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  • Care Management > Continuity of Care with Out-of-Network Providers

    Continuity/Transition of Care - New Members

    Upon enrollment, the member shall select a PCP from whom the member may request continuation of care. When appropriate, EmblemHealth will permit new members to continue seeing their current out-of-network practitioner for up to 60 days.

    If on the effective date of enrollment a member has a life-threatening disease or condition or a degenerative and disabling disease or condition, the member may continue to see their current out-of-network practitioner for up to 60 days. In the case of pregnancy, if the member has entered into her second trimester, she may continue to see the nonparticipating practitioner through delivery and postpartum care for up to 60 days for care related to the delivery for Medicaid members. All transitions of care and continuity of services must be reviewed and approved by EmblemHealth or the member's assigned managing entity (see back of member ID card) prior to the services continuing. For the request to be considered, the member must have at least one of the following health conditions:

    1. A condition in the midst of ongoing course of treatment with an out-of-network provider
    2. Second and third trimester of pregnancy (up to 60 days postpartum directly related to the delivery for Medicaid members)

    If transitions of care and/or continuity of care is approved, it will be for a period of up to 60 days from the effective date of enrollment when the eligibility criteria are met. A single case agreement for continued services with an out-of-network health care provider must be agreed upon by EmblemHealth and the provider. The provider must do all of the following:

    • Accept our reimbursement rates as payment in full
    • Adhere to our Quality Improvement program
    • Provide medical information related to the enrollee's care
    • Otherwise adhere to our policies and procedures including those regarding referrals and obtaining prior approvals and a treatment plan approved by our applicable Prior Authorization department. (See the How to Obtain Prior Approval section in this chapter.)

      EmblemHealth will not deny coverage of an ongoing course of care unless an appropriate provider of alternate level of care is approved for such care.

      This transitional method does not require EmblemHealth to provide coverage for benefits not otherwise covered or diminish or impair pre-existing condition limitations contained in the member agreement.

      Continuity/Transition of Care - Benefits Exhausted or Ended

      We collaborate with the members and their providers and practitioners to assure that members receive the services needed, within the benefit limitations of their contracts. When benefits end for members, the Utilization Management department will assist, if applicable, in the transition of their care.

      Continuity of Care - When Providers Leave the Network

      When a member's health care practitioner leaves EmblemHealth, the member will be given the option of continuing an ongoing course of treatment with his or her current practitioner for a transitional period of up to 90 days. If the member has entered the second trimester of pregnancy, the transitional period includes the provision of postpartum care through 60 days postpartum directly related to the delivery. Members who wish to continue seeing their current health care practitioner for a limited time must contact or have their provider contact the appropriate Anticipated Care department (see the How to Obtain Prior Approval section in this chapter).

      EmblemHealth will permit a member to continue with their current practitioner as long as the reason for leaving is not related to imminent harm to patients, to a determination of fraud or to a final disciplinary action by a state licensing board that impairs the health professional's ability to practice. The practitioner must agree to all of the following:

      1. Continue to accept reimbursement at the rates applicable prior to the start of the transitional period as payment in full
      2. Adhere to EmblemHealth's quality assurance requirements and provide us with necessary medical information related to such care
      3. Otherwise adhere to our policies, which include but are not limited to, procedures regarding referrals, obtaining prior approval for services and obtaining an approved treatment plan

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      Glossary terms found on this page:

      An activity of EmblemHealth or its subcontractor that results in:

      • Denial or limited authorization of a service authorization request, including the type or level of service
      • Reduction, suspension or termination of a previously authorized service
      • Denial, in whole or in part, of payment for a service
      • Failure to provide services in a timely manner
      • Failure of EmblemHealth to act within the time frames for resolution and notification of determinations regarding complaints, action appeals and complaint appeals

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

      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).

      When the maximum number of visits for a specific service is reached, further benefits will not be considered.

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

      Any medically determinable physical or mental impairment that can be expected to result in death or has lasted or can be expected to last for a continuous period of not less than 12 months and renders the member unable to engage in any substantial gainful activities.

      The date on which the coverage of an insurance policy goes into effect at 12:01 am.

      A determination of whether or not a person meets the requirements to participate in the plan and receive coverage under the plan.

      An individual who is enrolled and eligible for coverage under a health plan contract. Also called a member.

      A professionally licensed individual, facility or entity giving health-related care to patients. Physicians, hospitals, skilled nursing facilities, pharmacies, chiropractors, nurses, nurse-midwives, physical therapists, speech pathologist and laboratories are providers. All network providers are health care providers, but not all providers are network providers.

      An individual who: (1) has undergone formal training in a health care field; (2) holds an associate or higher degree in a health care field, or holds a state license or state certificate in a health care field; and (3) has professional experience in providing direct patient care.

      A card which allows the subscriber to identify himself or his covered dependents to a provider for health care services.

      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.

      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.

      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 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 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 pre-existing condition is any disease, symptom or condition that was present on the first day of coverage and for which medical advice or treatment was recommended or received during the six-month period prior to the enrollment date.

      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.

      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.


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