The following text outlines the legal agreement between the Practitioner and EmblemHealth with regards to the above information.
The term "Practitioner" hereunder shall refer to any contracted primary care physician, specialist, hospital facility and physician practicing within a physicians' group or hospital facility, unless otherwise noted.
Records and Reports
Practitioner shall document all Covered Services provided to Members in a format which is easily retrievable and which conforms with federal, state and local laws and regulations applicable to medical records. Practitioner shall permit the Plan's representative(s) access on-site at Practitioner's practice, upon reasonable prior notice and during regular business hours, to inspect and copy all medical, billing, and financial and statistical records relating to the provision of Covered Services to Members in accordance with all applicable laws and regulations and usual policies and procedures for the maintenance of such records.
Practitioner shall make Members' medical records available to the Plan or its designated representative(s) for, among other purposes, conducting utilization review and assessing quality of care and the Medical Necessity and appropriateness of care provided to Members. Practitioner shall comply with all federal, state and local laws and regulations applicable to the confidentiality, privacy, and maintenance of patient records, including requirements for maintaining such records for six (6) years (10 years for Medicare members) from the last date of treatment or, in the case of a minor, for six (6) years after the minor reaches the age of majority, or for such period of time as required by law, whichever is longer. Record maintenance and audit access shall survive the termination of this Agreement regardless of the cause giving rise to such termination.
Practitioner shall, no later than ten (10) business days after receipt of written request, provide a copy of a Member's medical records, encounter data or financial and statistical records relating to services rendered to Members to the Plan, NYSDOH, and to any other federal, state or local governmental agency, e.g., CMS or LDSS (for Medicaid only), involved in assessing the quality of care or investigating Member grievances or complaints, including the Comptroller General of the State of New York, the Department of Health and Human Services and the Comptroller General of the United States and their authorized representatives. Upon such request from any federal, state, or local government, Practitioner shall provide written notice of such request to the Plan within four (4) business days of such request. All requests for records shall be supplied to the Plan at Practitioner's expense. This provision shall survive termination of this Agreement regardless of the cause giving rise to such termination.
In the event that a Member transfers to another Participating Provider, Practitioner shall, within ten (10) days of a Member's authorization, provide a copy of the Member's medical records to the Member's new Participating Provider without charge. Moreover, Members shall be provided with a copy of their medical records, upon appropriate request, without charge from Practitioner. This procedure will ensure that the new PCP will have a continuous medical record of the member and that there should not be a lapse in continuity or treatment.
Non-Emergent Medical Record Transfer
Upon any change of PCP, the member should be asked to sign a Request for Medical Information. Dates of treatment would be inclusive of current and outstanding laboratory and/or x-ray reports. The Request for Medical Information will be sent to the previous PCP, and the copy of records will be forwarded to the new PCP's office as soon as possible.
Emergent Medical Record Transfer
In the event of a change in PCP in an emergency situation, the Plan may call the previous PCP office directly and request, by phone, that a copy of the medical records be forwarded to the new PCP. A written request would follow by mail within 24 hours of the initial phone contact.
Practitioner shall maintain and provide any other records the Plan may request for regulatory compliance or program management purposes and shall cooperate with the Plan in all fiscal and medical audits, site inspections, peer review, Utilization Management, credentialing and recredentialing and any other monitoring required by federal, state or local regulatory or accreditation agencies, including Utilization Review Accreditation Commission ("URAC") and the National Committee for Quality Assurance ("NCQA"). Any record required by a regulatory or accreditation agency shall, at Practitioner's expense, be delivered to the Plan within the time frame requested by the requesting agency, but in no event more than four (4) business days of its request. Practitioner shall promptly comply with all directives and recommendations issued as a result of any such inspection or audit. Practitioner shall retain all financial and administrative records relating to this Agreement for seven (7) years after the termination of this Agreement, or for such period of time as required by law, whichever is longer. This provision shall survive termination of this Agreement regardless of the cause giving rise to such termination.
Providing Access to Medical Records
Within ten days of a written request, a health care provider must provide an opportunity, for an individual to inspect any patient information (in the provider's possession) relating to the examination or treatment of an individual. The request may come from any qualified person. A "qualified person" means any properly identified subject, or an appointed guardian under article 81 of the mental hygiene law, a parent of an infant, a guardian of an infant appointed pursuant to article 17 of the surrogate's court procedure act (or other legally appointed guardian of an infant who may be entitled to request access to a clinical record) or an attorney representing or acting on behalf of the individual or the individual's estate.
A parent or guardian is not entitled to inspect or make copies of any patient information concerning the care and treatment of an infant where the health care provider determines that access to the information requested by the parent or guardian would have a detrimental effect on the provider's professional relationship with the infant, or on the care and treatment of the infant, or on the infant's relationship with his or her parents or guardian.
Note that a provider may refuse to provide access to information if the provider believes that (i) "review of the requested information can reasonably be expected to cause substantial and identifiable harm to the subject or others which would outweigh the qualified person's right to access to the information, or (ii) the material requested is personal notes and observations, or the information requested would have a detrimental effect as defined by law".
Providers should be familiar with Public Health Law sections 17 and 18 which further define when providers must provide access, timeframes, frequency, when charges may be imposed, etc.
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.
Services that have been approved for payment based on a review of EmblemHealth's policies.
Services that have been approved for payment based on a review of EmblemHealth's policies.
The government agency responsible for administering the Medicare and Medicaid programs.
Initial oral or written communication from a member or their designee or provider that expresses discontent with any aspect of their care or coverage with EmblemHealth. Specifically, it is dissatisfaction with:
- A determination made by the plan, other than a determination of medical necessity or a determination that a service is considered experimental or investigational
- Treatment experienced through the plan, its providers or contractors
- Any concern with the plan, its benefits, employees or providers.
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 medically necessary service for which a member is entitled to receive partial or complete coverage under the terms and conditions of the benefit program, is within the scope of the practitioner's practice and the practitioner is authorized to render pursuant to the terms of the agreement.
The US government's principal agency for protecting the health of all Americans and providing essential human services. Also called the DHHS.
Means a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (a) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy; (b) serious impairment to such person’s bodily functions; (c) serious dysfunction of any bodily organ or part of such person; or (d) serious disfigurement of such person.
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.
A hospital, ambulatory surgical facility, birthing center, dialysis center, rehabilitation facility, skilled nursing facility or other provider certified under New York Public Health Law. A hospice is a facility. An institutional provider of mental health substance abuse treatment operating under New York Mental Hygiene Law and/or approved by the Office of Alcoholism and Substance Abuse Services is a facility.
A request to change an adverse determination that was based on administrative policies, procedures or guidelines.
A professionally licensed individual, facility or entity giving health-related care to patients. Physicians, hospitals, skilled nursing facilities, pharmacies, chiropractors, nurses, nurse-midwives, physical therapists, speech pathologist and laboratories are providers. All network providers are health care providers, but not all providers are network providers.
An institution which provides inpatient services under the supervision of a physician, and meets the following requirements:
- Provides diagnostic and therapeutic services for medical diagnosis, treatment and care of injured and sick persons and has, as a minimum, laboratory and radiology services and organized departments of medicine and surgery
- Has an organized medical staff which may include, in addition to doctors of medicine, doctors of osteopathy and dentistry
- Has bylaws, rules and regulations pertaining to standards of medical care and service rendered by its medical staff
- Maintains medical records for all patients
- Has a requirement that every patient be under the care of a member of the medical staff
- Provides 24-hour patient services
- Has in effect agreements with a home health agency for referral and transfer of patients to home health agency care when such service is appropriate to meet the patient's requirements
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.
A city or county social services district as constituted by Section 61 of the New York State Social Services Law (SSL). Also called a Local Department of Social Services.
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.
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 nonprofit organization that performs quality-oriented accreditation reviews of HMOs and similar types of managed care plans. Also called NCQA.
A nonprofit organization that performs quality-oriented accreditation reviews of HMOs and similar types of managed care plans. Also called National Committee for Quality Assurance.
The state regulatory agency that certifies reimbursement methods and rates to hospitals and reviews HMO activities in the state of New York. Also called the New York State Department of Health.
A physician, hospital or other provider who has signed an agreement to covered services to EmblemHealth plan members. A participating provider is a member of the EmblemHealth network of providers applicable to the member's certificate. Therefore, they are more commonly referred to as network providers. Payment is made directly to a participating provider. Please consult the EmblemHealth Directory or go online to search for participating providers.
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 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 family physician, family practitioner, general practitioner, internist or pediatrician who is responsible for delivering or coordinating care. Also called a PCP.
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.
New York State Department of Health. This agency provides information for consumers, doctors, researchers and health care providers.
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.
A formal evaluation (prospective, concurrent or retrospective) of the coverage, medical necessity, efficiency or appropriateness of health services and treatment plans. Also called Coordinated Care.