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  • Dispute Resolution for Medicare Plans > 2017 Reconsideration Rights for Network Terminations and Non-renewal: EmblemHealth Medicare HMO

    A reconsideration request may be initiated if the terminated or non-renewed provider believes that there is significant and relevant information about his/her practice which might be unknown to EmblemHealth. EmblemHealth will review this additional information in reconsideration of this decision. All decisions are final. The terminated or non-renewed provider has thirty days from receipt of the termination letter or provider contract non-renewal notification letter to request reconsideration for the applicable Medicare networks. 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. For terminations and non-renewals from the Enhanced Care Prime Network (Medicaid, HARP and Essential Plan) see Dispute Resolution for Medicaid Managed Care Plans.

    To request a reconsideration of your non-renewal or termination, please follow these instructions:

    • Should you exercise your right to an appeal/hearing of this decision, your response should be sent to Tonya Volcy, Director of Credentialing by certified mail, return receipt requested, to the following address:

    Tonya Volcy
    Director of Credentialing
    EmblemHealth
    55 Water Street, 2nd floor
    New York, NY 10041

    • Requests submitted must include a letter describing special circumstances of which EmblemHealth may be unaware.
    • Reconsideration meetings will be scheduled and conducted via phone at an EmblemHealth location during normal business hours.
    • An Ad hoc Reconsideration Board, consisting of three physicians will conduct the reconsideration hearing.
    • The Ad hoc Reconsideration Board makes the final decision.
    • The provider will be notified in writing within seven business days of the decision.
    • Providers whose termination or non-renewal status is upheld will be notified, citing the original date of the change. Participation in the impacted networks will continue uninterrupted for providers whose termination or non-renewal status is overturned.
    • Prior to August 1, 2017, a checklist of the following, along with supporting documentation, as specified, was required. Reconsideration requests filed after this date do not require this additional information.

    Applicability Present in Practice
    (Yes/No) 
    CriteriaDocumentation Required
    PCPs

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

    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

    E-Prescribing
    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.

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    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 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.

    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.

    A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.

    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 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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