Members in the following benefit plans are excluded from the program managed by eviCore. A prior approval request must be submitted to EmblemHealth at www.emblemhealth.com for radiation therapy services:
- EmblemHealth Medicare Supplemental (Medicare Cost)
- GHI CBP Program for City of New York Employees and Retirees
- DC37 Med Team Program
- EmblemHealth Medicare ASO (underwritten by GHI)
- EmblemHealth EPO/PPO (underwritten by GHI)
- HIP Prime® HMO and POS Plans for City of New York Employees
- HIP and GHI FEHB plans
- Vytra ASO accounts (underwritten by Vytra Health Plans Managed Systems)
- Vytra HMO (underwritten by HIP)
Also excluded from this program are HIP members assigned to a Montefiore (CMO) or HealthCare Partners (HCP) PCP and members assigned to a PCP affiliated with AdvantageCare Physicians, as listed below.
- Manhattan's Physician Group
- Preferred Health Partners
- Queens-Long Island Medical Group
- Staten Island Physician Practice
For applicable benefit plans, these members can be identified by their member ID card.
For members excluded from the Radiation Therapy program managed by eviCore, please refer to the Care Management chapter for information on how to obtain prior approval.
Prior approval must be obtained from eviCore for radiation therapy services performed on or after October 1, 2012. To submit prior approval requests, visit www.evicore.com or call eviCore at 1-866-417-2345 for plans underwritten by HIP or 1-800-835-7064 for GHI HMO and EmblemHealth Medicare PPO plans. Representatives are available Monday through Friday, from 7 am to 7 pm. Multiple requests can be handled with one call.
Glossary terms found on this page:
A health insurance product offered by a health plan company that is defined by the benefit contract and represents a set of covered services. Also called a health benefit plan.
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.
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.
Specific conditions or circumstances that are not covered under the benefit agreement or Certificate of Insurance. It is very important to consult the benefit contract to understand what services are not covered benefits.
An organization that provides comprehensive health care coverage to its members through a network of doctors, hospitals and other health care providers. Also called a Health Maintenance Organization.
A card which allows the subscriber to identify himself or his covered dependents to a provider for health care 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 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 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.
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.
Treatment of disease by X-ray, radium, cobalt or high energy particle sources.