EmblemHealth Spine Surgery and Pain Management Therapies Program
This chapter contains policies and procedures for the EmblemHealth Spine Surgery and Pain Management Therapies Program:
- Place of service for select spine surgery and interventional pain management therapy procedures
- Program inclusion and exclusions
- ICD-10 Procedure/Diagnosis Codes
- Prior approval procedures
- Grievance and appeal process
Glossary terms found on this page:
Oral or written request from a member or their designee for EmblemHealth to review or reconsider a decision made by the plan.
Specific conditions or circumstances that are not covered under the benefit agreement or Certificate of Insurance. It is very important to consult the benefit contract to understand what services are not covered benefits.
A request to change an adverse determination that was based on administrative policies, procedures or guidelines.
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.