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  • Credentialing > Reporting To Outside Agencies

    In the event that a practitioner is de-credentialed for quality issues by the CRC, the Recredentialing Committee or an Ad Hoc Appellate Board, EmblemHealth is required by law to report such misconduct to the appropriate data collection service(s). Reporting shall occur within 30 days from the decision date, unless the practitioner requests an appeal.

    Reportable Actions

    Actions reportable to the National Practitioners Data Bank (NPDB) include:

    • Any professional review based on reasons related to professional competence or conduct which adversely affects EmblemHealth participation for a period longer than 30 days.
    • Voluntary surrender or restriction of clinical privileges while under, or to avoid, investigation.

    Actions reportable to the Healthcare Integrity and Protection Data Bank (HIPDB) include:

    • Health care related civil judgments entered in federal or state court.
    • Any other adjudicated actions or decisions that the CMS Secretary shall establish by regulation.

    Actions reportable to the applicable state office with oversight of professional conduct, e.g., New York State Office of Professional Medical Conduct (NYSOPMC) includes:

    • Termination of credentials based upon member complaints or peer review findings.

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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

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

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

    Initial oral or written communication from a member or their designee or provider that expresses discontent with any aspect of their care or coverage with EmblemHealth. Specifically, it is dissatisfaction with:

    • A determination made by the plan, other than a determination of medical necessity or a determination that a service is considered experimental or investigational
    • Treatment experienced through the plan, its providers or contractors
    • Any concern with the plan, its benefits, employees or providers.

    A health care benefit arrangement that is similar to a preferred provider organization in administration, structure and operation but does not cover out-of-network care. Also called an Exclusive Provider Organization.

    An organization 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.

    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.

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