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  • Care Management > Delineation of Responsibility

    EmblemHealth and our utilization agents, in collaboration with our contracted physicians and hospitals, perform utilization management activities as required by State and Federal law, and consistent with professional standards developed by the Centers for Medicare & Medicaid Services, NCQA and URAC. The responsibilities and authority of the parties associated with the Plan's utilization management activities are outlined below.

    Board of Directors

    The Board of Directors is the entity accountable for care management activities. The Board endorses the written Care Management program and receives and reviews care management statistical reports on a quarterly basis. The Board is responsible for considering and acting upon Care Management program recommendations. The Board may accomplish its duties through an appropriately designated subcommittee.

    Care Management Committee

    The Care Management Committee reviews clinician over- and underutilization patterns and trends, physician performance profiling, and a variety of data that monitor the effectiveness and efficiency of the Care Management processes.

    The committee is responsible for approval of EmblemHealth's Care Management policies and procedures, both current and proposed.

    Chief Medical Officer/Plan Medical Directors

    EmblemHealth's chief medical officer has overall accountability for the Care Management program and provides oversight and direction for all quality improvement and care management functions including establishing long- and short-range Care Management program goals relative to EmblemHealth's overall strategic plan.

    Medical directors serve as resource persons for physicians and Care Management nurses on clinical issues.

    Care Management Department

    The Care Management department functions to support the care management activities of EmblemHealth, participating clinicians, hospitals and other facilities. The Care Management department assists clinicians with the determination of appropriate care in an appropriate setting, including the use of participating clinicians to maximize the members' clinical outcome and benefit coverage. Our Care Management department consists of licensed physicians, nursing professionals and analysis personnel who work to improve the performance of internal processes, external processes and the care provided to members through data analysis and process management.

    Clinical Personnel

    Where procedures are used for prior approval and concurrent review, qualified health care professionals supervise utilization review decisions.

    Licensed nurses and other licensed health care professionals, in conjunction with the Medical Directors when appropriate, provide the clinical review and appropriateness of the referral of patient services based on accepted criteria. Data acquisition and utilization outcomes, trends, quality of care issues, and over- and underutilization statistics are reported to the Care Management Committee.

    Plan Utilization Review Agents

    A utilization review (UR) agent is often called a delegate. We jointly refer to EmblemHealth Care Management staff and the delegates as "managing entities." A UR agent or delegate is an entity (i.e., management services organization, independent practice association and/or hospital) that has been authorized by EmblemHealth to assume the authority and responsibility to perform certain utilization management and/or utilization review 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.

    Information relating to the patient's health.

    Occurs when a clinical professional reviews information about a patient's health.

    A legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.

    An entity contracted with EmblemHealth to perform various services including utilization review, credentialing and claims processing. Also called managing entities and carve outs.

    An individual other than the subscriber who is eligible to receive health care services under the member's Certificate of Insurance. Generally, dependents are limited to the subscriber's spouse and eligible children.

    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

    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 IPA.

    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.

    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 doctor of medicine or doctor of osteopathic medicine who is duly licensed to practice medicine and is an employee of, or party to a contract with, a utilization management organization, and has responsibility for clinical oversight of the utilization management organization's utilization management, credentialing, quality management and other clinical functions.

    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.

    A nonprofit organization that performs quality-oriented accreditation reviews of HMOs and similar types of managed care plans. Also called National Committee for Quality Assurance.

    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.

    The process to objectively and systematically monitor and evaluate the quality, timeliness and appropriateness of covered services, including both clinical and administrative functions, to pursue opportunities to improve health care and resolve identified problems in any of these services.

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

    A review to determine whether covered services that have been provided or are proposed to be provided to a member, whether undertaken prior to, concurrent with or subsequent to the delivery of such services are medically necessary. Also called Coordinated Care.

    A formal evaluation (prospective, concurrent or retrospective) of the coverage, medical necessity, efficiency or appropriateness of health services and treatment plans. Also called Coordinated Care.


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