Excluded from this payment policy are HIP/HIPIC-underwritten Benefit Plans members assigned to a Montefiore, HealthCare Partners (HCP) or AdvantageCare Physicians (ACPNY) PCP. These members can be identified by their member ID card or through member eligibility information on our secure website at: www.emblemhealth.com/providers. Protocols for GHI-underwritten plans are contained within the Radiology Privileging chapter.
Glossary terms found on this page:
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 determination of whether or not a person meets the requirements to participate in the plan and receive coverage under the plan.
A card which allows the subscriber to identify himself or his covered dependents to a provider for health care services.
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.
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.
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 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
- Doctor of podiatric medicine
- Physical therapist
- Nurse midwife
- Certified and registered psychologist
- Certified and qualified social worker
- Nurse anesthetist
- Speech-language pathologist
- 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.