriateness review is to ensure that:

    • All inpatient and outpatient care is medically necessary
    • All care occurs in the appropriate setting
    • Services and treatment are ordered and provided, whenever possible, by network providers

      Serious Medical Conditions

      As stated in the participating provider agreements, the provider acknowledges that we have procedures to identify, assess and establish treatment plans for individuals with complex or serious medical conditions. In signing their contracts, providers agree to comply with all applicable EmblemHealth administrative guidelines, including the policies and procedures.

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      Glossary terms found on this page:

      A determination by EmblemHealth or its agents that an admission, extension of stay or other health care service has been reviewed and, based on the information provided, is not medically necessary.

      A decision about the patient's medical treatment.

      The government agency responsible for administering the Medicare and Medicaid programs.

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

      A legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.

      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.

      Service provided after the patient is admitted to the hospital. Inpatient stays are those lasting 24 hours or more.

      An organization comprised of individual physicians or physicians in group practices that contracts with the managed care organization on behalf of its member physicians to provide health care services. Also called an Independent Practice Association.

      Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

      A 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.

      Health care that is rendered by a hospital or a licensed or certified provider and is determined by EmblemHealth to meet all of the criteria listed below:

      • It is provided for the diagnosis or direct care or treatment of the condition, illness, disease, injury or ailment.
      • It is consistent with the symptoms or proper diagnosis and treatment of the medical condition, disease, injury or ailment.
      • It is in accordance with accepted standards of good medical practice in the community.
      • It is furnished in a setting commensurate with the member's medical needs and condition.
      • It cannot be omitted under the standards referenced above.
      • It is not in excess of the care indicated by generally accepted standards of good medical practice in the community.
      • It is not furnished primarily for the convenience of the member, the member's family or the provider.
      • In the case of a hospitalization, the care cannot be rendered safely or adequately on an outpatient basis or in a less intensive treatment setting and, therefore, requires the member receive acute care as a bed patient.

      The fact that a provider has prescribed a service or supplies care does not automatically mean the service or supply will qualify for reimbursement under the EmblemHealth plan. To be eligible for reimbursement by EmblemHealth, all covered services must meet EmblemHealth's medical necessity criteria, described above.

      Medically necessary with respect to Medicaid and Family Health Plus members means health care and services that are necessary to prevent, diagnose, manage or treat conditions that cause acute suffering, endanger life, result in illness or infirmity, interfere with a person's capacity for normal activity or threaten some significant handicap.

      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 that is provided to a patient who is able to return home after care without an overnight stay in a hospital or other inpatient facility

      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 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 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 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.

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