Please refer to the Care Management chapter for information on prior approvals and concurrent reviews.
Glossary terms found on this page:
Services that have been approved for payment based on a review of EmblemHealth's policies.
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.
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 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.