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  • Directory > Additional Resources (Providers and Members)

    Additional Resources (Providers and Members)

    Entity Address Phone Email/Comments
    Chiropractic and Physical/Occupational Therapy

    Palladian Muscular Skeletal Health

    2732 Transit Road
    West Seneca, NY 14224

    (877) 774-7693

    www.palladianhealth.com

    Delegated for utilization management.

    Dental Services

    DentaQuest

    1-844-822-8108, Monday to Friday from 8 am to 5 pm.

    dentaquest.com

    Managing Entities

    HealthCare Partners (HCP)

    501 Franklin Ave., Suite 300
    Garden City, NY 11530-5807

    (516) 746-2200 or
    (888) 746-2200

    www.hcpipa.com

    Delegated for credentialing, utilization management, claims processing (except for HCP Cohort 2) and first call resolution.

    Montefiore CMO

    100 Corporate Drive
    Yonkers, NY 10701

    (877) 447-6668

    www.montefiore.org

    Delegated for credentialing, utilization management and claims processing.

    Radiology Services

    eviCore

    P.O. Box 61022
    Anaheim, CA 92803

    (800) 918-8924

    www.evicore.com
    Vision Services -Update for EyeMed
    EyeMed Vision Care
    For all members with a vision care benefit
    4000 Luxottica Place
    Mason, Ohio 45040
    877-324-2791
    Medicaid

    877-324-4063
    Commercial (HMO, PPO, POS)

    877-324-6211
    On/Off Individual and Group Exchange and Essential Plans
    EyeMed conducts claims processing for routine vision claims. There are specific CPT and diagnosis codes that fall under the umbrella of claims paid by EyeMed.
    Injectables and Specialty Pharmacy Program – Update of Magellen RX

    ICORE National, LLC

    5850 T.G. Lee Blvd.,
    Suite 510 Orlando, FL 32822

    (800) 424-4088

    www.icorehealthcare.comDelegated for utilization management.

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    Glossary terms found on this page:

    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.

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

    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.

    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.

    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.

    Treatment to restore a physically disabled person's ability to perform activities such as walking, eating, drinking, dressing, toileting and bathing (activities of daily living).

    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.

    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 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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