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  • Credentialing > Termination and Appeal

    The CRC and PRS have the authority to terminate practitioners from servicing EmblemHealth members. The committee and subcommittee make such a determination based on, in the case of the CRC, quality or credentials issues arising at recredentialing or, in the case of the PRS, complaints about quality of care. The procedures for termination and appeal are managed through our Credentialing department and apply to actions by either the CRC or PRS.

    Actions that may cause termination include, but are not limited to:

    • Engaging in acts of gross incompetence or gross negligence on a single occasion, or negligence or incompetence on more than one occasion.
    • Refusing to provide a client or patient service or medical care because of race, creed, color or national origin.
    • Practicing beyond the scope of the profession.
    • Failing to return or provide copies of records upon request.
    • Being sexually or physically abusive.
    • Abandoning or neglecting a patient in need of immediate care.
    • Performing unnecessary work or unauthorized services.
    • Practicing under the influence of alcohol or other drugs.
    • Promoting the sale of services, goods, appliances or drugs in a manner that exploits the patient.
    • Refusing to provide medical care because of race, creed, color or national origin.
    • Guaranteeing a cure.
    • Performing professional services not authorized by the patient.
    • Willfully harassing, abusing or intimidating a patient.
    • Ordering excessive tests or treatments.
    • Permitting or aiding an unlicensed person to perform activities which require a license.
    • Practicing the profession with a suspended or inactive license.
    • Revealing personally identifiable facts, data or information without consent of the patient, except as authorized or required by law.
    • Any conviction of a criminal offense related to a participating provider or that provider's managing employee involvement in any Medicare, Medicaid or Title XX services program.
    • Any provider denied credentialing for program integrity-related reasons such as being on a government program-excluded provider list and/or having existing fraud, licensing or OPMC issues.
    • Voluntary surrender or restriction of clinical privileges while under, or to avoid, investigation.
    • A finding of mental or physical impairment.
    • A finding of imminent harm to patient health, safety and welfare.
    • The voluntary or involuntary termination of a contract, employment or other affiliation to avoid the imposition of disciplinary measures.
    • Determination of fraud.
    • Determination of misconduct.
    • Releasing confidential information without authorization or as otherwise legally permitted.
    • Being convicted of a crime.
    • For other reasons, such as business decisions that are other than quality of care concerns.

    The CRC and PRS make decisions, except for termination for egregious reasons, at regularly scheduled meetings. The practitioner will receive a termination notice explaining the reasons for the proposed action, a termination date and a detailed explanation of the appeal process. Termination shall be effective no earlier than 60 days from the practitioner's receipt of the termination notice.

    Throughout the process, the CRC and PRS make every effort to ensure that the practitioner has adequate opportunity to contribute to any discussion on recredentialing or quality of care.

    Decisions of the practitioner's termination shall be effective not less than 60 days after the receipt by the practitioner of the termination notice.

    Appeal of Disciplinary Decisions

    The practitioner may appeal any formal CRC/PRS disciplinary action to a CRC Ad Hoc Appellate Board. Written notice of appeal must be sent to CRC within 30 days of receiving the termination notice. If no appeal is submitted within 30 days, the action will be reported to NPDB.

    If an appeal is requested, the practitioner will be contacted and, once a date is confirmed, will be notified by certified mail of the date and time of the appeal hearing. Said hearing shall take place no later than 30 days from the date of receipt of the provider's request for a hearing.

    The notice of hearing must be accompanied by copies of all documents, reports, cases or materials on which the Ad Hoc Appellate Board intends to rely. The practitioner may submit additional information (in writing) for consideration by the Ad Hoc Appellate Board within 30 days of filing the appeal. Additional materials must be received before the scheduled date of the hearing.

    The practitioner has the right to appear before the Ad Hoc Appellate Board through counsel.

    This hearing may be postponed only once, unless there are extenuating circumstances. If the practitioner elects to postpone the second hearing without extenuating circumstances, the Ad Hoc Appellate Board will convene as scheduled and make a decision based upon the information available.

    If the Ad Hoc Appellate Board upholds the original Committee's decision, EmblemHealth will proceed with reporting the action to appropriate regulatory agencies.

    Ad Hoc Appellate Board

    The Ad Hoc Appellate Board shall be compiled by EmblemHealth and shall contain three credentialed practitioners, at least one of whom specializes in the field appropriate to the review. The panel may consist of more than three provided that the number of clinical peers constitutes one-third or more of the total membership. Members of the CRC may serve on this board. However, no physician can vote on both an initial decision and an appeal for the same practitioner.

    The Ad Hoc Appellate Board decision may include reinstatement, provisional reinstatement with conditions set by the Board or termination. The Hearing Panel will render a decision in a timely manner. The practitioner will be notified by mail within five business days of the decision. A decision for termination shall be effective not less than 30 days after the practitioner's receipt of the Hearing Panel's decision.

    EmblemHealth will permit members to continue an on-going course of treatment for a transition period of up to ninety (90) days, and post-partum care, subject to the provider's agreement, pursuant to PHL §4403(6)(e).

    Termination For Egregious Reasons

    EmblemHealth can initiate an immediate termination in the event of:

    • Knowledge of a member's imminent harm by a clinician.
    • Determination of fraud by EmblemHealth's Special Investigations Unit (SIU).
    • Action by the NYSOPMC or other recognized regulatory agency, such as license suspension or revocation, or CMS sanction.

    A termination for any of the above reasons is reported to the NPDB and is not eligible for a hearing or a review.

    EmblemHealth will immediately remove any provider from the network who is unable to provide health care services due to a disciplinary action.

    Practitioner's Rights

    We recognize that practitioners have the following rights which may not justify termination or decredentialing:

    • To advocate on behalf of our members.
    • To file a complaint against EmblemHealth.
    • To appeal any decision made by EmblemHealth.
    • To provide information or file a report to PHL § 4406-c regarding prohibitions made by EmblemHealth.
    • To request a hearing or review.

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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.

    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.

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

    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.

    A permit (or equivalent) to practice medicine or a health profession that is: 1) issued by any state or jurisdiction in the United States and 2) required for the performance of job functions.

    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 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 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 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 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.

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