- Table of Contents
- How Do I...
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.
- 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.
Individuals with both Medicare and Medicaid coverage are called "dual eligibles." Depending on their category of Medicaid coverage, a dual eligible may receive state Medicaid plan assistance to cover their Medicare Part B premium, Medicare Parts A and B cost-share and certain benefits not covered by Medicare.
Centers for Medicare & Medicaid Services (CMS) guidelines stipulate that dual eligible|
If the referring physician disagrees with the determination, contact the Peer-to-Peer Consultation Line to discuss the case with a medical director. Call 1-866-417-2345 for GHI HMO, HIP, EmblemHealth CompreHealth EPO, EmblemHealth Medicare HMO and Vytra plans. Call 1-800-835-7064 for GHI HMO, GHI EPO/PPO, EmblemHealth EPO/PPO and EmblemHealth Medicare PPO plan members.
Claims will be denied and|
Vytra reimburses only radiologists for dual energy X-ray absorptiometry (DEXA) scans. PCPs and specialists other than radiologists are not reimbursed for DEXA scans, regardless of any prior arrangements with or payments from Vytra.
For a complete list of participating DEXA locations, visit www.emblemhealth.com. If the member's designated radiologist does not perform DEXAs, the referring physici|
Network providers, in agreeing to accept EmblemHealth's reimbursement schedule for services rendered, shall not bill or seek payment from the member for any additional expenses (except for applicable copayments, co-insurance or permitted deductibles) including, but not limited to:The difference between the charge amount and the EmblemHealth fee schedule or the difference between the member's cop|
Radiology centers treating a member outside their designation must call Vytra's Provider Service Line at 1-888-288-9872 before rendering services. During this call, the center must ensure prior approval is secured and use Vytra's Guarantee Waiver Agreement.
Each member seeking service outside their designated facility must sign Vytra's Guarantee Waiver Agreement. This is the only waiver recogni|
If it becomes necessary to change or update the procedure after prior approval is obtained, the program must be contacted no later than 48 hours after the modified procedure is performed. If the prior approval for the treatment plan is not updated and the claim does not match the authorized procedures, the claim will be denied for payment, with no liability to the member.|
To view the provider toolkit, click here.
...Radiology Program Prior Approval Code ListFor GHI HMO, HIP, EmblemHealth CompreHealth EPO, EmblemHealth Medicare HMO and VytraEffective January 1, 2016Radiology CPT CodeProcedure Description
MAGNETIC RESONANCE IMAGING TMJ
COMPUTED TOMOGRAPHY HEAD/BRAIN WITHOUT CONTRAST
COMPUTED TOMOGRAPHY HEAD/BRAIN WITH CONTRAST
COMPUTED TOMOGRAPHY HEAD/BRAIN WITHOUT AND WITH CONTR|