Provider Manual

Chapter 8: Access to Care and Delivery System

 

 

This chapter outlines EmblemHealth policies and procedures for the provision of medical care to our members, including participation requirements, role of primary care providers and provider termination procedures.

 

 

All EmblemHealth plan members are entitled to:

  • An initial assessment of their health care status performed within 90 days of enrollment (For Medicaid members over age 21, within 12 weeks [84 days])
  • Information regarding health care needs that require follow up
  • Self-care training (as necessary)

 

Health care professionals must notify EmblemHealth (and the HIP Network Services IPA, Inc., if applicable) within five business days after any change in office address, telephone number and/or office hours.

From time to time, regulatory agencies will audit Plans’ directories for accuracy and may impose fines and/or penalties when information is found to be inaccurate. Any fines/penalties received by the Plan or negative financial impact experienced by the Plan due to a Practitioner’s failure to notify the Plan of any required change listed above will be levied to the Practitioner in the amount equal to the fine/penalty.

Health care professionals doing business as primary care physicians must maintain office hours not less than two (2) days per week, eight hours per day, at each primary care office.

 

 

 

Telephone response to member calls to the office should be handled by the physician or designated office staff (as appropriate to the situation) while adhering to the following guidelines:

  • Emergency conditions should receive immediate response
  • Urgent conditions should be responded to within four hours
  • Semi-urgent conditions should be responded to during the current day
  • Routine conditions should be responded to within two working days
  • After hours calls where the nature is unclear should receive response within 30 minutes

Your practice information appears in our network directories (including our online Find a Doctor tool) and is used in claims processing. Keeping your information up to date helps ensure that patients can locate your practice and we process your claims accurately. You must report updates to your practice information whenever change occurs in the following:

  • Ability to accept new members
  • Age-range limitations applicable to the health care professional
  • Add or delete a provider from your practice
  • Email address
  • Fax number
  • Hospital affiliations
  • IRS taxpayer identification number (TIN)
  • Languages spoken in your office
  • Medicaid Number is assigned
  • Medicare Number is assigned
  • National Provider Identifier (NPI) number is assigned
  • Office hours
  • Opening or closing a primary care panel
  • Practice address
  • Practice phone number used for scheduling patient appointments
  • Billing information
  • Specialties
  • Wheelchair accessibility has been added to a practice location
  • When an OB/GYN opts to see GYN-only patients

Unless you’re part of a group that has arranged to submit changes via a spreadsheet/ dataset process, providers, and their staff, can access and update their practice records on our secure provider website. For changes that cannot be processed online, mail or fax your changes to our Provider Modifications team:

Provider Modifications Team 
EmblemHealth 
55 Water Street, 6th Floor 
New York, New York, 10041-8190

 

Fax: 1-877-889-9061

Providers must inform EmblemHealth as soon as possible or within five (5) business days after any change to office address, telephone number, office hours, specialty, languages spoken, hospital affiliation, addition or termination of an individual provider in a medical group. Updates to your practice information will be posted to the EmblemHealth website within 15 days. In general, some updates, such as to your license number, specialty or school, will be verified by our Credentialing department and may take longer to appear.

Note: Removing an individual provider from a service location will not affect previously submitted claims. EmblemHealth will continue to process claims with a Date of Service on or before the provider’s termination date for that location.

EmblemHealth may terminate a provider if he/she fails to notify EmblemHealth of any required changes in a timely manner (subject to any applicable reconsideration or hearing rights required by state or federal law).

From time to time, regulatory agencies will audit the Plans’ directories for accuracy and may impose fines and/or penalties when information is determined to be inaccurate. Any fines/penalties received by the Plan due to a Practitioner’s failure to notify the Plan of any required change listed above will be levied to the Practitioner in the amount equal to the fine/penalty.

Change of Ownership

A change of ownership (CHOW) cannot be performed online; a CHOW is treated like a new enrollment. When a change of ownership occurs, providers must contact EmblemHealth. The appropriate contact information can be located in the EmblemHealth Contact Information section of the Directory chapter.

Know Your Network Participation

The provider profile also lists your network affiliations. If the network information on the member's ID card matches your network affiliations, then you are in-network for that member's benefit plan. See the Provider Networks and Member Benefit Plans chapter for a listing of all networks and plans.

Note: Some government program cards don’t have network names; however, they are easily identified by the plan name. Digital representations of our most common member ID cards are located in the Member Identification Cards section of the Your Plan Members chapter.

Ask to see a member’s ID card at each appointment, emergency visit or inpatient stay. However, the provision of service should not be conditioned solely on the presentation of a member ID card because a member’s enrollment status can change due to various reasons. Sign in to our secure provider website to check your patients’ eligibility status.

Keeping your information current ensures we send your claims payments and other important correspondence to the correct address. It also helps our members contact you at your current location. We recommend that you periodically review the information we have on file for you and encourage you to share your network participation and any changes with your staff on a regular basis.

Revised June 6, 2018

Practitioners are expected to adhere to EmblemHealth's appointment availability and 24-hour access standards for primary care physicians, OB/GYNs, Oncologists, specialists and mental health and substance abuse practitioners (as appropriate). These standards are based on industry, Centers for Medicare and Medicaid Services (CMS) and New York State Department of Health (NYSDOH) access standards.

Appointment Availability Standards

Practitioner offices will schedule appointments in a timely and efficient manner. Member visits to see a practitioner shall be scheduled based on EmblemHealth's Appointment Availability Standards During Office Hours & After Office Hours Access Standards, which is available at the end of this chapter.

Starting January 1, 2019, new access to care standards will be introduced to meet the needs of Medicaid children. See Appointment Availability Standard by Service Type for Medicaid Children’s Health and Behavioral Health Benefits.

Customer Service will maintain and monitor standards for customer telephone access.

EmblemHealth conducts semi-annual appointment availability surveys by calling practitioner offices to determine the next available appointment for a given type of service. This determines both individual practitioner and overall network compliance with these standards as part of our Quality Management program. Noncompliant practitioners are notified and resurveyed approximately six months after the initial survey. Practitioners that are not compliant with these standards upon resurvey will be forwarded to our Recredentialing Committee for review and action.

24-hour Access Standards

All network practitioners must be available, either directly or through coverage arrangements, 24 hours a day, 7 days a week, 365 days a year. Availability must be by live voice direct to the practitioner or covering practitioner, or via an answering service that can reach the practitioner or covering practitioner. If an answering machine is used, it must provide an option for the member to directly contact the practitioner or covering practitioner in case of emergencies. An answering machine cannot simply refer the member to an emergency room unless it is a life-threatening issue.

Annual Practitioner Surveys for Appointment Availability and 24-hour Access

EmblemHealth conducts annual surveysfor appointment availability, by calling practitioner offices during office hours to determine the next available appointment for a given type of service, and 24-hour access by calling after-hours telephone numbers These surveys determine both individual practitioner and overall network compliance with these standards as part of our Quality Management program.

Noncompliant practitioners are notified by letter that they failed one or more components of the survey. Practitioners that fail the survey are automatically included in the next survey administration. Practitioners who are not compliant with the standards and fail when they are re-surveyed will be forwarded to our Credentialing/Recredentialing Committee (CRC) for review and action.

The NYSDOH may also conduct surveys of your appointment availability and after-hours access.

Covering Practitioners

Covering practitioners should be contracted and credentialed by EmblemHealth's companies. Practitioners must provide EmblemHealth with a list of the covering physicians and notify us of any changes. If the covering practitioner in the coverage group does not participate with the EmblemHealth plan, the network practice must inform that practitioner of our policies and procedures. Out-of-network practitioners are prohibited from balance billing and they must clearly identify the name of the practice/practitioner for whom they are covering. Patients should be instructed by the covering physician to follow up with their PCP. Only one visit will be approved for the covering practitioner's services, unless the office is closed for more than 24 hours. If a practice is closed for an extended period of time, the practice must notify the Provider Relations department and any members that may be affected by the closure.

Urgent Care Access

For urgent conditions that do not meet the layperson's definition of an emergency, EmblemHealth maintains a network Urgent Care Centers for all plan members. To access a list of participating urgent care centers, use the Find a Doctor tool on our website.

Retired as of 5/31/2018

Practitioners are expected to adhere to EmblemHealth's appointment availability and 24-hour access standards for primary care physicians, OB/GYNs, specialists and mental health and substance abuse practitioners (as appropriate). These standards are based on industry, Centers for Medicare and Medicaid Services (CMS) and New York State Department of Health (NYSDOH) access standards.

Appointment Availability Standards

Practitioner offices will schedule appointments in a timely and efficient manner. Member visits to see a practitioner shall be scheduled based on EmblemHealth's Appointment Availability Standards During Office Hours & After Office Hours Access Standards, which is available at the end of this chapter.

Customer Service will maintain and monitor standards for customer telephone access.

EmblemHealth conducts semi-annual appointment availability surveys by calling practitioner offices to determine the next available appointment for a given type of service. This determines both individual practitioner and overall network compliance with these standards as part of our Quality Management program. Noncompliant practitioners are notified and resurveyed approximately six months after the initial survey. Practitioners that are not compliant with these standards upon resurvey will be forwarded to our Recredentialing Committee for review and action.

24-hour Access Standards

All practitioners will provide access to medical advice or treatment when not in the office in the form of 24-hour coverage, seven days a week, 365 days a year. This 24-hour access will include:

  • An answering service or machine with an appropriate message explaining:
    • That patients should go to the emergency room if they reasonably believe that their health is in serious jeopardy if they do not seek immediate medical treatment.
    • How to access medical attention outside of an ER for conditions that are not life- or limb-threatening.
  • Coverage by another practitioner in the event the practitioner is unavailable. Please see the Claims chapter for details on covering practitioners.
  • A method to communicate issues, calls and advice from covering practitioners to the PCP and the member's file.

Covering practitioners should be contracted and credentialed by EmblemHealth's companies. Practitioners must provide EmblemHealth with a list of the covering physicians and notify us of any changes. If the covering practitioner in the coverage group does not participate with the EmblemHealth plan, the network practice must inform that practitioner of our policies and procedures. Out-of-network practitioners are prohibited from balance billing and they must clearly identify the name of the practice/practitioner for whom they are covering.

Patients should be instructed by the covering physician to follow up with their PCP. Only one visit will be approved for the covering practitioner's services, unless the office is closed for more than 24 hours. If a practice is closed for an extended period of time, the practice must notify the Provider Relations department and any members that may be affected by the closure.

Members also have access to urgent care centers. See the Care Management chapter for more information.

EmblemHealth conducts semi-annual surveys of 24-hour access by calling after-hours telephone numbers to determine whether members can reach a live voice and be connected either directly to their practitioner or to an answering machine/voice-mail system that asks the caller to leave a name and phone number so the call can be returned immediately. Noncompliant practitioners are notified and resurveyed approximately six months after the initial survey. Practitioners that are not compliant with these standards upon resurvey will be forwarded to our Recredentailing Committee for review and action.

EmblemHealth provides member services through our Customer Service. Customer Service Advocates assist members with questions about services, benefits, enrollment and other issues. Our computerized Member Contact System enables same-day responses to most member requests. If a member's inquiry cannot be resolved during the initial call on the same day, then a Customer Service Advocate strives to call the member back within 48 hours.

Provider Customer Care Advocates are dedicated on a full-time basis to assist providers with questions about EmblemHealth, participation status, contract questions and to provide education and educational material.

We are committed to encouraging and rewarding superior service and recognize that cooperation is an essential component of the provision of quality medical care.

Customer Service will maintain and monitor standards for customer telephone access.

Medical care for EmblemHealth plan members is provided by a network of thousands of contracted practitioners (including multi-specialty practices) that provide care both in medical centers and in their own offices within the community.

We have contracted with an extensive and comprehensive array of facilities and ancillary clinicians to ensure a full continuum of care including an extensive network of prestigious teaching and community hospitals, skilled nursing facilities and freestanding ambulatory care centers.

EmblemHealth will maintain a network of practitioners adequate to meet the comprehensive and diverse health needs of its enrollees. Practitioner selection is based on meeting our minimum criteria for credentialing, geographic standards for accessibility, compliance with the Americans with Disability Act and cultural and linguistic competency.

In the event that a participating practitioner is not available with the skills required to meet a member's needs or is not available within a reasonable distance from the member’s place of residence, EmblemHealth, when appropriate, will arrange and authorize the use of a nonparticipating practitioner at no additional out-of-pocket expense to the member.

EmblemHealth has engaged Beacon Health Options to administer behavioral health services for most of its members under two programs. Members of plans underwritten by HIP or HIPIC and ASO plans administered by VHMS have their behavioral health services administered by Beacon Health Options under the Emblem Behavioral Health Services Program (EBHSP). GHI-underwritten plan members by have their behavioral health services administered by Beacon Health Options under the EmblemHealth Behavioral Management Program (BMP). For more information, please see the Behavioral Health Services chapter.

EmblemHealth-contracted Primary Care Practitioners (PCPs) are responsible for supervising and coordinating medically necessary health care of their patients including, but not limited to:

  • Providing health counseling and advice
  • Baseline and periodic health examinations
  • Diagnosing and treating conditions not requiring the services of a specialist
  • Arranging inpatient care, specialist consults and laboratory/radiological services when medically necessary and in a timely manner
  • Coordinating the findings of consultants and laboratories and interpreting such findings to the member and the member's family (subject to HIPAA Privacy Rules)
  • Maintaining a current medical record for each patient

PCPs are required to follow the standards of care contained in this manual and the administrative guidelines posted to our website, which are reflective of professional and generally accepted standards of medical practice. One of the first and most important decisions any member makes is the selection of a PCP. It is equally important for PCPs to establish a meaningful professional and lasting relationship with their patients. A PCP cannot be his/her own or his/her family's primary care physician.

If a member is using a behavioral health clinic that also provides primary care services, the member may select the lead provider to be their PCP.

Credentialed advanced nurse practitioners (ANPs) may act as primary caregivers, maintaining their own panel of EmblemHealth members and issuing referrals for specialty care. All ANPs functioning as primary caregivers must maintain a current collaborative relationship with an EmblemHealth physician who is participating in the same networks and coverage arrangement for hospital admissions at an EmblemHealth contracted hospital. ANPs may submit to EmblemHealth either a written collaborative agreement or the NYS Education Department Collaborative Relationships Attestation Form(NP-CR). See the Credentialing Chapter for more information. In general, NPs and PAs are paid for covered services at 85 percent of what a physician is paid.

For more information on how to become credentialed with EmblemHealth as a primary caregiver, please sign in to our secure provider website at www.emblemhealth.com/providers and send us an email via our Message Center.

EmblemHealth encourages new members to contact their PCP within 90 days of enrollment for an initial evaluation. If the initial contact with the practitioner is for an acute visit, the practitioner should recommend that the member return for a general health assessment based on age, state of health and the member's last health assessment.

Each time a member needs to see a specialist, it is the PCP's/primary caregiver's responsibility to identify and refer the member to a participating practitioner and to give the member an appropriate referral, either for a consult only or for specific medical services. If the PCP or primary caregiver anticipates the need to refer a member for services that require a referral, prior approval, or the use of a non-participating provider, the request must be approved by EmblemHealth in advance.

All members have direct access to OB/GYN care without a referral or prior approval, as required by New York State law.

Primary Care Practitioner Responsibilities

Primary care practitioners (PCPs) are responsible for providing primary care services and managing all necessary health care services for the members assigned to them. Coordinating all care and maintaining an overall picture of member health is key to helping members stay healthy while effectively managing appropriate use of health care resources.

When providing primary health care services and coordination of care, the PCP must:

  • Provide for all primary health care services that do not require specialized care. These include, but are not limited to:
    • Routine preventive health screenings.
    • Physical examinations.
    • Routine immunizations.
    • Child/Teen Health Plan Services (C/THP) screenings for children and adolescents (required for Medicaid members; as appropriate for other members).
    • Reporting communicable and other diseases as required by Public Health Law.
    • Behavioral health screening (as appropriate).
    • Routine/urgent/emergent office visits for illnesses or injuries.
    • Clinical management of chronic conditions not requiring a specialist.
    • Hospital medical visits (when applicable).
    • Maintain appropriate coverage for members 24 hours a day, seven days a week, three hundred and sixty-five days a year as noted in the above section on 24-hour access.
  • Refer all members for services in accordance with EmblemHealth's referral policies and procedures. See the Care Management chapter of this manual for more details.
  • Provide services of available allied health professionals and support staff in your office.
  • Provide supplies, laboratory services and specialized or diagnostic tests that can be performed in the office.
  • Assure members understand the scope of referred specialty or ancillary services and how/where the member should access the care.
  • Communicate conditions, treatment plans and approved authorizations for services to member and appropriate specialists.
  • Consult and coordinate with members regarding specialist recommendations.
  • Comply with the New York State "Vaccine for Children Program," as appropriate, and with New York State and New York City requirements for reporting communicable diseases.

EmblemHealth Medicaid and Child Health Plus Participating Practitioners

Practitioners treating members enrolled in Medicaid or Child Health Plus shall have no more than 1,500 members on their panel or 2,400 for a physician practicing in combination with a registered physician assistant or certified nurse practitioner. Advanced nurse practitioners credentialed as primary caregivers shall have no more than 1,000 members on their panel.

These member-to-practitioner ratios are based on the assumption that the practitioner works 40 hours per week and therefore must be prorated for practitioners working less than 40 hours per week. The ratios apply to practitioners, not to each of their practice locations.

When EmblemHealth members first enroll, they choose where they want to receive medical care. Members can choose any participating primary care physician (PCP) with an open panel. Members who fail to select a PCP within a given period of time are assigned to a PCP and notified of the assignment in writing.

Members who subsequently wish to transfer to another network PCP may do so at any time for any reason by calling our Customer Service departments or by logging on to our Web site, www.emblemhealth.com. PCP changes take effect immediately upon request.

When members transfer from one network PCP practice to another, the PCP who previously treated the member is required to forward a copy of the member's medical record to the new PCP, allowing for continuity of care. The original record should be retained and treated as a terminated record.

Note that Medicaid members that are in the Restricted Recipient Program have restrictions on when they can change PCPs out of good cause reasons such as:

  • Provider no longer wishes to be the RRP member's provider;
  • Provider closed/moved servicing location or moved to a location that is beyond 30 minutes or 30 miles from RRP member's home;
  • Provider no longer participates in HIP's network;
  • Member moved beyond 30 minutes or 30 miles from RRP provider;
  • Other circumstances exist that make it necessary to change providers, including but not limited to good cause reasons for changing PCPs as provided by applicable statute and regulations.

A PCP or Primary Caregiver may request removal of a member from his/her panel or a specialty care practitioner may request to discontinue treating a member if:

  • The member repeatedly fails to keep appointments
  • The member repeatedly disregards the practitioner's medical advice
  • The member exhibits continual abusive behavior toward the practitioner or his/her office staff
  • The practitioner is unable to establish a mutually beneficial relationship with the member

The practitioner should provide at least 90 days prior written notice to Provider Relations that he/she will not continue as the member's physician. Provider Relations will coordinate with the Customer Service department to notify the member.

The medical records transfer procedure ensures that the new PCP will have a continuous medical record of the member. See the Medical Records Guidelines chapter of this manual for more details.

EmblemHealth contracted specialist physicians agree to see members referred by a participating primary care physician except when members are seeking services to which they are permitted to self-refer or when a member's benefit design does not require the selection of a PCP. (See the Direct Access section of this chapter.)

Specialists should make note of the scope of the referral and refer the member back to the referring PCP for continuation of care.

In order to ensure continuity of care, the specialist must communicate with the PCP, if applicable, regarding the consultation, findings and recommended treatment plan.

When a member has been referred to a specialist, the specialist is responsible for diagnosing the member's clinical condition and/or managing treatment of t he condition, up to the number of visits identified on the referral authorization. The scope of the services rendered is limited to those related to the clinical condition for which the primary care practitioner referred the member.

Age range now assigned to internal medicine clinicians:
Internists in the Prime Network and Premium Networks who have not specified an age range for members will have their records updated to reflect members aged 18 and over. If you treat members in a different age range, e.g. 21 and over, you may request a change via the Provider/Practice Profile or, if you are part of a group that is delegated for credentialing, submit it via the monthly file process.

When providing specialty care, the practitioner must:

  • Keep the PCP informed of the member's general condition with prompt verbal or written consult reports
  • Obtain PCP authorization for subsequent referrals for tests, hospitalization or additional covered services
  • Provide only those services authorized by a PCP and/or the medical director (or his or her designee) and emergency care
  • Deliver all medical health care services available to members with self-referral benefits

Note: OB/GYN specialists may see members without referral from a PCP consistent with § 4406-b of the New York State Public Health Law. OB/GYN specialists must be available after hours for emergency care of pregnant enrollees.

For information on specialists functioning as PCPs, see the Specialists as PCPs subsection in the Care Management chapter.

Note: Qualified providers of OB/GYN care are required to provide HIV pre-testing counseling with clinical recommendation of testing for all pregnant women. Those women and their newborns must have access to services for positive management of HIV disease, psychological support and case management for medical, social and addictive services. See Direct Access (Self-Referral) Services.

New policy for specialty designations
In order to improve our members’ experience while seeking care, and to reduce inappropriate calls to your office, we will periodically update our directories to change the OB/GYN specialty designation to GYN (gynecology) for those who have not submitted a claim for obstetric services in the prior 24 months. Please let us know if you stopped practicing obstetrics less than two years ago and we will update our records accordingly.

In New York State, voluntary HIV testing is part of routine medical care. Additionally, New York State public health law requires most medical facilities to offer voluntary HIV testing to patients of all ages. With limited exceptions, the law applies to anyone receiving treatment for a condition that is not life-threatening, whether in a hospital, emergency room or primary care setting such as a doctor's office or outpatient clinic.

For a summary of changes to simplify HIV testing consent and improve linkage to care, please see New York State HIV Testing Law Update: May 2014.

Consent Still Required

The amended law allows patients to give verbal consent for a rapid HIV test, which produces results within an hour. Consent must be documented in the patient's medical record, and the practitioner must counsel the patient on the following seven points about HIV:

  1. HIV is the virus that causes AIDS. HIV can be passed through:
    • Unprotected sex (vaginal, anal or oral sex without a condom) with a person who has HIV.
    • Shooting drugs with needles, or "works," of a person who has HIV.
    • Pregnancy, birth or breastfeeding.
  2. Treatments are available to help people living with HIV stay healthy. Getting tested early can help patients get the most from their health care benefits.
  3. HIV testing is important for women before or during pregnancy. Treatment can reduce the chance that a woman with HIV will pass the virus to her infant.
  4. Many resources are available in New York to help people living with HIV meet their medical, social and legal needs.
  5. HIV testing is confidential. A doctor can share HIV test results with other practitioners only when the information is needed for the patient's health care. The names of people who have HIV or other STDs, such as syphilis and gonorrhea, are confidentially sent to the State Health Department. This helps the State Health Department plan services for people with HIV.
  6. If test results show that a patient has HIV, the doctor will talk with the patient about urging sex and needle-sharing partners to get tested for HIV. Counselors from the Health Department's Partner Assistance Program (PNAP) or Contact Notification Assistance Program (CNAP in New York City) can help notify partners without revealing the patient's name.
  7. HIV testing is voluntary. The practitioner must ask the patient to sign a consent form for HIV testing, and the patient should read this form carefully. The practitioner will answer any questions the patient has about HIV testing.

Patients must still provide written consent for HIV tests that require more time, but the process has been simplified. Consent for HIV testing can now be included in a patient's general consent for routine medical care as long as the consent form permits patients to opt out of HIV testing.

Treating HIV/AIDS

We post clinical practice guidelines for the treatment of HIV/AIDS on our Web site. To review these guidelines, visit Clinical Corner at www.emblemhealth.com . In addition, New York State Quality Assurance Reporting Requirements (QARR) include four quality measures for HIV/AIDS Comprehensive Care. Recommended treatment and preventive criteria for people living with HIV/AIDS are:

  • Two outpatient visits occurring at least 182 days apart (every six months) for each patient age 2 and older.
  • Two annual viral load tests conducted at least 182 days apart for each patient age 2 and older.
  • One annual screening for syphilis for each patient age 19 and older.
  • One annual screening for cervical cancer for each female patient age 19 to 64.

Documentation of these measures must be included in the patient's medical records and will be reviewed as necessary.

Effective January 1, 2014, a hepatitis C screening test must be offered to every individual born between 1945 and 1965 when one of the following criteria is met:

  • Inpatient of a hospital
  • Receiving primary care services in the outpatient department of a hospital
  • In a freestanding diagnostic and treatment center
  • From a physician, physician assistant or nurse practitioner providing primary care regardless of setting type

If the test is reactive, follow-up health care including an HCV RNA test must be offered onsite or by referral.

For more information on hepatitis C, please visit the New York State Department of Health website at https://www.health.ny.gov/diseases/communicable/hepatitis/hepatitis_c/provider.htm.

The PCP will request all pertinent medical records from any other health practitioner from whom the member is receiving care. The following information will be requested:

  • Patient's name, EmblemHealth ID number and birth date
  • The problem or reason for visit, as stated by the patient
  • The duration of the problem
  • Findings on physical examination
  • Diagnosis or assessment of the patient's condition
  • Therapeutic or preventive services recommended or prescribed, if any, or that none were indicated
  • Dosage and duration information regarding any prescription given
  • Follow-up plan, or that no follow up was planned
  • Childhood immunization records

We make every effort to assist new members whose current providers are not participating with one of our plans. See the Continuity/Transition of Care - New Members section of the Care Management chapter for information on transition of care.

Upon a practitioner's termination from EmblemHealth, EmblemHealth shall:

  • Make a good faith effort to notify affected enrollees of a practitioner's termination 30 days prior to the effective date
  • Provide the affected practitioner with a written notice explaining the reasons for the termination or suspension as well as the right to a notice and hearing (See the Termination and Appeal section of the Credentialing chapter.)

We make every effort to assist members whose physicians end their participation with one of our plans. Members who wish to continue seeing their current health care provider for a limited time must contact or have their provider contact their plan/managing entity. See the Continuity of Care - When Providers Leave the Network subsection of the Care Management chapter on transitional care.

If the physician is a PCP and the member opts to stay with the PCP, the member must notify Customer Service of the new PCP who will manage their care following the 90-day transition period. If the physician leaving the network is a specialist and the member opts to stay with the specialist for the 90-day transition period, the member should obtain a referral to a new specialist for care following the 90-day transition period.

EmblemHealth Medicaid Newborns

Newborn children of mothers enrolled in EmblemHealth's Medicaid plans will be automatically enrolled in the Medicaid program of the mother's plan, and shall receive all benefits and services of that plan beginning on the newborn's date of birth, even if the newborn has not yet been enrolled.

All members should call our Customer Service department to provide their newborn's name, sex, date of birth, birth weight and birth hospital so that we can complete the enrollment process. Once enrolled, the newborn is issued a member ID card.

Note that enrollment could be delayed for a number of reasons. Therefore, if a newborn presents for care without an ID card, but the mother was an active Medicaid member on the date of the baby's birth, care must be rendered. Practitioners should call EmblemHealth's Customer Service Department to verify eligibility.

EmblemHealth Child Health Plus

Note: If a Child Health Plus member gives birth, the parent must complete an application for the newborn. There is no automatic enrollment in Child Health Plus. The parent can contact Customer Service for information on how to apply.

EmblemHealth contracts with health care professionals and facilities that have expertise in caring for medically fragile children, to ensure that they, including children with co-occurring developmental disabilities, receive services from appropriate providers. Network providers shall refer to appropriate network community and facility providers to meet the needs of the child, or seek authorization care for out-of-network providers when participating providers cannot meet the child’s needs.

EmblemHealth will authorize services in accordance with established time frames in the Medicaid Managed Care Model Contract;OHIP Principles for Medically Fragile Children (Attachment G); under EPSDT, HCBS, and CFCO rules; and with consideration for extended discharge planning.

EmblemHealth Members

EmblemHealth members can self-refer for the following services to network practitioners when covered by their benefit plan:

  • Chiropractic services*
  • Preventive and primary care services from the member's PCP
  • Preventive obstetric and gynecological care including mammography screenings and cervical cytology screenings
  • Ob-gyn Care: Prenatal care, two routine visits per year and any follow-up care, acute gynecological condition
  • One mental health visit and one substance abuse visit with a participating provider per year for evaluation.
  • Vision Care
    • Refractive eye exams from an optometrist or ophthalmologist
    • Eyeglasses (within benefit limits)
    • Diabetic eye exams from an ophthalmologist
  • HIV pre-test counseling with clinical recommendation of testing required for all pregnant women. Those women and their newborns must have access to services for positive management of HIV disease, psychosocial support and case management for medical, social and addictive services. (This requirement is applicable to all qualified providers of OB/GYN care whether the member directly accesses care or is referred by another provider. See the section titled Medical Specialists for more information.)
  • Emergency Care: Members should call 911.

*EmblemHealth Medicaid and Child Health Plus members do not have chiropractic coverage. See below for more details.

Medicare Members

Medicare members may self-refer to a participating clinician for certain EmblemHealth-covered services and certain Medicare-covered services at designated frequencies and ages:

  • Annual mammography screening
  • Annual routine eye exam
  • Colorectal screening
  • Four routine podiatry visits (VIP HMO, VIP Essential HMO, and VIP High Option HMO only)
  • Glaucoma screening, if at high risk
  • HIV screening
  • Influenza and pneumococcal vaccine
  • Initial chiropractic assessment
  • Initial mental health consultation
  • Nutritionist and social worker visit
  • Prostate cancer screening

Female members may self-refer to a participating women's health care specialist for the following routine and preventive health care services:

  • Pelvic exam
  • Screening Pap test
  • Bone mass measurement, if at risk

Members may also self-refer to a Medicare-certified hospice program.

EmblemHealth Medicaid and Child Health Plus Members

In addition to the above services to which all members have direct access, there are some services to which members in state sponsored programs (Medicaid and Child Health Plus) may also self-refer. Unless otherwise indicated, members in all state sponsored programs may self-refer to the following services:

  • Unlimited behavioral health and substance use assessments (except for ACT, inpatient psychiatric hospitalization, partial hospitalization, HCBS services)
  • Dental Services - Primary and preventive services from the member's assigned network dentist or to a dental clinic operated by an academic dental center.
  • Orthodontic services (Medicaid only) - For orthodontic services, Medicaid members may also self-refer to Academic Dental Clinics affiliated with Article 28 Academic Centers, Medicaid fee-for-service dentists.
  • Nonemergency transportation services (Medicaid members) - See the Transportation Services section of this chapter for more details.
  • Family planning and reproductive health services include:
  • Access to birth control
  • Sterilization procedures
  • Medically necessary abortions
  • Screening for anemia, cervical cancer, sexually transmitted diseases, breast disease, pelvic abnormality and pregnancy

Medicaid members can obtain these services from a participating practitioner or any Medicaid fee-for-service provider. Participating practitioners must bill EmblemHealth and not Medicaid FFS for family planning services. If the member is assigned to a Managing Entity, the participating practitioner must bill the Managing Entity at the address on the back of the member's ID card. However, all Child Health Plus members must self-refer to a participating clinician for family planning/reproductive health services.

All members must use network physicians for all other gynecologic and obstetric care, including hysterectomies, routine Gynecological exams, prenatal and postpartum care.

Federal regulations require patient notification for hysterectomy and sterilization procedures. The patient or their representative must sign the required consent form for the service to be deemed a covered service under the Medicaid plan. This form must also accompany manual claim submissions as proof of consent. If the required form is not received, then the claim will be returned requesting the required form. Once the form is received, then the claim will be considered eligible and processed.

Claims for hysterectomy procedures must be submitted along with a copy of the completed and signed Acknowledgment of Receipt of Hysterectomy Information Form, LDSS-3113. When billing for procedures performed for the purpose of sterilization (Code F), a completed Sterilization Consent Form, LDSS-3134, is required and must be attached to the claim. Both forms can be obtained from the New York State Department of Health’s website at Local Districts Social Service Forms.

  • Assessments for Foster Care Children (Medicaid) - EmblemHealth requires a 30-day obligation to complete a comprehensive physical that includes a behavioral health assessment and an assessment of exposure to any infectious disease. Foster Care children are not eligible for CHPlus.

    Starting in 2019, EmblemHealth will manage the delivery of expanded behavioral and physical health services for this population. Please see the end of this chapter for a copy of Foster Care Initial Health Services. This table outlines the time frames for initial health activities, to be completed within 60 days of placement. These assessments are a critical component to the development of a comprehensive plan of care.

  • Child Protective Services (Medicaid) - EmblemHealth physicians shall comply with agencies such as Child Protective Services (CPS) or any other court-ordered services. This compliance includes, but is not be limited to, the provision of medical information to the CPS agency's investigation and any subsequent amendments thereto. If the child is referred by a court order for covered medical services, these services must be provided whether or not they are covered by the plan. Clinicians that are not currently participating with EmblemHealth will be reimbursed at the Medicaid fee schedule. For CHPlus, court-ordered services are only covered if they are medically necessary and covered by the plan.
  • Immunizations - Members can obtain immunization services from an EmblemHealth network practitioner. However, immunizations provided to all Child Health Plus members and to Medicaid children under 19 years of age must be given with vaccines obtained through the Vaccines for Children Program. See the Pharmacy chapter of this manual for more details.
    In addition, Medicaid members can obtain immunization services from a public health agency clinic. Public health agencies are required to make reasonable efforts to contact the member's PCP to ascertain the member's immunization status prior to service delivery. If the public health agency clinic is unable to verify the immunization status from the PCP or learns that immunization is needed, it is authorized to render the service as appropriate and bill EmblemHealth or the responsible full risk provider.
  • Tribal Health Center Services - Native Americans enrolled in EmblemHealth's Medicaid plan are free to access primary care services through their tribal health center without a referral or prior approval. EmblemHealth network PCPs must develop a relationship with tribal health center PCPs to ensure coordination of patient care.
  • Tuberculosis (TB) screening, diagnosis and treatment, administered by EmblemHealth participating practitioners or from public health agency facilities. Public health agencies are required to notify EmblemHealth or the member's PCP of the presentation of TB in order to verify previous TB treatments and bill for the services rendered.
    EmblemHealth does not cover, and Medicaid FFS should be billed for, the following TB-related services:
    • Direct observed therapy (DOT) due to noncompliance with TB care regiments
    • HIV counseling and testing during a TB-related visit at a public health clinic
    • Testing for chlamydia

EmblemHealth participating practitioners and laboratories must report TB and STD cases to the local public health agency. State and local departments of health will be available to offer technical assistance in establishing TB reporting policies.

  • HIV counseling and testing services administered by:
    • EmblemHealth network practitioners
    • Anonymous HIV counseling and testing centers
    • For Medicaid members, any Medicaid fee-for-service practitioner as part of a family planning encounter
    • For New York City Medicaid members, any New York City Department of Health and Mental Hygiene clinic
  • HIV / AIDS treatment services administered by EmblemHealth network practitioners
  • Emergency care - EmblemHealth covers emergency care for Medicaid and Child Health Plus members in all 50 United States, Washington D.C, Canada, the United States Territories of the Virgin Islands, Puerto Rico, Guam, American Samoa, the Northern Mariana Islands and American territorial waters. Members that have a condition meeting the definition of emergency while in one of these areas can go to the nearest emergency room or call 911. Emergency care services are covered in Mexico for Child Health Plus members.

Medicaid Pregnant Members Only

  • HIV pre-test counseling services with a clinical recommendation of testing
    Those women and their newborns must have access to services for positive management of HIV disease, psychosocial support and case management for medical, social and addictive services.

The mission of EmblemHealth Neighborhood Care is to reinforce a holistic approach to health and wellness and help health plan and community members take a more active role in their mental and physical well-being. EmblemHealth Neighborhood Care offers our plan members and other community members a place to go to get the personalized, one-on-one support of experts in clinical, benefits and health management solutions. Neighborhood Care does not provide medical services. Instead, our role is to help practitioners manage patient care by supporting the primary practitioner-patient relationship.

Using the EmblemHealth Neighborhood Care Provider Recommendation Form, providers can recommend that a plan member visit a local Neighborhood Care site for the services listed below (see the forms at the end of this chapter and at emblemhealth.com):

  • In-person EmblemHealth customer service (billing, claims)
  • Health plan navigation
  • Care management and coordination (for EmblemHealth plan members)
  • Assistance with DME fulfillment
  • Health and wellness resources
  • Fitness and wellness classes
  • Health care education
  • Behavioral health care
  • Medication support
  • Disease and condition self-management

 

The Neighborhood Care team of professionals consists of:

  • Site Managers: Site managers oversee the staff and operations of the site and also function as customer care navigators to help make appropriate connections for customers. They also work with community partners and care providers to develop health and educational programming relevant to the site to address the needs specific to the community.
  • Customer Care Navigators: Customer Care Navigators help connect EmblemHealth members to health and wellness services, care coordination and customer service, and community resources. They also make warm connections to sales partners to help visitors determine their eligibility for health care, choose a health plan and complete health plan enrollment.
  • Social Workers: Certified Social Workers assist members with matters such as housing, financial assistance, education and career guidance and specialized health services. They also help make connections to community resources.

 

Neighborhood Care locations:

Manhattan

EmblemHealth Neighborhood Care — Harlem (AdvantageCare Physicians next door)

215 W 125 Street | 866-469-0999

EmblemHealth Neighborhood Care — Chinatown

87 Bowery | 855-283-2151

EmblemHealth Neighborhood Care at AdvantageCare Physicians Express

52 Duane Street 212-423-3901

Queens

EmblemHealth Neighborhood Care — Cambria Heights (AdvantageCare Physicians next door)

206-20 Linden Blvd | 866-539-0999

EmblemHealth Neighborhood Care at AdvantageCare Physicians Flushing Medical Office

140-15 Sanford Ave Suite A, Area G | 800-447-0752

Brooklyn

EmblemHealth Neighborhood Care — Crown Heights (AdvantageCare Physicians next door)

546 Eastern Parkway | 855-283-2156

EmblemHealth Neighborhood Care at AdvantageCare Physicians Brooklyn Heights Medical Office

195 Montague Street, Floor 2 | 212-423-3901

EmblemHealth Neighborhood Care — Bensonhurst at EmblemHealth sales office

2482 86th Street | 800-447-0856

Visit the EmblemHealth Neighborhood Care website at emblemhealth.com/community for more details.

Emergency transportation services for EmblemHealth members with conditions that meet the definition of emergency can call 911 for emergency transportation. Non-emergency transportation for EmblemHealth Medicaid and Medicaid Advantage members should be arranged according to the instructions in the Transportation chapter.

EmblemHealth members enrolled in either a Medicaid or Medicare-Medicaid plan are able to access telehealth services from approved home health care agencies as a covered benefit if the members are assessed by the home health care agency on an individual basis and the members meet specific criteria.

To be eligible, the member must have conditions needing frequent monitoring and be at-risk of acute or long-term care facility admission. (Congestive heart failure, asthma, cardiac conditions, chronic obstructive pulmonary disease (COPD), HIV and diabetes are the most frequent diagnoses for those currently receiving telehealth services. However, this is not an exhaustive list of conditions for which telehealth may be indicated. Each case is assessed individually to determine the appropriateness of telehealth monitoring.) Telehealth services may only be provided during an episode of home care. They must be an adjunct to nursing care and they do not replace physician-ordered nursing visits.

The home health care agency must submit a doctor's order to EmblemHealth along with the member's assessment in order to obtain prior approval to provide telehealth services to the member as a covered benefit.

EmblemHealth will cover telehealth services if they are deemed medically necessary. If a member enrolls in EmblemHealth while in receipt of telehealth services through Medicaid fee-for-service, we provide transitional care while we conduct our own assessment of the individual's care needs. Our review may include review of the original assessment or we may request a new assessment.

Only home care agencies approved by Medicaid as providers of telehealth are authorized to provide telehealth monitoring.

The home health care agency may then bill using HCPCS code T1014 for either the nursing visit or the installation, but not both. Authorization is given for 30 days. On day 30, another 30 days may be requested. If longer than 60 days are needed, the member must be reassessed.

The risk assessment tool completed by the home care agency incorporates the following information. The member:

  • Is at risk for hospitalization or emergency care visits
  • Lives alone
  • Has a documented history of, or is at risk of, requiring unscheduled nursing visits or interventions
  • Has a history of non-compliance in adhering to disease management recommendations
  • Requires ongoing symptom management related to dyspnea, fatigue, pain, edema, or medication side effect or adverse effects
  • Resides in a medically under-served, rural or geographically inaccessible area
  • Requires frequent physician office visits
  • Has difficulty traveling to and from home for medical appointments
  • Has the functional ability to work with the telehealth monitoring equipment in terms of sight, hearing, manual dexterity, comprehension and ability to communicate

EmblemHealth shall not prohibit or restrict any practitioner from disclosing to any member, patient or designated representative any information that the practitioner deems appropriate regarding a condition or course of treatment with a member including the availability of other therapies, tests, medications, etc., regardless of benefit coverage limitations. EmblemHealth shall not prohibit or restrict a health care professional, acting within the lawful scope of practice, from advocating on behalf of an individual who is a patient and enrolled under EmblemHealth. Practitioners shall not be prohibited from discussing the risks, benefits and consequences of treatment (or absence of treatment) with the member, patient or designated representative. Patients shall have the opportunity to refuse treatment and to express preferences about future treatment decisions.

EmblemHealth Medicaid and Child Health Plus Responsibilities to Government Agencies

Any activities and reporting responsibilities delegated to a subcontractor, including a practitioner, shall be performed pursuant to standards set forth by the SDOH. In the event such policies and procedures are not complied with and the practitioner does not meet the SDOH requirements, EmblemHealth and/or SDOH may revoke the delegation in whole or in part. SDOH may also impose other sanctions if the practitioner's performance does not satisfy standards set forth in the agreement between EmblemHealth and SDOH for the Medicaid program. As required, the practitioner shall take any necessary corrective action(s) with respect to any delegated activities and responsibilities.

Subcontractors, including practitioners, shall perform all work and render all services in accordance with the terms of the agreement between EmblemHealth and SDOH for Medicaid. Practitioners agree to comply with and be bound by the confidentiality provisions set forth in the above referenced agreement. Any obligations and duties imposed on sub-contactors, including participating practitioners, do not impair any rights accorded to LDSSs, SDOH, the New York City Department of Health and Mental Hygiene (NYCDOHMH) or DHHS.

EmblemHealth contracts with vendors to provide services to EmblemHealth plan members. These vendors are considered network providers. Prior approval, if required, must be obtained directly from these vendors. For a listing of EmblemHealth network vendors, please go to the Directory in this manual. More information about each vendor is organized by subject or specialty in the various chapters of this manual.

In the event EmblemHealth elects to operate a physician incentive plan, no specific payment will be made directly or indirectly to a network practitioner or group as an inducement to reduce or limit medically necessary services furnished to a member. All practitioner agreements will include language requiring that the practitioner submit incentive plan information to EmblemHealth in an accurate and timely manner and in the format requested by the NYSDOH.

As of January 1, 2017, DentaQuest manages the dental benefits for members in the VIP Prime; Medicare Essential; Enhanced Care Prime; Prime; Premium (aka Vytra Premium); and Select Care Networks. This also includes those using the out of area benefits (via Careington) through our Preferred/Plus Dental Network. Go to dentaquest.com for more details, or call DentaQuest at 1-844-822-8108, Monday to Friday from 8 am to 5 pm.

See the following pages for the EmblemHealth Neighborhood Care Provider Recommendation Forms for the Cambria Heights and Harlem locations