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  • Fully Integrated Dual Advantage (FIDA) > Utilization Management

    Utilization Management Process and Role of the Interdisciplinary Team

    The IDT is the primary source for approval of services and approval of the PCSP. The IDT is responsible for monitoring participant service plans, assuring that services are provided consistent with the plan, staying apprised of changes in status, assessing the continued appropriateness of the plan between reassessments, and identifying emerging needs. The care manager has overall responsibility for these tasks and works directly with community and network providers and community-based or facility-based LTSS providers, as well as members of the IDT, including rehab, nutrition, behavioral health specialists and the consulting pharmacist. 

    The IDT will assist participants in obtaining needed medical, behavioral health, prescription and nonprescription drugs, community-based and facility-based LTSS, and social, educational, psycho-social, financial and other services in support of the PCSP, regardless of whether the needed services are covered under the provider payment. Consumer direction is included in the covered services and in the service planning process. 

    The IDT is, at a minimum, comprised of the participant and/or his/her designee, and the assigned care manager. Other members, as agreed to by the participant, include the PCP (or a designee with clinical experience from the PCP’s practice who has knowledge of the needs of the Participant), a behavioral health professional (when appropriate), the participant’s home care aide (if indicated), and other providers either as requested by the participant or his/her designee or as recommended by other IDT members. The IDT makes coverage determinations that may not be modified by the FIDA Plan outside of this team and that can be appealed by the participant. 

    Practitioners who participate on an IDT are eligible for additional compensation for IDT meeting attendance. For more information about additional compensation, see the Billing section of this chapter.


    For more information about IDT, see the Medicare Special Needs Plans section of the Provider Networks and Member Benefit Plans chapter.




    Utilization Management - Clinical Practice Guidelines

    EmblemHealth utilizes approved criteria, which are objective and based on medical evidence, as well as the plan’s internal medical guidelines, when making determinations for clinical appropriateness. These criteria, which consider the needs of the participant and are applied to individual cases, are based on an assessment of the local delivery system. Along with the pre-established health care industry clinical review criteria used as guidelines, determinations are also based on a physician’s general medical knowledge and judgment.

    Other medical necessity criteria, such as InterQual/CMS, are also utilized by EmblemHealth to identify the medical necessity and appropriate level of care. These guidelines are reviewed and approved by the Medical Policy Subcommittee on a biennial basis. If evidence-based clinical practice guidelines from a recognized source are not used, EmblemHealth gives board-certified practitioners from the specialties that would use the guidelines an opportunity to provide input during guideline development. In those cases where criteria do not apply, a referral is made to the medical director for higher level determinations. An application of alternate criteria, when reasonable, can be applied to assist in the decision-making process.

    The plan medical guidelines are internally created using evidence-based medical information. They are initially reviewed by practitioners with current knowledge in the appropriate areas. Afterwards, they are presented for review and approval to the Medical Policy Subcommittee, which is chaired by a medical director. This evaluation process is conducted biennially. This process applies throughout care management, including but not limited to pre-service review, concurrent review, case management and retrospective review.

    In presenting the guidelines, EmblemHealth publishes a direct website link to the organization whose guidelines were adopted. Clinical practice guidelines are distributed to the appropriate practitioners via the Provider Manual, the EmblemHealth website and notices of updates in the provider newsletter. A paper copy of the posted Clinical Practice Guidelines is also available on request. For more information about clinical practice guidelines, refer to the Clinical Practice Guidelines chapter.

    Utilization Management - Prior Approval and Referral Procedures

    Referrals are not required for covered items and services under the FIDA Demonstration. The IDT makes all service and authorization decisions. Authorizations between IDT meetings and before the PCSP is developed may be made through EmblemHealth’s Utilization Management process for Medicare-only GuildNet members. Prior approval is not required for FIDA participants for the following services:

    • Emergency or urgently needed care
    • Out-of-network dialysis when the participant is out of the service area
    • Primary care doctor visits
    • Physician specialty services, excluding psychiatric services
    • Family planning and women’s health specialists services
    • Indian health care providers for any participant that is Indian eligible
    • Public health agency facilities for tuberculosis screening, diagnosis and treatment
    • Immunizations
    • Palliative care
    • Other preventive services
    • Vision services through Article 28 clinics that provide optometry services and are affiliated with the College of Optometry of the State University of New York to obtain covered optometry services
    • Dental services through Article 28 clinics operated by academic dental centers
    • Cardiac rehabilitation, first course of treatment (physician or RN approval for subsequent treatment)
    • Supplemental education, wellness and health management services
    • Prescription drugs:
      • which are on the formulary
      • which are not on the formulary, but where a refill request is made for an existing prescription within the 90-day transitional period
    • Mental Health Specialty Services – Non-Physician
      • Authorization required after initial visit for visits 2-5
      • Additional authorization required thereafter
    • Psychiatric services
      • Authorization required after initial visit for visits 2-5
      • Additional authorization required thereafter
    • Outpatient diagnostic procedures, Tests and Lab Services
      • Genetic testing subject to prior authorization rules
    • Outpatient Diagnostic and Therapeutic Radiological Services
      • Authorization required for MRI, MRA, CT, PET scans and nuclear imaging
    • Outpatient Substance Abuse Services
      • Authorization required after initial visit for visits 2-5
      • Additional authorization required thereafter

    The PCSP identifies all services authorized by the IDT and identifies and prioritizes the participant’s need for medically necessary covered services and for LTSS necessary for maintaining or improving the participant’s functional independence. Preserving the participant’s ability to remain in the least restrictive environment is the goal.

    At a minimum, participants are eligible for any covered service that is medically necessary to treat or manage a medical or behavioral condition. LTSS for independent living may be authorized strategically for the purpose of:

    • Maintaining or improving a participant’s level of functional independence
    • Reducing a participant’s risk for more restrictive care because of a loss of functional independence

      Participants may obtain a second opinion from a qualified health care professional regarding the assessment of needs, statement of goals and services prescribed in their PCSP at no cost to the member. For more information about second opinions, refer to the Referral Procedures section of the Care Management chapter.

      For information about accessibility requirements, please refer to the Access to Care and Delivery System chapter.

      Utilization Management - Continuity of Care

      Participants receiving any service other than nursing facility services at the time of enrollment may continue with their current providers and service levels until the later of the two scenarios:

      • At least 90 days after enrollment
      • Until a comprehensive assessment has been completed and a PCSP is put in place

        The provider must agree to accept the plan rate, adhere to plan quality assurance and other policies, and provide medical information about the participant’s care.

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        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.

        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.

        Conditions that affect thinking and the ability to figure things out that affect perception, mood and behavior.

        A health insurance product offered by a health plan company that is defined by the benefit contract and represents a set of covered services. Also called a health benefit plan.

        A program that assists the patient in determining the most appropriate and cost-effective treatment plan, including coordinating and monitoring the care with the ultimate goal of achieving the optimum health care outcome.

        Occurs when a clinical professional reviews information about a patient's health.

        The written screens, decision rules, medical protocols or guidelines used by the utilization management agent as an element in the evaluation of medical necessity and appropriateness of requested admissions, procedures and services under the auspices of the applicable health benefit plan.

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

        Services rendered by a physician whose opinion or advice is requested by another physician for further evaluation or management of the patient.

        An individual person who is the direct or indirect recipient of the services of the organization. Depending on the context, consumers may be identified by different names, such as "member," "enrollee," "beneficiary" or "patient." A consumer relationship may exist even in cases where there is not a direct relationship between the consumer and the organization. For example, if an individual is a member of a health plan that relies on the services of a utilization management organization, then the individual is a consumer of the utilization management organization.

        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 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.

        An entity contracted with EmblemHealth to perform various services including utilization review, credentialing and claims processing. Also called managing entities and carve outs.

        An individual other than the subscriber who is eligible to receive health care services under the member's Certificate of Insurance. Generally, dependents are limited to the subscriber's spouse and eligible children.

        A person authorized by the insured to assist in obtaining access to, or payment to, the insured for health care services. If the insured has already received health care services and has no liability for payment of services, a designee will not be authorized for the purpose of requesting an external appeal.

        Means a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (a) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy; (b) serious impairment to such person’s bodily functions; (c) serious dysfunction of any bodily organ or part of such person; or (d) serious disfigurement of such person.

        A hospital, ambulatory surgical facility, birthing center, dialysis center, rehabilitation facility, skilled nursing facility or other provider certified under New York Public Health Law. A hospice is a facility. An institutional provider of mental health substance abuse treatment operating under New York Mental Hygiene Law and/or approved by the Office of Alcoholism and Substance Abuse Services is a facility.

        A range of medical, social or rehabilitation services a person needs over months or years to improve or maintain function or health that are provided in a long-term care facility such as a nursing home (not including assisted-living residences). Also called facility-based long-term services and supports.
        A Medicare-Medicaid alignment initiative developed to better serve individuals eligible for both Medicare and Medicaid (Medicare-Medicaid enrollees). Also called fully-integrated duals advantage demonstration.
        A managed care plan under contract with the Centers for Medicare & Medicaid Services and the State to provide the fully-integrated Medicare and Medicaid benefits under the FIDA demonstration. Also called fully-integrated duals advantage plan.

        A list of preferred pharmaceutical products that health plans, working with pharmacists and physicians, have developed to encourage greater efficiency in the dispensing of prescription drugs without sacrificing quality. Also called a drug formulary.

        A professionally licensed individual, facility or entity giving health-related care to patients. Physicians, hospitals, skilled nursing facilities, pharmacies, chiropractors, nurses, nurse-midwives, physical therapists, speech pathologist and laboratories are providers. All network providers are health care providers, but not all providers are network providers.

        An individual who: (1) has undergone formal training in a health care field; (2) holds an associate or higher degree in a health care field, or holds a state license or state certificate in a health care field; and (3) has professional experience in providing direct patient care.

        The group of individuals who provide person-centered care coordination and care management to participants in a FIDA plan. Each participant will have an interdisciplinary team (IDT). Each IDT will be comprised, first and foremost, of the participant and/or his or her designee, and the participant’s designated care manager, primary care physician, behavioral health professional, home care aide, and other providers either as requested by the participant or his or her designee or as recommended by the care manager or primary care physician and approved by the participant and/or his or her designee. The IDT facilitates timely and thorough coordination between a FIDA plan and the IDT, primary care physician and other providers. The IDT makes coverage determinations. Accordingly, the IDT’s decisions serve as service authorizations, may not be modified by a FIDA plan outside of the IDT, and are appealable by the participant, their providers and their representatives. IDT service planning, coverage determinations, care coordination and care management are delineated in the participant’s person-centered service plan and are based on the assessed needs and articulated preferences of the participant.



        The use of providers who participate in the health plan's provider network. Many benefit plans encourage enrollees to use network providers to reduce the enrollee's out-of-pocket expense.

        The group of individuals who provide person-centered care coordination and care management to participants in a FIDA plan. Each participant will have an interdisciplinary team (IDT). Each IDT will be comprised, first and foremost, of the participant and/or his or her designee, and the participant’s designated care manager, primary care physician, behavioral health professional, home care aide, and other providers either as requested by the participant or his or her designee or as recommended by the care manager or primary care physician and approved by the participant and/or his or her designee. The IDT facilitates timely and thorough coordination between a FIDA plan and the IDT, primary care physician and other providers. The IDT makes coverage determinations. Accordingly, the IDT’s decisions serve as service authorizations, may not be modified by a FIDA plan outside of the IDT, and are appealable by the participant, their providers and their representatives. IDT service planning, coverage determinations, care coordination and care management are delineated in the participant’s person-centered service plan and are based on the assessed needs and articulated preferences of the participant.



        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.

        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 doctor of medicine or doctor of osteopathic medicine who is duly licensed to practice medicine and is an employee of, or party to a contract with, a utilization management organization, and has responsibility for clinical oversight of the utilization management organization's utilization management, credentialing, quality management and other clinical functions.

        Health care that is rendered by a hospital or a licensed or certified provider and is determined by EmblemHealth to meet all of the criteria listed below:

        • It is provided for the diagnosis or direct care or treatment of the condition, illness, disease, injury or ailment.
        • It is consistent with the symptoms or proper diagnosis and treatment of the medical condition, disease, injury or ailment.
        • It is in accordance with accepted standards of good medical practice in the community.
        • It is furnished in a setting commensurate with the member's medical needs and condition.
        • It cannot be omitted under the standards referenced above.
        • It is not in excess of the care indicated by generally accepted standards of good medical practice in the community.
        • It is not furnished primarily for the convenience of the member, the member's family or the provider.
        • In the case of a hospitalization, the care cannot be rendered safely or adequately on an outpatient basis or in a less intensive treatment setting and, therefore, requires the member receive acute care as a bed patient.

        The fact that a provider has prescribed a service or supplies care does not automatically mean the service or supply will qualify for reimbursement under the EmblemHealth plan. To be eligible for reimbursement by EmblemHealth, all covered services must meet EmblemHealth's medical necessity criteria, described above.

        Medically necessary with respect to Medicaid and Family Health Plus members means health care and services that are necessary to prevent, diagnose, manage or treat conditions that cause acute suffering, endanger life, result in illness or infirmity, interfere with a person's capacity for normal activity or threaten some significant handicap.

        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.

        Conditions that affect thinking and the ability to figure things out that affect perception, mood and behavior.

        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 network provider is a member of the EmblemHealth network of network providers applicable to the member's certificate. Therefore, they are sometimes referred to as participating providers. Payment is made directly to a network provider. Please consult the EmblemHealth Directory or go online to search for network providers.

        The use of health care providers who have not contracted with the health plan to provide services. Depending on the member's contract, out-of-network services may not be covered.

        A family physician, family practitioner, general practitioner, internist or pediatrician who is responsible for delivering or coordinating care. Also called a primary care physician.

        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 written order or refill notice issued by a licensed medical professional for drugs available only through a pharmacy.

        Drugs and medications that are required by law to be dispensed by written prescriptions from a licensed physician.

        A family physician, family practitioner, general practitioner, internist or pediatrician who is responsible for delivering or coordinating care. Also called a PCP.

        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 set of providers contracted with a health plan to provide services to the enrollees.

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

        A review done after services are completed (usually as part of a claim or appeal) that ensures the care given was medically necessary.

        The voluntary option or mandatory requirement to visit another physician or surgeon regarding diagnosis, course of treatment or having specific types of elective surgery performed.

        The geographic area in which a health plan is prepared to deliver health care through a contracted network of participating providers.

        A licensed institution (or a distinct part of a hospital) that is primarily engaged in providing continuous skilled nursing care and related services for patients who require medical care, nursing care or rehabilitation services. Also called a skilled nursing facility.

        The use of one or more drugs for purposes other than those for which they are prescribed or recommended.

        A review to determine whether covered services that have been provided or are proposed to be provided to a member, whether undertaken prior to, concurrent with or subsequent to the delivery of such services are medically necessary. Also called Coordinated Care.

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