Utilization management decisions
EmblemHealth is dedicated to providing quality care and service to all our members. We do not make any payment, directly or indirectly, to a physician, physician group, or other practitioner as an inducement to reduce or limit medically necessary services. When conducting utilization review, EmblemHealth bases all decisions solely on the appropriateness of care and services, existence of coverage, benefit design, appropriate place of service, medical necessity, and applicable state and federal law. In addition, staff making utilization management (UM) decisions do not receive financial incentives or rewards for issuing denials of coverage and are not encouraged to make improper denials.
Availability of utilization management criteria upon request
In addition to publishing utilization management criteria in the EmblemHealth Provider Manual and in Clinical Corner, EmblemHealth makes the criteria available upon request:
- By telephone at 866-447-9717.
- Through the Message Center on our secure provider portal.
Affirmative statement regarding incentives
EmblemHealth distributes a statement to all members, practitioners, providers, and employees who make UM decisions, affirming the following:
- UM decision making is based only on appropriateness of care and service, and existence of coverage.
- EmblemHealth does not specifically reward practitioners or other individuals for issuing denials of coverage.
- Financial incentives for UM decision makers do not encourage decisions that result in underutilization.
The statement can also be found in the Provider Manual.
Member responsibility for self-care
Member rights and responsibilities include their responsibility to self-care. For a complete description of what members can expect of EmblemHealth and what responsibilities our members have to EmblemHealth, visit the member policies and rights section of the Provider Manual.
Check panel reports - schedule new patient visits
Managing a busy practice is a challenge, and welcoming new members is an important part of providing care. We encourage our primary care physicians to routinely check their panel reports and reach out to new patients to schedule an initial visit. Please log in to our provider portal to find your reports and more. Please encourage new Medicare and Dual Eligible Special Needs Plan (SNP) members to complete and submit their Health Risk Assessments.
All members have the right to dispute a determination that results in a denial of payment and/or covered services. The process, terminology, filing instructions, applicable time frames, and additional rights (including external review rights) vary based on the type of plan in which the member is enrolled. Our Provider Manual includes separate chapters on the dispute resolutions for:
- Commercial & Child Health Plus plans.
- Medicare plans.
- Medicaid/HARP plans.
We will not attempt to terminate a practitioner agreement or disenroll a member who disputes a determination.