Telephonic medicine includes, but is not limited to, diagnosis, treatment, advice and instruction given to patients over the phone. EmblemHealth does not pay for telephonic consultations as a separate billable service.
We expect the highest quality of care, including face-to-face interaction between the patient and provider whenever possible. To reduce liability and the risk of medical errors made possible by telephonic consultations, we require practitioners to adhere to the following procedures:
- Document every phone call in the patient's medical record.
- Base notes on the same principles of documentation as during face-to-face interaction.
- Whenever practical, have the patient's medical records available when telephone interaction is conducted from the practitioner's office.
- All covering physicians should provide the attending physician's office with clearly labeled notes of telephonic interactions.
- Office staff who interact with patients telephonically regarding medical issues including, but not limited to, appointment reminders, refills and diagnostic reports should also document these interactions in the medical record.
Glossary terms found on this page:
An activity of EmblemHealth or its subcontractor that results in:
- Denial or limited authorization of a service authorization request, including the type or level of service
- Reduction, suspension or termination of a previously authorized service
- Denial, in whole or in part, of payment for a service
- Failure to provide services in a timely manner
- Failure of EmblemHealth to act within the time frames for resolution and notification of determinations regarding complaints, action appeals and complaint appeals
The physician primarily responsible for the care of a patient during hospitalization. The physician is licensed, board-certified or board-eligible and qualified to practice in the area appropriate to treat the member's life-threatening or disabling condition or disease. The attending physician must be a network provider with EmblemHealth or one to which EmblemHealth has referred the member.
Services rendered by a physician whose opinion or advice is requested by another physician for further evaluation or management of the patient.
A licensed doctor of medicine or osteopathy who has an agreement with a network provider to provide covered services to members when the network provider is not available.
A health care benefit arrangement that is similar to a preferred provider organization in administration, structure and operation but does not cover out-of-network care. Also called an Exclusive Provider Organization.
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 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 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.