Table of Contents
Search
How Do I...

Search Tips

Table of Contents Search

  • For more specific results, select both a chapter and section.
  • To move from section to section within a chapter, use the left navigation bar.

Keyword Search

  • For best results, select a recommended search term if one appears in the search box.
  • To narrow your search, use the Filter By and Additional Keywords features in the left navigation bar.
  • To find an exact phrase, use quotes (e.g., “prior approval”).
  • To find all search terms, use the word AND in capital letters between search terms.
  • To find at least one search term, use the word OR in capital letters between search terms.
×
  • Dispute Resolution for Medicaid Managed Care Plans > Key Terminology

    The descriptions below provide a general overview of the terminology used with Medicaid Managed Care and Family Health Plus plans.

    Service Authorization Request

    A request submitted to EmblemHealth for the provision of a service (including requests for referral or noncovered services). The request can be classified in one of two categories:

    • Prior Approval Request
      A type of service authorization request applicable to coverage of a new service, whether for a new authorization period or within an existing authorization period, before such service is provided.
    • Concurrent Review Request
      A type of service authorization request applicable to continued, extended or additional service beyond what is currently authorized.

    Service Authorization Determination

    The decision regarding a service authorization request, whether approved or denied.

    Adverse Determination

    The denial of a service authorization request, or approval in an amount, duration or scope that is less than requested. The initial adverse determination may be appealed by the member or the provider. If the decision is upheld it is considered a final adverse determination.

    Action

    An activity performed by EmblemHealth or its subcontractor that results in the:

    • 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.
    • In rural areas, as defined by 42 CFR §412.62(f)(a), where enrollment in the MMC program is mandatory and there is only one managed care organization (MCO), the denial of a member's request to obtain services outside the plan's network pursuant to 42 CFR §438.52(b)(2)(ii).

    Also, an "action" is an activity performed by EmblemHealth or its subcontractor that is caused by the:

    • Failure to act in a timely manner as defined by applicable state law and regulation.
    • Failure to act within the time frames for resolution and notification of determinations regarding Complaints, Action Appeals and Complaint Appeals.

    Notice of Action

    A notification sent when an action is taken.

    Action Appeal

    A request to review an action.

    Complaint

    A request to review an administrative process, service or quality-of-care issue, or any aspect of care not pertaining to an action.

    Complaint Appeal

    A request to review a complaint determination.

    Dispute

    Either an action appeal or complaint appeal.

    Certain disputes and requests for prior approval and concurrent review may be filed as expedited or standard depending on the urgency of the patient's condition.

    My Subscriptions

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

    Submit
    ×

    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 for EmblemHealth to review or reconsider an action by EmblemHealth or its subcontractor.

    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.

    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.

    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 business entity that performs delegated functions on behalf of the insurer or managed care organization.

    A medically necessary service for which a member is entitled to receive partial or complete coverage under the terms and conditions of the benefit program, is within the scope of the practitioner's practice and the practitioner is authorized to render pursuant to the terms of the agreement.

    Final determination made on a first level utilization review appeal, where an initial adverse determination has been upheld.

    Initial determination made by a utilization management agent for a denial of a service authorization request on the basis that the requested service is not medically necessary or an approval of a service authorization in an amount, duration or scope is less than requested.

    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.

    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.

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

    A request by the member or their provider (on the member's behalf) to have a service provided. This includes a:

    • Request for referral
    • Request for non-covered service
    • Request for prior authorization for coverage of a new service
    • Request for concurrent review for continued, extended or additional services than what is currently authorized.
    ×

You are now leaving the Medicare section of the EmblemHealth website.

Click to Continue ×

Your member ID # is on the front of your ID card.