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  • 2019 Provider Networks and Member Benefit Plans > Know Your Networks

    You can help your patients keep their costs down by using in-network services and providers. To do this, you need to understand:

    • Your own network participation.
      Knowing your network participation is critical. It will determine whether you are in-network for your patient and which facilities and health care professionals you may coordinate with in the care of your EmblemHealth patients.
    • How to identify the network your patients can access.
      See our Access to Care chapter for instructions for keeping your information current.
    • How to refer your patients for services and identify in-network facilities.
      • Help your members avoid surprise bills and avoidable costs by keeping care in-network even if no formal referral is needed for the benefit plan. Examples of plans that do not require referrals include:

        Commercial
        • Access I
        • Access II
        • EmblemHealth Platinum Choice
        • EmblemHealth Gold Choice
        • EmblemHealth Silver Choice
        • EmblemHealth Gold Premier 1
        • EmblemHealth Silver Plus 1
        • EmblemHealth Silver Premier
        • EmblemHealth Platinum Premier
        • EmblemHealth Gold Premier
        • EmblemHealth EPO Value
        • EmblemHealth EPO Value HDHP

        Medicare
        • EmblemHealth VIP GO
        • EmblemHealth Affinity Medicare Ultimate (HMO SNP)
        • EmblemHealth Affinity Medicare Solutions (HMO SNP)
        • EmblemHealth Affinity Medicare Passport Essentials (HMO)
        • EmblemHealth Affinity Medicare Passport Essentials NYC (HMO)

      • “Referral & Prior Approval” feature has doctor search feature that will return results that are limited to the member’s network.
      • Use our hospital PEAR grid to see which hospitals are in-network and which have participating pathology, emergency, anesthesia, and radiology (PEAR) physician groups to help guide where you admit your patients.
    • In addition to the networks described in this chapter, you are required to utilize and refer your patients to appropriate participating laboratories, and other ancillary services that make up the networks our members are entitled to access. Generic referrals should never be given.

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    Glossary terms found on this page:

    Auxiliary or supplemental services (i.e., diagnostic services, physical therapy and medications) used to support diagnosis and treatment of a patient's condition.

    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.

    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.

    Means a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (a) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy; (b) serious impairment to such person’s bodily functions; (c) serious dysfunction of any bodily organ or part of such person; or (d) serious disfigurement of such person.

    A health care benefit arrangement that is similar to a preferred provider organization in administration, structure and operation but does not cover out-of-network care. Also called an Exclusive Provider Organization.

    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.

    The use of providers who participate in the health plan's provider network. Many benefit plans encourage enrollees to use network providers to reduce the enrollee's out-of-pocket expense.

    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.

    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 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.

    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.

    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.

    A recommendation by a physician that an enrollee receive care from a specialty physician or facility.

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