Podiatry > Requests for Exceptional Case Review
Exceptional cases are members whose podiatric services present a high degree of severity or complexity and/or require significant frequency of service or volume of care within their respective six-month periods. Payments must have been previously adjudicated under the Market Share Payment (MSP) program in order to be reviewed and reclassified as exceptional.
MSP participating podiatrists who wish to have a case reviewed for this determination must submit the following supporting documentation:
- Cover letter providing detail to support adjustment request
- Copy of previously submitted claim form
- Clinical notes
- Radiological and operative reports
The above information may be sent to:
Co-Chairman, Podiatry Professional Advisory Committee
55 Water Street
New York, NY 10041-8190
The Podiatry Professional Advisory Committee (PAC), a panel composed of professional EmblemHealth staff and practitioners from the New York podiatric community, will review qualifying cases during each of the committee's quarterly meetings. Podiatrists will be told the outcome of their request within a reasonable timeframe thereafter.
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 application for payment of benefits under a health care plan.
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 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 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.