Radiology Program > Vytra Plans Radiology Program for Dates of Service Prior to January 1, 2016
Vytra HMO contracted with various groups to provide radiology services for its members. All participating Vytra PCPs designated a radiology center that their Vytra patients used exclusively. The designated radiology center appeared on the ID card of each Vytra member on the PCP's panel.
Designated Radiology Centers
For radiology services to be covered, Vytra plan members used the designated radiology center specified on their Vytra ID card. If no radiology center appeared on the ID card, the member was able to go to any Vytra network radiologist. Participating practitioners sent members directly, without a referral, to the designated radiologist by writing a prescription detailing the test required.
PCPs with more than one office location were able to select a different radiology center for each of their offices.
In the rare instance that the designated radiology center could not meet the member's needs, the practitioner contacted Vytra's Care Management department at 1-888-288-9872 for prior approval to send the member to another facility.
Guarantee Waiver Agreement for Radiology Groups
Radiology centers treating a member outside their designation called Vytra's Provider Service Line at 1-888-288-9872 before rendering services. During this call, the center ensured prior approval was secured and use Vytra's Guarantee Waiver Agreement.
Each member seeking service outside their designated facility signed Vytra's Guarantee Waiver Agreement. This was the only waiver recognized by Vytra. At time of signing, members were advised that they would be responsible for payment of all services performed. Practitioners had the right to withhold service to any member who chose not to sign this waiver.
If the radiology facility rendered services without having a signed waiver, the member was reimbursed for any up-front payment and could not be balance billed. Vytra reserves the right to withhold future payment to the facility until the member was reimbursed.
Changing Designated Radiology Groups
PCPs were able to change their designated radiologist under the following circumstances:
- PCP requested a change and Vytra's Provider Relations department deemed the change to be in the best interest of the PCP's patients (e.g., quality of care related, PCP location change)
- A corporate decision allowed all PCPs to change their designated radiologist
- Administrative purposes (e.g., correction of database)
All quality-related issues had to be reported to Vytra at 1-888-288-9877 promptly for immediate resolution.
Copies of X-Rays
Copies of X-rays were not reimbursed unless the member received a second opinion for a cancer diagnosis and the practitioner received proper approval. Eligible copies were reimbursed at the then current fee schedule.
Radiation therapy required the hematologist/oncologist to obtain prior approval.
If appropriate, a Care Management representative authorized an initial series of three visits for radiation therapy. Upon completing the initial evaluation, the radiation oncologist contacted Vytra's Care Management department with the findings.
The radiologist then forwarded a copy of the proposed treatment plan to the referring hematologist/oncologist. Specialists were required to communicate with the member's PCP regarding all treatment and follow-up care provided.
Vytra reimbursed only radiologists for dual energy X-ray absorptiometry (DEXA) scans. PCPs and specialists other than radiologists were not reimbursed for DEXA scans, regardless of any prior arrangements with or payments from Vytra.
If the member's designated radiologist did not perform DEXAs, the referring physician called Vytra's Care Management department to authorize services at another network radiologist.
Glossary terms found on this page:
Services that have been approved for payment based on a review of EmblemHealth's policies.
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 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.
The fee determined by the insurer to be acceptable for a procedure or service that the physician agrees to accept as payment in full.
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.
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.
The group of physicians, hospital, and other medical care providers that a specific plan has contracted with to deliver medical services to its members.
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 written order or refill notice issued by a licensed medical professional for drugs available only through a pharmacy.
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.
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.
Treatment of disease by X-ray, radium, cobalt or high energy particle sources.
A recommendation by a physician that an enrollee receive care from a specialty physician or facility.
The voluntary option or mandatory requirement to visit another physician or surgeon regarding diagnosis, course of treatment or having specific types of elective surgery performed.