This manual applies to all EmblemHealth, GHI, HIP, HIPIC and Vytra plans, and it replaces all provider manuals published before November 2009. It includes detailed information about your administrative responsibilities, contractual and regulatory obligations, and best practices for interacting with our plans and helping our members navigate our delivery systems.
You will also find information on our wellness programs, which foster disease prevention and healthier living. These services support our mission of providing a choice of products and services, so that our members have access to the medical care they need when they need it at prices they can afford. More Information on our member’s Protections for Out-of-Network Emergency Services and Surprise Bills can be found on emblemhealth.com.
Keep your email address with us current so that you can receive electronic communications with new and updated operational information. To update your email address and directory information, sign in to our secure provider website at www.emblemhealth.com/providers.
This manual is an extension of your Provider Agreement and is amended as our operational policies change. We regularly communicate these updates and other important information through available communication channels, including:
Note: This copy of the EmblemHealth Provider Manual was last updated on October 27, 2015. Updates to the Provider Manual occur as policies are reviewed and updated, new programs are introduced and contractual and regulatory obligations change. Please visit www.emblemhealth.com/ProviderManual for the most current information. To receive email notifications of updates, select a chapter or chapter section and click the "Subscribe" button at the top right of the page.
EmblemHealth and its companies Group Health Incorporated (GHI), HIP Health Plan of New York, HIP Insurance Company of New York and Vytra Health Plans Managed Systems (together referred to as EmblemHealth) arrange for the delivery of health care services in accordance with, and subject to, the terms of the certificates of coverage and benefit packages purchased either by our members or on their behalf. We do not directly provide these services or supplies. Rather, these services and supplies are provided by independent contractors. The health care providers listed in the various provider directories who deliver health care services are not the employees or agents of our companies. EmblemHealth will not be liable for any negligent act or omission by any of the providers listed in the directory, or any of their employees or agents, who may from time to time provide medical services to EmblemHealth members. EmblemHealth expressly disclaims any agency relationship, actual or implied, with any health care provider. Any decisions made by EmblemHealth concerning appropriateness of setting or whether any services or supply is medically necessary, pursuant to the certificate of coverage, will be deemed to be made solely for the purpose of determining whether benefits are due under the agreement between the member and EmblemHealth, and not for the purpose of recommending any medical treatment or nontreatment. EmblemHealth does not exercise any control or directory over the medical judgment or clinical decision of any health care provider listed in their directory, and does not interfere with the physician-patient relationship between the provider and EmblemHealth member.
Note: This provider manual links to websites as a convenience as well as an educational and informational service to our providers. These links are not intended to provide medical or professional advice. All medical information, whether from these links or from any other source, needs to be reviewed carefully by the practitioner. The opinions and information expressed therein are not necessarily EmblemHealth's. EmblemHealth does not guarantee or warrant that the links referenced in this manual, or any information therein contained, are complete, accurate or up to date since the date of this manual's publication or last update.
Glossary terms found on this page:
Services available to a member as defined in his or her contract. Benefit design includes the types of benefits offered, limits (e.g., number of visits, percentage paid or dollar maximums applied) and subscriber responsibility (cost sharing components).
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.
A decision about the patient's medical treatment.
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 business entity that performs delegated functions on behalf of the insurer or managed care organization.
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.
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 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.
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.
Professional services rendered by a physician for the treatment or diagnosis of an illness or injury.
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.
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 group of physicians, hospital, and other medical care providers that a specific plan has contracted with to deliver medical services to its members.
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 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.