In this chapter you will find credentialing and recredentialing requirements, including the managed care law requiring provisional credentialing, and the practitioner appeal process for changes in participation. EmblemHealth permits the delegation of credentialing to certain large organizations that are subject to strict oversight protocols. Check with your practice administrator to see if delegation protocols apply to your organization.
Glossary terms found on this page:
Oral or written request from a member or their designee for EmblemHealth to review or reconsider a decision made by the plan.
The process by which the organization permits another entity to perform functions and assume responsibilities covered under these standards on behalf of the organization, while the organization retains final authority to provide oversight to the delegate.
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.
Any form of health plan that uses selective provider contracting to have patients seen by a network of contracted providers and that requires prior approval of certain services.