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  • Care Management > Hospital and Facility Procedures

    The care management process is intended to establish and support a strong patient care team approach, which results in higher quality of care and lower costs. This process includes, but is not limited to, prior approval of facility admissions, concurrent management in the hospital, use of alternate care facilities and post-discharge follow-up.

    Elective Inpatient Procedures - Admitting Physicians

    The admitting network physician is required to obtain prior approval for elective inpatient procedures at least 10 business days in advance of the desired hospital admission date. This allows us sufficient time to obtain the necessary clinical information to process the request and to make appropriate arrangements for members (e.g., booking the facility space for the procedures and securing all lab work).

    Physicians can confirm the prior approval status of an admission for a HIP-, CompreHealth EPO- or EmblemHealth-managed member by signing in to or calling 1-866-447-9717.

    If the admitting physician is out-of-network, the member is responsible for contacting the plan for prior approval. For more information, see the How To Obtain a Prior Approval and Referrals and Elective Hospital Prior Approvals by Plan tables in this chapter.

    Elective Admission Procedures - Hospitals and Facilities

    (Including Acute, Inpatient Rehabilitation and Psychiatric Facilities)

    The admitting facility (including hospitals) must confirm there is a prior approval on file for all elective, non-emergent admissions and ambulatory procedures.

    In the event the facility is aware that the planned admission/procedure date has changed within a 90-day period, the facility should notify the plan of the new date(s) and ask the plan to modify the date(s) of the prior approval. An anticipated care report will be faxed daily to the facility listing those days/services that have been approved. If no services were approved for the facility, no report will be sent. (See the sample report at the end of this chapter.)

    The facility must ask to see the member's ID card upon admission. The ID card will provide line of business information as well as the managing entity's information for requesting prior approval and submitting claims. The facility must verify member benefit and eligibility information by signing in to or as indicated in the Confirm Member Eligibility table in the Your Plan Members chapter.

    If no prior approval has been issued where one is required, the claim submitted will be denied. Please see the Dispute Resolution chapters - Commercial/CHP, Medicaid, and Medicare - for information on denial determinations.

    Should the facility feel that an overnight stay is warranted for an outpatient service, the plan must re-evaluate the admission for medical necessity. All necessary information must be submitted to the managing entity for re-approval.

    Emergency Admission Procedures

    If a member presents at a hospital emergency room and needs to be admitted, the hospital is required to notify the member's PCP immediately and to notify the member's managing entity listed on the back of the ID card within 24 hours or as soon as practicable thereafter. Following are ways to notify us of an emergency admission:

    1. Contracted hospitals may notify HIP and the managing entities, HealthCare Partners and Montefiore CMO, electronically of all admissions through the emergency room by signing in to for HIP, GHI HMO, CompreHealth EPO and Medicare HMO members. Benefits of electronic notifications are:
      1. 24/7 access.
      2. Automatic date/time-stamped receipt immediately sent back as proof of the notification.
      3. Immediate confirmation of member eligibility.
      4. Automatic and immediate routing for those cases managed by another entity on HIP's behalf; includes date/time stamp of notification to HIP.
      5. PCP name and contact information provided.
      6. Ability to follow status of inpatient case at As soon as a notification is submitted, an inpatient case is created and assigned the same trace number referenced on the ER Admission Notification Receipt. For HIP-managed members, hospitals may use the trace number to find the inpatient case using the prior approval inquiry features. All cases appear in a pended status until all necessary information is received and concurrent review is performed.
    2. Contacted hospitals may notify HIP of emergency admissions for HIP, GHI HMO, CompreHealth EPO and Medicare HMO members by calling 1-866-447-9717 or faxing the notification to 1-866-215-2928.
    3. Contracted hospitals may notify Vytra by calling 1-888-288-9872.
    4. Contracted hospitals must notify GHI EPO/PPO and EmblemHealth EPO/PPO plans by calling 1-800-223-9870 or faxing the notification to 1-212-563-8391.

    Note: Our plans do not require prior approval for an admission through the emergency room; rather, we require notification so that the case may be reviewed on a concurrent basis. No authorization number is required, and the managing entity will not issue an authorization and/or case number until the case has been reviewed for medical necessity.

    If the facility fails to notify the managing entity of an admission through the emergency room, the managing entity will request medical records upon receipt of the claim and conduct a retrospective utilization review for medical necessity. Please see the Dispute Resolution chapters - Commercial/CHP, Medicaid, and Medicare - for more details.

    A member's PCP should respond to the hospital emergency room page within 30 minutes. If the hospital attempts to contact the member's PCP and does not make contact within 30 minutes, the hospital is instructed to contact the managing entity listed on the member's ID card for assistance in locating the PCP. The responding managing entity will obtain all relevant clinical information about the member.

    Once the managing entity is notified of the admission, the concurrent review nurses will review the case regularly to determine the appropriateness of ongoing care and the setting in which it is being delivered.

    Concurrent Review Status Report

    The Concurrent Review Status Report (see an example at the end of this chapter) will be posted to our secure website at, Monday through Friday (excluding holidays), twice a day at around 10 am and 5 pm. This report lists each admitted member and whether the current day is approved, denied or pending further information. Pending information means we require additional information to make a determination. If the requested information is not provided, the day will be denied with a provider/facility denial. The member may not be billed for this day.

    Emergency Services for Out-of-Area

    Medicaid and Commercial members are covered for emergency care in all 50 United States, Canada, Puerto Rico and the United States Territories of the Virgin Islands, Guam, American Samoa and the Northern Marianna Islands. Medicare members are covered for emergency care worldwide. In an emergency that meets this definition, members in one of these areas can go to the nearest emergency room or call 911.

    In-Hospital Services

    All in-hospital services and ancillary support should be provided by network physicians.

    See the Use of Out-of-Network Providers subsection in the Care Management chapter.

    Medicare Outpatient Observation Notice MOON

    On August 6, 2015, Congress enacted the Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act, which requires all hospitals and critical access hospitals (CAHs) to provide written notification and an oral explanation of such notification to individuals receiving observation services as outpatients for more than 24 hours. A standardized Medicare Outpatient Observation Notice (MOON), form CMS-10611 was developed to inform all Medicare beneficiaries when they are an outpatient receiving observation services, and are not an inpatient of the hospital or CAH.

    In accordance with the statute, the notice must include the reasons the individual is an outpatient receiving observation services and the implications of receiving outpatient services, such as required Medicare cost-sharing and post-hospitalization eligibility for Medicare coverage of skilled nursing facility services. Hospitals and CAHs must deliver the notice no later than 36 hours after observation services are initiated or sooner if the individual is transferred, discharged, or admitted.

    All hospitals and CAHs are required to provide this statutorily required notification no later than March 8, 2017.  The notice and accompanying instructions are available at:  

    Discharge Planning

    The discharge planning process should begin as soon as possible to allow time for the arrangement of appropriate resources for the member's care.

    For post-acute care based services, which may include acute rehabilitation, skilled nursing facility stay, home care, durable medical equipment (DME), hospice care and transportation, the concurrent review nurse will facilitate prior approvals of medically necessary treatments if the member's benefit plan includes these services.

    Readmission Policy

    Care Management reviews all readmissions to the same facility on a concurrent and retrospective basis for payment adjudication. The discharging facility is responsible for performing discharge planning and assuring the member is appropriate for discharge. This applies to all lines of business, including Medicare, Medicaid and Commercial. Note: Members may not be balanced billed for claims denied due to our readmission policy.

    Concurrent Reviews (Effective August 1, 2017)
    On a concurrent basis, any medically necessary readmission to the same facility/hospital/hospital system within 14 calendar days of a member's discharge for the same or similar diagnosis will be subject to a clinical review.

    For facilities that bill under diagnosis-related groups (DRGs) or case rates:

    • Relapse of conditions noted on the first admission
    • Complications of treatment or diagnostic investigations
    • Insufficient stabilization of patient’s condition prior to discharge

    The admission will be denied and a benefit denial will be issued. The facility will be advised of its grievance rights. In the event that a readmission case requires additional clinical information and it is provided by the facility, the review determines if the circumstances of the second admission are related to the first admission.

    For facilities that bill per diem (by the day):

    • We will not make any changes or additions to the first hospital admission. The second admission will only be approved if we decide it's a separate event from the first admission.
    • If the second admission is deemed a continuation of the first admission, it will be denied. A benefit denial will be sent with instructions about how to file a grievance (complaint).

    Facilities may ask for the claim to be reconsidered (a peer-to-peer discussion) and reopened (Medicare only). If the facility sends additional clinical information, EmblemHealth will review the claim and decide if the second admission is related to the first.

    Concurrent Reviews (Retired July 31, 2017)
    On a concurrent basis, any medically necessary readmission to the same facility within three calendar days following discharge from a medically necessary admission will be reviewed for the circumstances of the admission. The readmission will not be authorized for facility payment if due to one of the following:

    • Relapse of conditions noted on the first admission
    • Complications of treatment or diagnostic investigations
    • Insufficient stabilization of patient’s condition prior to discharge

    The admission will be denied and a benefit denial will be issued. The facility will be advised of its grievance rights. In the event that a readmission case requires additional clinical information and it is provided by the facility, the review determines if the circumstances of the second admission are related to the first admission.

    Out-of-Network Facility Admissions

    Admissions to out-of-network facilities in or out of the service area are monitored by telephonic review on a concurrent basis by the managing entity listed on the member's ID card. If the member is stable and needs ongoing care, a transfer may be initiated to facilitate the return of the member to care within the primary delivery system.

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    Glossary terms found on this page:

    The process by which a claim is paid or denied based on eligibility and contract determination.

    Formal acceptance as an inpatient by an institution, hospital or health care facility.

    The physician responsible for admission of a patient to a hospital or other inpatient health facility.

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

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

    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.

    Services available to a member as defined in his or her contract. Benefit design includes the types of benefits offered, limits (e.g., number of visits, percentage paid or dollar maximums applied) and subscriber responsibility (cost sharing components).

    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.

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

    The government agency responsible for administering the Medicare and Medicaid programs.

    Initial oral or written communication from a member or their designee or provider that expresses discontent with any aspect of their care or coverage with EmblemHealth. Specifically, it is dissatisfaction with:

    • A determination made by the plan, other than a determination of medical necessity or a determination that a service is considered experimental or investigational
    • Treatment experienced through the plan, its providers or contractors
    • Any concern with the plan, its benefits, employees or providers.

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

    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.

    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.

    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.

    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 hospital, ambulatory surgical facility, birthing center, dialysis center, rehabilitation facility, skilled nursing facility or other provider certified under New York Public Health Law. A hospice is a facility. An institutional provider of mental health substance abuse treatment operating under New York Mental Hygiene Law and/or approved by the Office of Alcoholism and Substance Abuse Services is a facility.

    A request to change an adverse determination that was based on administrative policies, procedures or guidelines.

    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.

    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.

    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 facility that is part of EmblemHealth's provider network and has signed an agreement to provide covered services to its members. Sometimes, network facilities are referred to as participating facilities.

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

    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 facility that does not have a participation agreement with EmblemHealth or another EmblemHealth plan to provide facility services to persons covered under EmblemHealth.

    A health care provider, such as a physician, skilled nursing facility, home health agency or laboratory, that does not have an agreement with EmblemHealth plans to provide covered services to members. Also called a Non-Participating Provider.

    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 geographic area in which a health plan is prepared to deliver health care through a contracted network of participating providers.

    A licensed institution (or a distinct part of a hospital) that is primarily engaged in providing continuous skilled nursing care and related services for patients who require medical care, nursing care or rehabilitation services. Also called a SNF.

    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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