Contracted delegates may be engaged for one or all of the following functions:
- Claims processing
- Customer services
- Complaints and grievances
- Utilization or quality management
- Disease and complex case management programs
- Health and wellness
Prior to entering into a written contractual agreement with an outside entity, EmblemHealth reviews the entity's ability to perform one or all functions to our standards. The QIC must approve all delegated entities, and the relationship is subject to an annual review based on EmblemHealth standards. Annual auditing may result in a corrective action plan to ensure that the delegate meets our requirements within a specific time frame. In the event EmblemHealth identifies an issue that may result in an adverse member event and/or noncompliance with our standards, we reserve the right to monitor any delegated entity on a more frequent basis or to terminate the contract for failure to comply with its quality standards.
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
A program that assists the patient in determining the most appropriate and cost-effective treatment plan, including coordinating and monitoring the care with the ultimate goal of achieving the optimum health care outcome.
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.
Initial oral or written communication from a member or their designee or provider that expresses discontent with any aspect of their care or coverage with EmblemHealth. Specifically, it is dissatisfaction with:
- A determination made by the plan, other than a determination of medical necessity or a determination that a service is considered experimental or investigational
- Treatment experienced through the plan, its providers or contractors
- Any concern with the plan, its benefits, employees or providers.
A legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.
An entity contracted with EmblemHealth to perform various services including utilization review, credentialing and claims processing. Also called managing entities and carve outs.
The process by which the organization permits another entity to perform functions and assume responsibilities covered under these standards on behalf of the organization, while the organization retains final authority to provide oversight to the delegate.
A request to change an adverse determination that was based on administrative policies, procedures or guidelines.
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.