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Provider Manual
EmblemHealth Provider Manual
The EmblemHealth Provider Manual provides convenient access to EmblemHealth, GHI and HIP plan policies and procedures, which may affect your patients’ coverage and how you work with us.
Updated: 2/2010
Additional Resources/Administrative Guidelines
Find information that affects you and your patients below. This resource page is organized according to the EmblemHealth Provider Manual. Within each section, you may link to the relevant area in the Provider Manual or to additional resources on our Web site and on the internet.
Directory
Contact information for parties within EmblemHealth, our delegated relationships and other external resources
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- GHI Phone Numbers and Addresses
- HIP and CompreHealth Provider IVR Phone System
- GHI AnswerLine
- GHI Mental Health Consultation Line/ValueOptions
- Quest Diagnostics
- GHI HMO Designated AIDS Centers (DACs)
- HIP Designated AIDS Centers
- HIP and CompreHealth Mammography Sites
- HIP and CompreHealth Urgent Care Center Locations
- Compare Hospitals
- New York State Nursing Home Profile
Quick Reference Cards:
YOUR PLAN MEMBERS
Information on our networks and the benefit plans within them as well as our members rights and responsibilities, including privacy rights and sample ID cards
View Your Plan Members
ACCESS TO CARE AND DELIVERY SYSTEMS
Policies and procedures for the provision of medical care to our members, including:
- Participation requirements
- Role of primary care providers
- Provider termination procedures
View Access To Care And Delivery Systems
MEDICAL RECORD GUIDELINES
Policies on how to maintain member medical records, including
- Medical record standards
- Contractual requirements regarding retention and disclosure of information
View Medical Record Guidelines
CARE MANAGEMENT
Our philosophy, policies and procedures for the coordinated care of our members, including referral and prior approval requirements, case management programs, and utilization review guidelines
View Care Management
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More:
- Check Status of GHI Member Inpatient Stays by Phone
- Complex Case Management
- Expansion of Transition of Care Program
- Medical policies
- Medical Policy Subcommittee Technology Updates
- Occupational Health Clinics for GHI HMO Members
CLINICAL PRACTICE GUIDELINES
Evidence-based recommendations to assist practitioners in providing medical care
View Clinical Practice Guidelines
Quality Improvement
Summarizes our quality improvement programs established to improve the medical and mental health care outcomes for our members
- HEDIS/QARR
View Quality Improvement
HEALTH PROMOTION AND DISEASE MANAGEMENT
Quality improvement programs available to help members with identified conditions and diseases.
View Health Promotion and Disease Management
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- Chronic Kidney Disease (CKD) Management Program
- COPD: Awareness, Prevention and Treatment: Questions & Answers
- Depression disease management program
- Health Care Proxy
- Help your patients stop smoking
- Help Your Patients With Breast Cancer
- HIP OB/GYN Quick Reference Card
- Metabolic Syndrome
- Personal Health Passports
- Prenatal Program for Medicaid and Family Health Plus
- Smoking Cessation (Fax-to-Quit Program): Tobacco Free Fax, Overview, Do’s and Dont’s, Fax Referral Form
- Weight management resources
INTEGRATIVE WELLNESS
Plan and community programs that promote healthy living, particularly to frail seniors and at-risk members.
View Integrative Wellness
Pharmacy Services
Prescription drug coverage, including:
- Pharmacy benefit designs
- Medication Therapy Management program
- Home delivery
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- Medco - HIP’s Mail Order Pharmacy Provider
- 2010 EmblemHealth Formulary
- 2010 GHI/GHI HMO Formulary
- 2010 GHI Select Formulary
- 2010 HIP Formulary
- Express Scripts Formulary Lists
- Express Scripts Medicare Part D Payer Sheet
- Standing Orders for Influenza Vaccination and Other Vaccinations
- Aspirin Therapy
- Potentially Inappropriate Medication Use in Older Adults
- Vaccines for Children: Q&A
- Vaccine Information
DURABLE MEDICAL EQUIPMENT
Policies for the prescription of durable medical equipment for members
View Durable Medical Equipment
RADIOLOGY AND CARDIOLOGY PRIVILEGING
Radiology and cardiology privileging protocols to improve quality of care and make imaging services available when rendered by physicians other than radiologists
View Radiology and Cardiology Privileging
Radiology Program
Diagnostic imaging management program for outpatient radiology services for all members, including prior approval and radiology scheduling procedures
View Radiology Program
CARDIOLOGY IMAGING SERVICES
Diagnostic imaging management program for outpatient cardiology for selected HIP members, including:
- Prior approval procedures
- Cardiology imaging scheduling procedures
View Cardiology Imaging Services
Mental Health and Substance Abuse
Policies and procedures for mental health and substance abuse services, including:
- Prior approval procedures
- Post-discharge protocol
- Mental Health Parity Law
View Mental Health and Substance Abuse
Chiropractic Program
Network and utilization management program for chiropractic services provided to designated members
View Chiropractic Program
Podiatry
Special reimbursement program for podiatry services provided by designated providers
View Podiatry
Claims
Policies and procedures for submitting your claims:
- Recent managed care laws
- Electronic claims submission
- Where to file claims or documentation for plan members
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- Claims Corner for updated information so that you may pay your claims quickly and accurately
- GHI’s Claim Coding Policies FAQ
- GHI Electronic Funds Transfer (EFT)
- GHI Electronic Media Claims (Medical)
- GHI Electronic Media Claims (Hospital)
- GHI Hospital Claim Processing Codes
- GHI NYHCRA Billing Information
- HIP and CompreHealth Claim Submission for Unlisted Procedure or Service Code Special Report
- National Provider Identifier (NPI) Reporting Sheet
- Questions and Answers: NPI
- Claims Review Software
Complaints, Grievances and Appeals
Policies and procedures for practitioners to address issues for yourself or on behalf of a member, such as:
- Rights and procedures for grievances, complaints and appeals
- New law on rare diseases
- Adverse determinations and retrospective reviews
- Medical Director availability after an adverse determination
- Fair Hearings
View Complaints, Grievances and Appeals
Credentialing
Credentialing and recredentialing requirements:
- New managed care law requiring provisional credentialing
- Practitioner appeal process for changes in participation
View Credentialing
Regulatory Mandatory Reporting
Outlines mandatory reporting requirements for New York State and New York City
View Regulatory Mandatory Reporting
Medical Transportation Procedures
Information on Medicaid policies for transporting or reimbursing Medicaid, Family Health Plus and Medicare Advantage members
View Medical Transportation Procedures
NYS Standard Clauses
Mandatory contract language required by the State of New York
View NYS Standard Clauses
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