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  • Clinical Practice Guidelines > EmblemHealth-Adopted Clinical Practice Guidelines

    Medical Management

    (Please access these clinical practice guidelines at

    • Adults Exposed to the World Trade Center Disaster
    • Adult Preventive Services
    • Appropriate Use of Antibiotics for Adults and Children
    • Arthritis
    • Asthma
    • Cholesterol Management for Adults at Risk for Cardio/Vascular Disease
    • Chronic Kidney Disease
    • Chronic Obstructive Pulmonary Disease (COPD)
    • Community-Acquired Pneumonia in Adults
    • Congestive Heart Failure
    • Coronary Artery Disease
    • Diabetes Mellitus
    • Helicobacter Pylori
    • HIV/AIDS
    • Hypertension
    • Low Back Pain Diagnosis and Treatment
    • Lyme Disease
    • Obesity and Weight Management in Adults
    • Obesity and Weight Management in Children and Adolescents
    • Osteoporosis
    • Pediatric and Adolescent Preventive Services
    • Preconception Care
    • Prenatal/Postpartum Care
    • Sexually Transmitted Diseases (STDs)
    • Smoking Cessation
    • Stroke Prevention
    • Tuberculosis
    • Urinary Incontinence

    Behavioral Health Services

    Beacon Health Options manages behavioral health services for members served by Emblem Behavioral Health Services Program (for plans underwritten by HIP and HIPIC and administered by VHMS) and Behavioral Management Program (for plans underwritten by GHI).

    Please access the Beacon Health Options Treatment Guidelines listed below at

    Diagnosed Based

    Program Based

    Treatment Based

    My Subscriptions

    Enter your e-mail address to receive a link to your subscriptions.


    Glossary terms found on this page:

    Conditions that affect thinking and the ability to figure things out that affect perception, mood and behavior.

    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.

    When a member is covered by more than one benefit plan, with both providing similar benefits, EmblemHealth coordinates with the other carrier to ensure appropriate reimbursement. Also called Coordination of Benefits.

    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.

    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 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 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.

    Provides managed mental health and substance abuse (MHSA) programs, workplace services, employee assistance programs (EAP), psychiatric disability management, Medicaid behavioral health management and child welfare programs for over 23 million lives. Visit the ValueOptions Web site at


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