Table of Contents
Search
How Do I...

Search Tips

Table of Contents Search

  • For more specific results, select both a chapter and section.
  • To move from section to section within a chapter, use the left navigation bar.

Keyword Search

  • For best results, select a recommended search term if one appears in the search box.
  • To narrow your search, use the Filter By and Additional Keywords features in the left navigation bar.
  • To find an exact phrase, use quotes (e.g., “prior approval”).
  • To find all search terms, use the word AND in capital letters between search terms.
  • To find at least one search term, use the word OR in capital letters between search terms.
×
  • Required Provisions to Network Provider Agreements

    In this chapter, you will find mandatory contract language required by the State of New York and the Centers for Medicare & Medicaid Services, including the Managed Care Law of 2009, the NYSDOH Standard Clauses, the Special Provisions Related to Medicaid Members and the Medicare Advantage Addendum.

    My Subscriptions

    Enter your e-mail address to receive a link to your subscriptions.

    Submit
    ×

    Glossary terms found on this page:

    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 organization comprised of individual physicians or physicians in group practices that contracts with the managed care organization on behalf of its member physicians to provide health care services. Also called an Independent Practice Association.

    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.

    Any form of health plan that uses selective provider contracting to have patients seen by a network of contracted providers and that requires prior approval of certain services.

    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 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. Also known as MA.

    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.

    The state regulatory agency that certifies reimbursement methods and rates to hospitals and reviews HMO activities in the state of New York. Also called the New York State Department of Health.

    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.

    New York State Department of Health. This agency provides information for consumers, doctors, researchers and health care providers.

    ×

You are now leaving the Medicare section of the EmblemHealth website.

Click to Continue ×

Your member ID # is on the front of your ID card.