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  • Medical Record Guidelines > Accessing Medical Records

    Responsibility for maintaining and securely storing a member's medical record lies with the office of the Primary Care Physician. An active member's record should be available for review both at the time of the member's appointment and when requested by EmblemHealth, the NYSDOH, CMS (and LDSS for Medicaid only) or other authorized entity for utilization review and for quality and other applicable audits.

    Practitioners are responsible for maintaining a patient's original medical records for six years (or 10 years for Medicare members) after either the last date of service rendered or the date the member no longer seeks care from that provider. In the case of a minor, the records shall be retained for three years after the member reaches the age of majority or six years after the date of service, whichever is later. This timeline applies even if the patient has terminated his/her EmblemHealth coverage.

    All practitioners must observe applicable state and federal laws, rules and regulations concerning the confidentiality of medical records.

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    Glossary terms found on this page:

    Services that have been approved for payment based on a review of EmblemHealth's policies.

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

    The date on which a service was rendered.

    A city or county social services district as constituted by Section 61 of the New York State Social Services Law (SSL). Also called a Local Department of Social 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.

    A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.

    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.

    The state regulatory agency that certifies reimbursement methods and rates to hospitals and reviews HMO activities in the state of New York. Also called the New York State Department of Health.

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

    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.

    New York State Department of Health. This agency provides information for consumers, doctors, researchers and health care providers.

    A formal evaluation (prospective, concurrent or retrospective) of the coverage, medical necessity, efficiency or appropriateness of health services and treatment plans. Also called Coordinated Care.

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