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  • Radiology Program > Members Exempt from the EmblemHealth Radiology Program

    While most of our members' covered radiology services are managed by eviCore, the following exceptions apply.

    Members whose care is managed by Montefiore Medical Group (CMO), HealthCare Partners (HCP) or Inspiris must contact the applicable organization for prior approval. See the member's ID card or eligibility information on www.emblemhealth.com to determine whether HIP, CMO, HCP or Inspiris is the managing entity responsible for managing a member's care; if HIP is the managing entity, then eviCore is the organization to contact for prior approval.

    Members who selected a PCP assigned to one of the following physician group practices or hospital system (see member's ID card), as well as Vytra benefit plans, are excluded from this program. PCPs in the physician group practices must enter a prior approval request on www.emblemhealth.com.

    Physician Group Practices

    • Manhattan's Physician Group
    • Preferred Health Partners
    • Queens-Long Island Medical Group
    • Staten Island Physician Practice

    Hospital System

    • St. Barnabas Hospital

    The Prior Approval HIP CPT code list later in this chapter applies to the members listed above as well. Only the managing entity varies. Please refer to the Care Management chapter for information on how to obtain prior approval for these members.

    GHI

    The following groups are exempt from prior approval requirements for all radiology services. Group names, numbers and category codes appear on the member's ID card.

    GHI Group Name Category Code(s) Group Number(s)

    Fidelis Child Health Plus (family planning only)

    18D

    N0004761

    Jefferson County

    79B, 7EG

    N3683, N3684, N4093, N4453 N4725

    Vytra

    Vytra HMO and Vytra ASO plans cover radiology services for their members and are excluded from the EmblemHealth Radiology Program. The terms of this coverage are described at the end of this chapter.

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    Glossary terms found on this page:

    A health insurance product offered by a health plan company that is defined by the benefit contract and represents a set of covered services. Also called a health benefit plan.

    A determination of whether or not a person meets the requirements to participate in the plan and receive coverage under the plan.

    This number identifies the subscriber's employer or Union Benefits Fund.

    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.

    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

    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.

    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 family physician, family practitioner, general practitioner, internist or pediatrician who is responsible for delivering or coordinating care. Also called a primary care physician.

    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.

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