The EmblemHealth Vision Program, developed with EyeMed, provides routine vision management for all EmblemHealth members that have a routine vision and materials benefit. Please note that not all members have a routine vision benefit.
EyeMed will administer all routine exams (to determine if corrective lenses are required) and the dispensing of hardware such as frames, lenses and contact lenses based on the member’s benefit. EyeMed is responsible for the provider network including contracting and credentialing, claims processing and payment, routine vision grievances and claims appeals.*
*Exception: Medicare grievances and claim appeals will continue to be managed by EmblemHealth.
Glossary terms found on this page:
Oral or written request from a member or their designee for EmblemHealth to review or reconsider a decision made by the 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 legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.
A request to change an adverse determination that was based on administrative policies, procedures or guidelines.
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.
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 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.
A set of providers contracted with a health plan to provide services to the enrollees.