Your practice information appears in our network directories (including our online Find a Doctor tool) and is used in claims processing. Keeping your information up to date helps ensure that patients can locate your practice and we process your claims accurately. You must report updates to your practice information whenever change occurs in the following:
- Ability to accept new members
- Age-range limitations applicable to the health care professional
- Add or delete a provider from your practice
- Email address
- Fax number
- Hospital affiliations
- IRS taxpayer identification number (TIN)
- Languages spoken in your office
- Medicaid Number is assigned
- Medicare Number is assigned
- National Provider Identifier (NPI) number is assigned
- Office hours
- Opening or closing a primary care panel
- Practice address
- Practice phone number used for scheduling patient appointments
- Billing information
- Wheelchair accessibility has been added to a practice location
- When an OB/GYN opts to see GYN-only patients
Unless you’re part of a group that has arranged to submit changes via a spreadsheet/ dataset process, providers, and their staff, can access and update their practice records on our secure provider website. For changes that cannot be processed online, mail or fax your changes to our Provider Modifications team:
Provider Modifications Team
55 Water Street, 6th Floor
New York, New York, 10041-8190
Providers must inform EmblemHealth as soon as possible or within five (5) business days after any change to office address, telephone number, office hours, specialty, languages spoken, hospital affiliation, addition or termination of an individual provider in a medical group. Updates to your practice information will be posted to the EmblemHealth website within 15 days. In general, some updates, such as to your license number, specialty or school, will be verified by our Credentialing department and may take longer to appear.
Note: Removing an individual provider from a service location will not affect previously submitted claims. EmblemHealth will continue to process claims with a Date of Service on or before the provider’s termination date for that location.
EmblemHealth may terminate a provider if he/she fails to notify EmblemHealth of any required changes in a timely manner (subject to any applicable reconsideration or hearing rights required by state or federal law).
From time to time, regulatory agencies will audit the Plans’ directories for accuracy and may impose fines and/or penalties when information is determined to be inaccurate. Any fines/penalties received by the Plan due to a Practitioner’s failure to notify the Plan of any required change listed above will be levied to the Practitioner in the amount equal to the fine/penalty.
Change of Ownership
A change of ownership (CHOW) cannot be performed online; a CHOW is treated like a new enrollment. When a change of ownership occurs, providers must contact EmblemHealth. The appropriate contact information can be located in the EmblemHealth Contact Information section of the Directory chapter.
Know Your Network Participation
The provider profile also lists your network affiliations. If the network information on the member's ID card matches your network affiliations, then you are in-network for that member's benefit plan. See the Provider Networks and Member Benefit Plans chapter for a listing of all networks and plans.
Note: Some government program cards don’t have network names; however, they are easily identified by the plan name. Digital representations of our most common member ID cards are located in the Member Identification Cards section of the Your Plan Members chapter.
Ask to see a member’s ID card at each appointment, emergency visit or inpatient stay. However, the provision of service should not be conditioned solely on the presentation of a member ID card because a member’s enrollment status can change due to various reasons. Sign in to our secure provider website to check your patients’ eligibility status.
Keeping your information current ensures we send your claims payments and other important correspondence to the correct address. It also helps our members contact you at your current location. We recommend that you periodically review the information we have on file for you and encourage you to share your network participation and any changes with your staff on a regular basis.
Glossary terms found on this page:
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.
The government agency responsible for administering the Medicare and Medicaid programs.
The date on which a service was rendered.
A determination of whether or not a person meets the requirements to participate in the plan and receive coverage under the plan.
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 form sent to the enrollee after a claim for payment has been processed by the health plan. The form explains the action taken on that claim. This explanation usually includes the amount paid, the benefits available, reasons for denying payment and the claims appeal process. Also called Explanation of Benefits.
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 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.
A unique number which identifies the member's enrollment with EmblemHealth. EmblemHealth's claims are processed by this number. Also known as Member ID Number.
A card that allows the subscriber to identify himself or his covered dependents to a provider for health care services.
A unique number that identifies the member's enrollment with EmblemHealth. EmblemHealth's claims are processed by this number. Also known as Member ID Number.
The group of individuals who provide person-centered care coordination and care management to participants in a FIDA plan. Each participant will have an interdisciplinary team (IDT). Each IDT will be comprised, first and foremost, of the participant and/or his or her designee, and the participant’s designated care manager, primary care physician, behavioral health professional, home care aide, and other providers either as requested by the participant or his or her designee or as recommended by the care manager or primary care physician and approved by the participant and/or his or her designee. The IDT facilitates timely and thorough coordination between a FIDA plan and the IDT, primary care physician and other providers. The IDT makes coverage determinations. Accordingly, the IDT’s decisions serve as service authorizations, may not be modified by a FIDA plan outside of the IDT, and are appealable by the participant, their providers and their representatives. IDT service planning, coverage determinations, care coordination and care management are delineated in the participant’s person-centered service plan and are based on the assessed needs and articulated preferences of the participant.
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.
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 permit (or equivalent) to practice medicine or a health profession that is: 1) issued by any state or jurisdiction in the United States and 2) required for the performance of job functions.
Specific circumstances or services listed in the contract for which benefits will be limited.
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.
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.
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.
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
- Doctor of podiatric medicine
- Physical therapist
- Nurse midwife
- Certified and registered psychologist
- Certified and qualified social worker
- Nurse anesthetist
- Speech-language pathologist
- 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 set of providers contracted with a health plan to provide services to the enrollees.
A request for inpatient review, made while the member is still in the facility, of a case that was denied on the basis of medical necessity.