This chapter applies to home health care (HHC) services for most EmblemHealth Members enrolled in the Health Insurance Plan of Greater New York (HIP) starting January 1, 2018. eviCore healthcare will manage most HHC prior approvals for HIP members.
EmblemHealth will continue to manage Personal Care Assistants and Consumer Directed Personal Assistance Programs. See Care Management chapter for rules that will continue to apply to these services, excluded members, and to Group Health Incorporated (GHI) members.
Prior approvals do not guarantee claim payment. Services must be covered by the member’s health plan and the member must be eligible at the time services are rendered. Claims submitted may be subject to benefit denial.
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 individual person who is the direct or indirect recipient of the services of the organization. Depending on the context, consumers may be identified by different names, such as "member," "enrollee," "beneficiary" or "patient." A consumer relationship may exist even in cases where there is not a direct relationship between the consumer and the organization. For example, if an individual is a member of a health plan that relies on the services of a utilization management organization, then the individual is a consumer of the utilization management organization.
Health care services rendered to a member in their home in lieu of confinement in a hospital or skilled nursing facility. Care must be under the supervision of a registered professional nurse. This type of care may include physical, occupational or speech therapy, medical supplies and medication prescribed by a doctor.
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.
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 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.