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  • Physical and Occupational Therapy Program > GHI and EmblemHealth EPO/PPO Plans

    PT/OT Benefits

    EmblemHealth PPO/EPO and GHI plan members are not covered under the Palladian program. They have a capped, limited benefit of 30 visits per calendar year. PPO members are allowed to go out of network. EPO members may only see network providers.

    There are no referral or prior approval requirements for these initial base benefit visits. If more visits are needed in a calendar year, the provider may follow the member grievance process in the Dispute Resolution for Commercial/CHP Members chapter.

    City of New York (Including Unions and Locals)

    City of New York members (including all unions and locals) have a base benefit of 16 visits per calendar year for outpatient physical therapy (PT) only, both office-based and hospital-based. They do not have outpatient occupational therapy (OT) as a covered service. OT is only covered as part of home care services.

    Benefit Extensions

    The Benefit Extension process is implemented when additional visits above the base benefit are requested and are provided for under an EmblemHealth EPO/PPO or GHI EPO/PPO member's contract.

    Where EmblemHealth EPO/PPO or GHI is listed as the primary insurer, you may submit a benefit extension request from our secure Provider Web site at www.emblemhealth.com. Once signed in, look for the option on the left-hand navigation bar. (The member's primary insurer may also be verified through our secure site.)

    You may also request a Benefit Extension Treatment Plan Form for an EmblemHealth EPO/PPO or GHI member by calling:

    • EmblemHealth: 1-877-482-3625
    • GHI: 1-800-223-9870

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    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).

    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 medically necessary service for which a member is entitled to receive partial or complete coverage under the terms and conditions of the benefit program, is within the scope of the practitioner's practice and the practitioner is authorized to render pursuant to the terms of the agreement.

    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.

    A request to change an adverse determination that was based on administrative policies, procedures or guidelines.

    An institution which provides inpatient services under the supervision of a physician, and meets the following requirements:

    • Provides diagnostic and therapeutic services for medical diagnosis, treatment and care of injured and sick persons and has, as a minimum, laboratory and radiology services and organized departments of medicine and surgery
    • Has an organized medical staff which may include, in addition to doctors of medicine, doctors of osteopathy and dentistry
    • Has bylaws, rules and regulations pertaining to standards of medical care and service rendered by its medical staff
    • Maintains medical records for all patients
    • Has a requirement that every patient be under the care of a member of the medical staff
    • Provides 24-hour patient services
    • Has in effect agreements with a home health agency for referral and transfer of patients to home health agency care when such service is appropriate to meet the patient's requirements

    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.

    The group of physicians, hospital, and other medical care providers that a specific plan has contracted with to deliver medical services to its members.

    A physician, hospital or other provider who has signed an agreement to covered services to EmblemHealth plan members. A network provider is a member of the EmblemHealth network of network providers applicable to the member's certificate. Therefore, they are sometimes referred to as participating providers. Payment is made directly to a network provider. Please consult the EmblemHealth Directory or go online to search for network providers.

    Treatment to restore a physically disabled person's ability to perform activities such as walking, eating, drinking, dressing, toileting and bathing (activities of daily living).

    Treatment involving physical movement to relieve pain, restore function and prevent disability following disease, injury or loss of limb.

    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.

    A recommendation by a physician that an enrollee receive care from a specialty physician or facility.

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