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  • Dispute Resolution for Medicare Plans > 2016 Reconsideration Rights for Network Non-renewal: for Medicare HMO Line of Business Only

    A reconsideration request may be initiated if the non-renewed provider believes that there is information about his/her practice which might be unknown to EmblemHealth and should be reviewed in reconsideration of this decision. Please note, however, that reconsideration applies only to the Medicare HMO line of business; no other plans/lines of business are subject to reconsideration. All decisions are final. The non-renewed Medicare HMO provider has thirty days from receipt of the provider contract non-renewal notification letter to request reconsideration for the Medicare HMO line of business. Upon receipt of a completed reconsideration request, EmblemHealth will schedule an in-person meeting to be held during normal business hours at an EmblemHealth location.

    To request a reconsideration of your non-renewal from the Medicare Essential and/or Medicare Advantage HMO networks, please follow these instructions:

    • Submit requests for reconsideration in writing to:

    55 Water Street, North Tower
    Dept. 30301 – Non Renewal Coordinator
    New York, NY 10041-8190

    • Requests must include the following:
      • A letter describing what special circumstances of which EmblemHealth may be unaware.
      • A checklist of the following, along with supporting documentation, as specified.

    ApplicabilityPresent in Practice
    CriteriaDocumentation Required

    Patient Center Medical Home (PCMH)
    Evidence of participation in a Level 2 or Level 3 PCMH.

    Patient Centered Medical Practice (PCSP)
    Evidence of participation as a PCSP.
    All Physicians

    Electronic Health Record (EHR)
    A copy of the CMS attestation proving EHR stage 1 or stage 2 meaningful use.
    All Physicians

    Identification of the E-prescribing vendor used and the date implemented.
    All Physicians

    Hierarchical Condition Categories (HCC)
    Any evidence of adoption of ePASS® for reporting HCC gap closure to EmblemHealth.
    All Physicians

    Wellness Programs
    Example(s) of any wellness programs administered by the practice to EmblemHealth members. Please include any improved outcomes demonstrated by these wellness programs.
    All Physicians

    Electronic Lab Results
    Any evidence of the practice’s adoption of Care360®, a free tool used to order lab tests and obtain results from Quest Diagnostics, EmblemHealth’s preferred diagnostic testing laboratory.
    All Physicians Other info
    Any documentation supporting specified criteria.

    • After receipt of this information, reconsideration meetings will be scheduled and conducted at an EmblemHealth location during normal business hours.
    • An Adhoc Reconsideration Board, consisting of three physicians will conduct the reconsideration hearing.
    • The Adhoc Reconsideration Board makes the final decision.
    • The provider will be notified in writing within seven business days of the decision.
    • Providers whose non-renewal status is upheld will be notified, citing the original date of non-renewal. Participation in the Medicare HMO line of business will continue uninterrupted for providers whose non-renewal status is overturned.

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    Glossary terms found on this page:

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

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

    A test or procedure ordered by a physician to determine if the patient has a certain condition or disease based upon specific signs or symptoms demonstrated by the patient. Such diagnostic tools include radiology, ultrasound, nuclear medicine, laboratory and pathology services.

    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.

    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 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 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. Also known as MA.

    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 family physician, family practitioner, general practitioner, internist or pediatrician who is responsible for delivering or coordinating care. Also called a primary care physician.

    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 request for inpatient review, made while the member is still in the facility, of a case that was denied on the basis of medical necessity.


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