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.

 

 

This chapter outlines EmblemHealth policies and procedures for the provision of medical care to our members, including provider participation requirements, provider roles and responsibilities, and provider termination procedures. Note: “provider” and “practitioner” are used interchangeably within this manual.

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)

See the Member Policies and Rights chapter for more information.

Member telephone calls should be handled by the practitioner or designated office staff (as appropriate to the situation) in line with the following guidelines:

  • Emergency conditions: respond immediately 
  • Urgent conditions: respond within four hours
  • Semi-urgent conditions: respond during the same day 
  • Routine conditions: respond within two working days
  • After-hours calls where the urgency is unclear: respond within 30 minutes
  • 24/7 availability for direct calls or through coverage services

EmblemHealth’s Appointment Availability Standards During Office Hours & After Office Hours Access Standards are available on the Provider Toolkit in the Resources section of emblemhealth.com/providers.

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

 

Appointment Availability Standards

Practitioner offices must schedule appointments i na timely and efficient manner in accordance with EmblemHealth'sappointment availability standards, including the Appointment Availability Standards by Service Type for Medicaid Children’s Health and Behavioral Health Benefits.

 

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

 

Noncompliant practitioners are notified by letter about failing one or more components of the survey. Practitioners who fail the survey are automatically included in the next survey. Practitioners who are not compliant with the standards and fail when they are re-surveyed are 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.

 

Urgent Care Access

For urgent conditions that do not meet the layperson's definition of an emergency, EmblemHealth maintains a network of 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 at emblemhealth.com/find-a-doctor.

Your practice information appears in our network directories (including our online Find a Doctor tool) and is used in claims processing. Keeping your informatio nupdated helps patients find your practice and helps us accurately process your claims. You must report updates to your practice information if any of the following changes occur:

  • Ability to accept new members
  • Age-range limitations applicable to the health care professional 
  • Add or delete a provider from your practice
  • Board certifications
  • Change in current and valid state (NJ, NY, CT, MA) licenses
  • Change in DEA or CDS certificate
  • Email address 
  • Fax number
  • Gender
  • Hospital affiliations
  • NYS PCMH or NCQA PCMH certifications
  • IRS taxpayer identification number (TIN) 
  • Languages spoken by you or within your office 
  • Medicaid number is assigned
  • Medical group affiliation
  • Medicare number is assigned
  • National Provider Identifier (NPI) number is assigned 
  • OB/GYN opts to see GYN-only patients
  • Office hours
  • Opening or closing a primary care panel 
  • Practice addresses
  • Practice phone numbers used for scheduling patient appointments 
  • Billing information
  • Specialties
  • Wheelchair accessibility at a practice location

Providers and their staff can sign in to update their practice records at emblemhealth.com/providers unless the provider is part of a group with arrangements to send changes via a spreadsheet/dataset process. For changes that cannot be processed online, mail or fax your changes to EmblemHealth’s 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 within five (5) business days, or as soon as possible, after any change to office address, telephone number, office hours, specialty, languages spoken, hospital affiliation, or 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. 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 does not affect previously submitted claims. EmblemHealth processes claims for a location with a Date of Service on or before the provider’s termination date.

 

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 EmblemHealth’s directories for accuracy and may impose fines and/or penalties for inaccurate information. Any fines/penalties or negative financial impact incurred by EmblemHealth due to a practitioner’s failure to notify us of any required change listed above are charged to the practitioner in an amount equal to the fine/penalty.

 

Change of Ownership

A change of ownership cannot be performed online; it is treated like a new enrollment. Providers must contact EmblemHealth when a change in ownership occurs. The appropriate contact information is located in the EmblemHealth Contact Information section of the Directory chapter.

 

Know Your Network Participation

The provider profile at emblemhealth.com/providers lists your network affiliations. We recommend you periodically review the information we have on file for you. We also encourage you to regularly share your network participation and any changes with your staff. If the network information on the member's ID card matches your network affiliations, then you are in-network for the member's benefit plan. See the Provider Networks and Member Benefit Plans chapter for a listing of all networks and plans.

 

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

 

Ask to see a member’s ID card at each appointment, emergency visit, or inpatien tstay. However, the provision of services hould 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 emblemhealth.com/providers to check your patient’s eligibility status.

EmblemHealth contracts with an extensive array of facilities and ancillary clinicians, including a network of prestigious teaching and community hospitals, skilled nursing facilities, and freestanding ambulatory care centers. EmblemHealth plan members have access to a network of thousands of contracted practitioners (including multi-specialty practices) who provide care both in medical centers, in their own offices within the community, and via telehealth.

 

EmblemHealth maintains an adequate network of practitioners to meet the comprehensive and diverse health needs of its members. Practitioners are selected 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 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 arranges and authorizes, when appropriate, the use of a nonparticipating practitioner at no additional out-of-pocket expense to the member.

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, go to the Directory chapter. More information about each vendor is organized by subject or specialty in the various chapters of this manual.


Medicaid and Child Health Plus Responsibilities to Government Agencies

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

 

Subcontractors, including practitioners, will perform all work and render all services in accordance with the terms of the agreement between EmblemHealth, NYSDOH, Centers for Medicare & Medicaid Services (CMS), and accreditation agencies. Practitioners agree to comply with and be bound by the confidentiality provisions set forth in the above-referenced agreements. Any obligations and duties imposed on sub-contractors, including participating practitioners, do not impair any rights accorded to Local Departments of Health (LDSS), NYSDOH, New York City Department of Health and Mental Hygiene (NYCDOHMH), U.S. Department of Health and Human Services (DHHS), CMS, or the accreditation agencies.

It is important for primary care practitioners (PCPs) to establish a meaningful, professional, and lasting relationship with their patients. EmblemHealth encourages new members to contact their PCP for an initial evaluation within 90 days of enrollment. If the initial contact with the practitioner is for an acute visit, the practitioner should recommend 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 requiring a referral, prior approval, or the use of a non-participating provider, the request must be approved by EmblemHealth in advance.A PCP may refer members with chronic, disabling, or degenerative conditions or diseases to a specialist for a set number of visits within a specified time. An EmblemHealth or managing entity medical director must approve standing referrals via the prior approval process.

 

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 has the same coverage arrangement for hospital admissions at an EmblemHealth-contracted hospital. ANPs may submit to EmblemHealth either a written collaborative agreement or the Advanced Nurse Practitioner Requesting Additional Status as Primary Caregiver form.

 

For more information on how to become credentialed with EmblemHealth as a primary caregiver, see the  Credentialing  chapter.

 

Primary Care Practitioner Responsibilities

EmblemHealth-contracted PCPs are responsible for providing primary care services and managing all medically necessary health care services for their assigned members. PCPs help members stay healthy and maintain an overall picture of health by supervising and coordinating all care with medical and behavioral health practitioners, and by 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, including:
    • Routine preventive health screenings 
    • Health counseling and advice
    • Physical examinations
    • Baseline and periodic 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 screenings (as appropriate) and referral to appropriate services
    • Routine/urgent/emergent office visits for illnesses or injuries 
    • Diagnosis and treatment of conditions not requiring the services of a specialist
    • Clinical management of chronic conditions not requiring a specialist 
    • Hospital medical visits (when applicable)
  • Maintain appropriate coverage for members 24 hours a day, 7 days a week, 365 days a year as noted in the above section on 24-hour access.
  • Maintain office hours not less than two (2) days per week, eight hours per day, at each primary care office.
  • Maintain a current medical record for each patient.
  • 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.
  • Refer all members for services in accordance with EmblemHealth's referral policies and procedures. See the Utilization and Care Management chapter of this manual for more details.
  • Provide servicesby 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.
  • Arrange inpatient care, specialist consults, and diagnostics, including, but not limited to, laboratory/radiological services when medically necessary and in a timely manner.
  • 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 members and appropriate specialists.
  • Coordinate the findings of consultants and laboratories and interpret such findings to the member/member's family (subject to the HIPAA Privacy Rule).
  • Consult and coordinate with members regarding specialist and behavioral health recommendations.
  • Comply with the New York State "Vaccines for Children Program," as appropriate, and with New York State and New York City requirements for reporting communicable diseases.

When EmblemHealth members first enroll, they choose where they want to receive medical care. Members whose benefit design requires the selection of a PCP can choose any participating PCP with an open panel. 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. A PCP cannot be his/her own or his/her family's primary care practitioner.

 

Members who fail to select a PCP within a given time frame 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 EmblemHealth’s Customer Service departments or by logging on to emblemhealth.com/members. 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. This helps with continuity of care. The original record should be retained and treated as a terminated record.

 

Medicaid and Child Health Plus Participating Practitioners

Practitioners treating members enrolled in Medicaid or Child Health Plus (CHPlus) will have no more than 1,500 members on their panel, or 2,400 members for a physician practicing in combination with a registered physician assistant or certified nurse practitioner. Advanced nurse practitioners credentialed as primary caregivers will have no more than 1,000 members on their panel. These member-to-practitioner ratios assume 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.

 

Medicaid members in the Restricted Recipient Program (RRP) have restrictions on when they can change PCPs. They may change PCPs for good-cause reasons such as:

  • Provider no longer wishes to be the RRP member's provider
  • Provider closed servicing location or moved to a location not convenient to the RRP member
  • Provider no longer participates in the network
  • Member moved beyond 30 minutes or 30 miles from RRP provider
  • Other circumstances exist that make it necessary to change providers

A PCPor primary caregiver may request removal of a member from his/herpanel,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 Customer Service indicating he/she will not continue as the member's practitioner. Provider Customer Service will coordinate with Members Services to notify the member.

The member’s new PCP should request all pertinent medical records from any other health practitioner providing care for the member. The following information should 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 if none were indicated
  • Dosage and duration information regarding any prescription given
  • Follow-up plan, as needed
  • Childhood immunization records

When a practitioner is terminated, EmblemHealth will:

  • 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 request a hearing (see the Termination and Appeal section of the Credentialing chapter)

We make every effort to assist members when their practitioner stops participation with one of our plans. Members who wish to continue an ongoing course of treatment with 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 Utilization and Care Management chapter on transitional care.

 

If the practitioner is a PCP and the member opts to stay with the PCP during the 90-day transition period, the member must notify Customer Service of the new PCP who will manage their care after the transition. If the practitioner 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 contracted specialist physicians agree to see members referred by a participating PCP, 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 (Self-Referral) Services 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. 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 is referred to a specialist, the specialist is responsible for diagnosing the member's clinical condition and/or managing treatment of the condition, up to the number of visits identified on the referral authorization. The scope of services rendered is limited to those related to the clinical condition for which the PCP refers the member.

 

When providing specialty care, the practitioner must:

  • Keep the PCP informed of the member's general condition through 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/her designee) and emergency care
  • Deliver all medical health care services available to members with self-referral benefits

OB/GYN specialists may see members without referral or prior approval 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 Utilization and Care Management chapter.

EmblemHealth Members

EmblemHealth members can self-refer to network providers for the following services 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, and acute gynecological condition
  • At least 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/care 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.)
  • 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, including:

  • Annual mammography screening 
  • Annual routine eye exam 
  • Colorectal screening
  • Glaucoma screening, if at high risk
  • HIV screening
  • Influenza and pneumococcal vaccine 
  • Initial chiropractic assessment 
  • Outpatient mental health visits 
  • Nutrition therapy services
  • 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.

 

Medicaid and Child Health Plus Members (CHPlus)

In addition to the above services to which all EmblemHealth members have direct access, there are some services to which members in state sponsored programs (Medicaid and CHPlus) may also self-refer. Unless otherwise indicated, members in all state sponsored programs may self-refer to the services outlined in Section 10.15 of the Medicaid Managed Care Model Contract:

  1. Mental Health and Chemical Dependence Services
  2. Vision Services
  3. Diagnosis and Treatment of Tuberculosis
  4. Family Planning and Reproductive Health Services

    Note
    : Federal regulations require patient consent forms and paper claims for hysterectomy and sterilization procedures for Medicaid members. For more details, see Claims Corner at emblemhealth.com.
  5. Article 28 Clinics Operated by Academic Dental Centers

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 non-life-threatening condition, whether in a hospital, emergency room, or primary care setting such as a doctor's office or outpatient clinic. For a summary of changes in the law see HIV Testing, Reporting and Confidentiality in New York State 2017-18 Update. (Current as of Feb. 19, 2020)

 

Consent Required

The 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 important points to know about HIV testing.

 

Treating HIV/AIDS

Visit the Clinical Corner at emblemhealth.com for clinical practice guidelines for the treatment of HIV/AIDS. 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 are reviewed as necessary.

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, visit the New York State Department of Health website.

EmblemHealth Medicaid Newborns

Newborn children of mothers enrolled in EmblemHealth's Medicaid plans are automatically enrolled in the mother's plan. These newborns receive all benefits and services of the plan beginning on their date of birth. All members should call EmblemHealth’s Customer Service department to provide their newborn's name, sex, date of birth, birth weight, and birth hospital so we can complete the enrollment process. Once enrolled, the newborn is issued a member ID card.

 

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

 

EmblemHealth Child Health Plus

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

EmblemHealth contracts with health care professionals and facilities with expertise in caring for medically fragile children. This ensures children with co-occurring developmental disabilities receive services from appropriate providers. Network providers refer to appropriate network community and facility providers to meet the needs of the child or seek authorization for out-of-network providers when participating providers cannot meet the child’s needs. For more information, see the Prior Approval Procedures section of the Utilization and Care Management chapter.

EmblemHealth members enrolled in either a Medicaid or Medicare-Medicaid plan can 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. Only home care agencies approved by Medicaid as providers of telehealth are authorized to provide telehealth monitoring.

 

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 to obtain prior approval to provide telehealth services as a covered benefit. EmblemHealth covers 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 evaluation may include a review of the original assessment or we may request a new assessment.

 

The home health care agency may 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 documents the following about 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, medication side effect, or medication adverse effect 
  • 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 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. For more information, visit emblemhealth.com/Neighborhood.

EmblemHealth will not prohibit or restrict any practitioner from disclosing to any member, patient, or designated representative any information the practitioner deems appropriate regarding a member’s condition or course of treatment, including the availability of other therapies, tests, medications, etc., regardless of benefit coverage limitations. EmblemHealth will 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 will not be prohibited from discussing the risks, benefits, and consequences of treatment (or absence of treatment) with the member, patient, or designated representative. Patients will have the opportunity to refuse treatment and to express preferences about future treatment decisions.

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