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  • Medical Transportation Procedures > Emergency Ambulance

    TABLE 5
    EMERGENCY AMBULANCE

    Service Area

    Medicaid

    Medicaid Advantage HMO

    Dual Eligible (HMO) SNP MAP-MLTC & MLTC

    Dual Eligible HMO/PPO SNP

    New York City

    Covered by Medicaid FFS

    Covered by the Plan

    Covered by the Plan

    Covered by the Plan

    Nassau

    Covered by the Plan

    Covered by the Plan

    Covered by the Plan

    Covered by the Plan

    Rockland

    N/A

    Covered by the Plan

    Covered by the Plan

    Covered by the Plan

    Suffolk

    Covered by the Plan

    Covered by the Plan

    Covered by the Plan

    Covered by the Plan

    Westchester

    Covered by Medicaid FFS

    Covered by the Plan

    Covered by the Plan

    Covered by the Plan

    Prior Approval: Emergency services are not subject to prior approval. Call 911.

    Who Arranges Services: Anyone who can. Call 911.

    Provider Reimbursement: Ambulance providers submit claims to the address on the back of the member's ID card. For Dual Eligible (PPO) SNP: Ambulance providers submit claims to: EmblemHealth Medicare PPO, PO Box 2830, New York, NY 10016-2830. When covered by Medicaid FFS, ambulance providers bill Medicaid FFS.

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    Glossary terms found on this page:

    An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.

    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.

    An organization that provides comprehensive health care coverage to its members through a network of doctors, hospitals and other health care providers. Also called a Health Maintenance Organization.

    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.

    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.

    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.

    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.

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

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