EmblemHealth requires that each employee and committee member sign a Confidentiality Agreement to ensure that information regarding its members and practitioners/providers is held to confidentiality standards. Confidentiality standards are governed by written policies and procedures and are applicable to oral and written confidential information, including member, practitioner/provider, and company proprietary information. In addition, key departments have internal privacy and confidentiality policies and procedures specific to their function. It is the responsibility of department management to review these policies and procedures annually with each of their employees. The Corporate Compliance Committee has oversight responsibility for development and implementation of privacy and confidentiality policies.
All quality assessment and improvement data, committee minutes, reports, recommendations, and actions are kept strictly confidential and under the auspices of the Quality Improvement Committee. Information pertaining to a member and his/her family will not be released to any third party without the expressed written authorization of the member or his/her legal guardian except as required or permitted by law or with a bona fide legal demand. All medical information utilized to study the general quality and effectiveness of medical services provided to members shall be presented in de-identified form, excluding all individual patient information.
Provider, and practitioner-specific quality assessment and improvement information is maintained in each provider and practitioner’s file with restricted access. Documents and information obtained through the Quality Improvement Program are regarded as confidential and protected under Quality Assurance and Peer Review processes.
EmblemHealth is responsible for developing, compiling, evaluating, and reporting certain measures and other information to CMS, its enrollees, and the general public. EmblemHealth safeguards the confidentiality of the doctor-patient relationship, and reports to CMS in the manner required for cost of operations, patterns of utilization of services, and availability, accessibility, and acceptability of Medicare-approved and covered services. All documentation required by regulatory and accrediting bodies, including CMS, is made available in the format required by the regulatory and accrediting bodies, upon request. This includes, but is not limited to, the Quality Improvement Program Description, Work Plan, Evaluation, Policies, Operational Processes, Quality Improvement Activities, etc.
Glossary terms found on this page:
An activity of EmblemHealth or its subcontractor that results in:
- Denial or limited authorization of a service authorization request, including the type or level of service
- Reduction, suspension or termination of a previously authorized service
- Denial, in whole or in part, of payment for a service
- Failure to provide services in a timely manner
- Failure of EmblemHealth to act within the time frames for resolution and notification of determinations regarding complaints, action appeals and complaint appeals
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.
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.
An individual who is enrolled and eligible for coverage under a health plan contract. Also called a member.
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.
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 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.
The process to objectively and systematically monitor and evaluate the quality, timeliness and appropriateness of covered services, including both clinical and administrative functions, to pursue opportunities to improve health care and resolve identified problems in any of these services.