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  • Access to Care and Delivery System > Direct Access (Self-Referral) Services

    EmblemHealth Members

    EmblemHealth members can self-refer for the following services to network practitioners when covered by their benefit plan:

    • Chiropractic services*
    • Preventive and primary care services from the member's PCP
    • Preventive obstetric and gynecological care including mammography screenings and cervical cytology screenings
    • Ob-gyn Care: Prenatal care, two routine visits per year and any follow-up care, acute gynecological condition
    • One mental health visit and one substance abuse visit with a participating provider per year for evaluation.
    • Vision Care
      • Refractive eye exams from an optometrist or ophthalmologist
      • Eyeglasses (within benefit limits)
      • Diabetic eye exams from an ophthalmologist
    • HIV pre-test counseling with clinical recommendation of testing required for all pregnant women. Those women and their newborns must have access to services for positive management of HIV disease, psychosocial support and case management for medical, social and addictive services. (This requirement is applicable to all qualified providers of OB/GYN care whether the member directly accesses care or is referred by another provider. See the section titled Medical Specialists for more information.)
    • Emergency Care: Members should call 911.

    *EmblemHealth Medicaid and Child Health Plus members do not have chiropractic coverage. See below for more details.

    Medicare Members

    Medicare members may self-refer to a participating clinician for certain EmblemHealth-covered services and certain Medicare-covered services at designated frequencies and ages:

    • Annual mammography screening
    • Annual routine eye exam
    • Colorectal screening
    • Four routine podiatry visits (VIP HMO, VIP Essential HMO, and VIP High Option HMO only)
    • Glaucoma screening, if at high risk
    • HIV screening
    • Influenza and pneumococcal vaccine
    • Initial chiropractic assessment
    • Initial mental health consultation
    • Nutritionist and social worker visit
    • Prostate cancer screening

    Female members may self-refer to a participating women's health care specialist for the following routine and preventive health care services:

    • Pelvic exam
    • Screening Pap test
    • Bone mass measurement, if at risk

    Members may also self-refer to a Medicare-certified hospice program.

    EmblemHealth Medicaid and Child Health Plus Members

    In addition to the above services to which all members have direct access, there are some services to which members in state sponsored programs (Medicaid and Child Health Plus) may also self-refer. Unless otherwise indicated, members in all state sponsored programs may self-refer to the following services:

    • Unlimited behavioral health and substance use assessments (except for ACT, inpatient psychiatric hospitalization, partial hospitalization, HCBS services)
    • Dental Services - Primary and preventive services from the member's assigned network dentist or to a dental clinic operated by an academic dental center.
    • Orthodontic services (Medicaid only) - For orthodontic services, Medicaid members may also self-refer to Academic Dental Clinics affiliated with Article 28 Academic Centers, Medicaid fee-for-service dentists.
    • Nonemergency transportation services (Medicaid members) - See the Transportation Services section of this chapter for more details.
    • Family planning and reproductive health services include:
    • Access to birth control
    • Sterilization procedures
    • Medically necessary abortions
    • Screening for anemia, cervical cancer, sexually transmitted diseases, breast disease, pelvic abnormality and pregnancy

    Medicaid members can obtain these services from a participating practitioner or any Medicaid fee-for-service provider. Participating practitioners must bill EmblemHealth and not Medicaid FFS for family planning services. If the member is assigned to a Managing Entity, the participating practitioner must bill the Managing Entity at the address on the back of the member's ID card. However, all Child Health Plus members must self-refer to a participating clinician for family planning/reproductive health services.

    All members must use network physicians for all other gynecologic and obstetric care, including hysterectomies, routine Gynecological exams, prenatal and postpartum care.

    Federal regulations require patient notification for hysterectomy and sterilization procedures. The patient or their representative must sign the required consent form for the service to be deemed a covered service under the Medicaid plan. This form must also accompany manual claim submissions as proof of consent. If the required form is not received, then the claim will be returned requesting the required form. Once the form is received, then the claim will be considered eligible and processed.

    Claims for hysterectomy procedures must be submitted along with a copy of the completed and signed Acknowledgment of Receipt of Hysterectomy Information Form, LDSS-3113. When billing for procedures performed for the purpose of sterilization (Code F), a completed Sterilization Consent Form, LDSS-3134, is required and must be attached to the claim. Both forms can be obtained from the New York State Department of Health’s website at Local Districts Social Service Forms.

    • Assessments for Foster Care Children (Medicaid) - EmblemHealth requires a 30-day obligation to complete a comprehensive physical that includes a behavioral health assessment and an assessment of exposure to any infectious disease. Foster Care children are not eligible for CHPlus.

      Starting in 2019, EmblemHealth will manage the delivery of expanded behavioral and physical health services for this population. Please see the end of this chapter for a copy of Foster Care Initial Health Services. This table outlines the time frames for initial health activities, to be completed within 60 days of placement. These assessments are a critical component to the development of a comprehensive plan of care.

    • Child Protective Services (Medicaid) - EmblemHealth physicians shall comply with agencies such as Child Protective Services (CPS) or any other court-ordered services. This compliance includes, but is not be limited to, the provision of medical information to the CPS agency's investigation and any subsequent amendments thereto. If the child is referred by a court order for covered medical services, these services must be provided whether or not they are covered by the plan. Clinicians that are not currently participating with EmblemHealth will be reimbursed at the Medicaid fee schedule. For CHPlus, court-ordered services are only covered if they are medically necessary and covered by the plan.
    • Immunizations - Members can obtain immunization services from an EmblemHealth network practitioner. However, immunizations provided to all Child Health Plus members and to Medicaid children under 19 years of age must be given with vaccines obtained through the Vaccines for Children Program. See the Pharmacy chapter of this manual for more details.
      In addition, Medicaid members can obtain immunization services from a public health agency clinic. Public health agencies are required to make reasonable efforts to contact the member's PCP to ascertain the member's immunization status prior to service delivery. If the public health agency clinic is unable to verify the immunization status from the PCP or learns that immunization is needed, it is authorized to render the service as appropriate and bill EmblemHealth or the responsible full risk provider.
    • Tribal Health Center Services - Native Americans enrolled in EmblemHealth's Medicaid plan are free to access primary care services through their tribal health center without a referral or prior approval. EmblemHealth network PCPs must develop a relationship with tribal health center PCPs to ensure coordination of patient care.
    • Tuberculosis (TB) screening, diagnosis and treatment, administered by EmblemHealth participating practitioners or from public health agency facilities. Public health agencies are required to notify EmblemHealth or the member's PCP of the presentation of TB in order to verify previous TB treatments and bill for the services rendered.
      EmblemHealth does not cover, and Medicaid FFS should be billed for, the following TB-related services:
      • Direct observed therapy (DOT) due to noncompliance with TB care regiments
      • HIV counseling and testing during a TB-related visit at a public health clinic
      • Testing for chlamydia

    EmblemHealth participating practitioners and laboratories must report TB and STD cases to the local public health agency. State and local departments of health will be available to offer technical assistance in establishing TB reporting policies.

    • HIV counseling and testing services administered by:
      • EmblemHealth network practitioners
      • Anonymous HIV counseling and testing centers
      • For Medicaid members, any Medicaid fee-for-service practitioner as part of a family planning encounter
      • For New York City Medicaid members, any New York City Department of Health and Mental Hygiene clinic
    • HIV / AIDS treatment services administered by EmblemHealth network practitioners
    • Emergency care - EmblemHealth covers emergency care for Medicaid and Child Health Plus members in all 50 United States, Washington D.C, Canada, the United States Territories of the Virgin Islands, Puerto Rico, Guam, American Samoa, the Northern Mariana Islands and American territorial waters. Members that have a condition meeting the definition of emergency while in one of these areas can go to the nearest emergency room or call 911. Emergency care services are covered in Mexico for Child Health Plus members.

    Medicaid Pregnant Members Only

    • HIV pre-test counseling services with a clinical recommendation of testing
      Those women and their newborns must have access to services for positive management of HIV disease, psychosocial support and case management for medical, social and addictive services.

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      Glossary terms found on this page:

      Services that have been approved for payment based on a review of EmblemHealth's policies.

      Conditions that affect thinking and the ability to figure things out that affect perception, mood and behavior.

      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 program that assists the patient in determining the most appropriate and cost-effective treatment plan, including coordinating and monitoring the care with the ultimate goal of achieving the optimum health care outcome.

      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.

      Services rendered by a physician whose opinion or advice is requested by another physician for further evaluation or management of the patient.

      A medically necessary service for which a member is entitled to receive partial or complete coverage under the terms and conditions of the benefit program, is within the scope of the practitioner's practice and the practitioner is authorized to render pursuant to the terms of the agreement.

      Medical equipment, goods, implements and prosthetics that are prescribed for patient care, usually in an outpatient setting. Examples of such equipment include hospital beds, wheelchairs and walkers.

      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.

      Care for a person with an emergency condition.

      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.

      A payment method in which the insurer will reimburse the member or provider directly for each covered medical expense.

      The fee determined by the insurer to be acceptable for a procedure or service that the physician agrees to accept as payment in full.

      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.

      A facility or service that provides care for the terminally ill patient and support to the family. The care, primarily for pain control and symptom relief, can be provided in the home or in an inpatient setting.

      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.

      Service provided after the patient is admitted to the hospital. Inpatient stays are those lasting 24 hours or more.

      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.

      A city or county social services district as constituted by Section 61 of the New York State Social Services Law (SSL). Also called a Local Department of Social 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.

      A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.

      Health care that is rendered by a hospital or a licensed or certified provider and is determined by EmblemHealth to meet all of the criteria listed below:

      • It is provided for the diagnosis or direct care or treatment of the condition, illness, disease, injury or ailment.
      • It is consistent with the symptoms or proper diagnosis and treatment of the medical condition, disease, injury or ailment.
      • It is in accordance with accepted standards of good medical practice in the community.
      • It is furnished in a setting commensurate with the member's medical needs and condition.
      • It cannot be omitted under the standards referenced above.
      • It is not in excess of the care indicated by generally accepted standards of good medical practice in the community.
      • It is not furnished primarily for the convenience of the member, the member's family or the provider.
      • In the case of a hospitalization, the care cannot be rendered safely or adequately on an outpatient basis or in a less intensive treatment setting and, therefore, requires the member receive acute care as a bed patient.

      The fact that a provider has prescribed a service or supplies care does not automatically mean the service or supply will qualify for reimbursement under the EmblemHealth plan. To be eligible for reimbursement by EmblemHealth, all covered services must meet EmblemHealth's medical necessity criteria, described above.

      Medically necessary with respect to Medicaid and Family Health Plus members means health care and services that are necessary to prevent, diagnose, manage or treat conditions that cause acute suffering, endanger life, result in illness or infirmity, interfere with a person's capacity for normal activity or threaten some significant handicap.

      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.

      Conditions that affect thinking and the ability to figure things out that affect perception, mood and behavior.

      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 public agency that works to control the spread of infectious diseases, monitor the health of New Yorkers and create an environment that protects and promotes health by using regulations, education and advocacy and providing direct health services. Also known as NYCDOHMH.

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

      The use of health care providers who have not contracted with the health plan to provide services. Depending on the member's contract, out-of-network services may not be covered.

      A physician, hospital or other provider who has signed an agreement to covered services to EmblemHealth plan members. A participating provider is a member of the EmblemHealth network of providers applicable to the member's certificate. Therefore, they are more commonly referred to as network providers. Payment is made directly to a participating provider. Please consult the EmblemHealth Directory or go online to search for participating providers.

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

      A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.

      A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.

      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.

      The use of one or more drugs for purposes other than those for which they are prescribed or recommended.


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