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  • Medical Record Guidelines > Medical Record Guidelines

    EmblemHealth requires its practitioners to maintain accurate medical records.

    The medical record contains information about each member, identifies the patient's complaints/symptoms or lack thereof, contains the diagnosis and basis for the diagnosis, the communication and discussion of treatment options, side effects, decisions made and treatments rendered. The primary purpose of the record is to document the course of the member's health or illness and treatments and serve as a mode of communication between physicians and other professionals participating in the care rendered. The entire medical record of an active member must remain in the primary care physician's office and must be consistent with all relevant local, state and federal laws, rules and regulations.

    The following guidelines assist EmblemHealth in assuring the appropriate exchange and retention of member medical data and are used to perform clinical audits in conjunction with ongoing quality assurance activities.

    Please note that EmblemHealth may request a copy of, or make an on-site visit to review, your medical records for internal and regulatory chart audits.

    Access to medical records

    A member has the right to review, copy and request amendments to his or her medical record. Any member or qualified person who desires a copy of the medical record may obtain one by submitting a written request to his or her participating practitioner or facility.

    Our member handbook tells members how to give consent to the collection, use and release of personal health information, how to obtain access to their medical records and what we do to protect access to their personal information.

    A member or qualified person may challenge the accuracy of the information in the medical record. In addition, he or she may require that a statement describing the challenge be added to the record.

    Access by a member or qualified person to information in the medical record may be denied, but only if the participating provider or facility determines that:

    Access can reasonably be expected to cause substantial harm to the member or to others; or

    Access would have a detrimental effect on the participating practitioner's or facility's professional relationship with the member, or on their ability to provide treatment.

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    Glossary terms found on this page:

    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.

    Medical equipment, goods, implements and prosthetics that are prescribed for patient care, usually in an outpatient setting. Examples of such equipment include hospital beds, wheelchairs and walkers.

    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.

    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.

    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 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 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 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
    • 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.


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