There are many clinical reasons practitioners other than radiologists perform in-office imaging as part of their diagnostic and treatment plans. We have radiology and cardiology imaging privileging protocols for HIP/HIPIC-underwritten Benefit Plans that are administered by EmblemHealth, which include Commercial (including GHI HMO, Vytra branded plans), state-sponsored and Medicare plans. These privileging protocols make up the Diagnostic Imaging Self-Referral Payment Policy. They are designed to promote the appropriate use of diagnostic imaging by clinicians in office settings.
The payment policy applies to services performed in an office setting (POS 11). It is based on a careful review of the literature and standards of the American Society of Echocardiography (ASE), Intersocietal Accreditation Commission (IAC), American College of Cardiology (ACC) and American Board of Radiology (ABR). The policy designates which imaging procedures will be reimbursed (subject to the member’s benefit plan) according to practitioner specialty. It also describes the minimum accreditation and certification requirements.
For providers to perform imaging procedures within their specialty, they must meet and maintain the minimum certification requirements. These requirements are listed in the Outpatient Imaging Self-Referral Payment Policy chart in this chapter. When imaging procedures are performed outside the practitioner’s specialty or when the practitioner fails to maintain the minimum certification requirements or obtain Prior Approval when required, claims for such services will be denied, with no liability to the member.
Glossary terms found on this page:
An evaluative process in which a health care organization undergoes an examination of its policies and procedures to determine whether the procedures meet designated criteria as defined by the accrediting body, and to ensure that the organization meets a specified level of quality.
A health insurance product offered by a health plan company that is defined by the benefit contract and represents a set of covered services. Also called a health benefit plan.
A process in which an individual, an institution or educational program is evaluated and recognized as meeting certain predetermined standards. Certification usually applies to individuals; accreditation usually applies to institutions.
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 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.
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 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 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.
The process of obtaining advanced approval of coverage for a health care service or medication. The request for services is reviewed to assess medical necessity and appropriateness of elective hospital admissions and non-emergency outpatient services before the services are provided. Also called pre-authorization or pre-certification or pre-determination.
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
- Doctor of podiatric medicine
- Physical therapist
- Nurse midwife
- Certified and registered psychologist
- Certified and qualified social worker
- Nurse anesthetist
- Speech-language pathologist
- 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 recommendation by a physician that an enrollee receive care from a specialty physician or facility.