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  • Access to Care and Delivery System > Primary Care Physician Selection, Assignment and Change Policy for Members Whose Benefit Design Requires the Selection of a PCP

    When EmblemHealth members first enroll, they choose where they want to receive medical care. Members can choose any participating primary care physician (PCP) with an open panel. Members who fail to select a PCP within a given period of time are assigned to a PCP and notified of the assignment in writing.

    Members who subsequently wish to transfer to another network PCP may do so at any time for any reason by calling our Customer Service departments or by logging on to our Web site, PCP changes take effect immediately upon request.

    When members transfer from one network PCP practice to another, the PCP who previously treated the member is required to forward a copy of the member's medical record to the new PCP, allowing for continuity of care. The original record should be retained and treated as a terminated record.

    Note that Medicaid members that are in the Restricted Recipient Program have restrictions on when they can change PCPs out of good cause reasons such as:

    • Provider no longer wishes to be the RRP member's provider;
    • Provider closed/moved servicing location or moved to a location that is beyond 30 minutes or 30 miles from RRP member's home;
    • Provider no longer participates in HIP's network;
    • Member moved beyond 30 minutes or 30 miles from RRP provider;
    • Other circumstances exist that make it necessary to change providers, including but not limited to good cause reasons for changing PCPs as provided by applicable statute and regulations.

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    Glossary terms found on this page:

    An agreement in which a patient assigns to another party, usually a physician or hospital, the right to receive payment from a public or private insurance program for the service the patient has received.

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

    Professional services rendered by a physician for the treatment or diagnosis of an illness or injury.

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

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

    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.


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