Provider Manual

Chapter 18: Clinical Practice Guidelines

This chapter contains evidence-based recommendations to assist practitioners in providing medical care.

EmblemHealth encourages the use of Clinical Practice Guidelines (CPGs) for assistance in the treatment of acute, chronic and behavioral health issues. We've adopted these guidelines from professionally recognized sources and through consultation between board-certified specialists and our Health Status Improvement Subcommittee.

All CPGs are reviewed at a minimum of every two years and are updated as appropriate. (The HIV/AIDS CPGs are reviewed and updated annually.)

CPGs are not intended as a substitute for the professional assessment of the health care practitioner but to assist the practitioner in the management of certain types of preventive and clinical care. Individual patient treatment may vary from these guidelines based on the health care practitioner's clinical judgment.

The CPGs approved by EmblemHealth are listed below. Updates will be posted regularly to our Web site, so please check for updates on a monthly basis. If you are unable to access a specific CPG on the Web, please contact our Quality Management department at 1-888-447-5451 to request a mailed copy.

Medical Management

(Please access these clinical practice guidelines.)

  • Adult Preventive Services
  • Appropriate Use of Antibiotics for Adults and Children
  • Arthritis
  • Asthma
  • Cholesterol Management for Adults at Risk for Cardio/Vascular Disease
  • Chronic Kidney Disease
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Community-Acquired Pneumonia in Adults
  • Congestive Heart Failure
  • Coronary Artery Disease
  • Diabetes Mellitus
  • Helicobacter Pylori
  • HIV/AIDS
  • Hypertension
  • Low Back Pain Diagnosis and Treatment
  • Lyme Disease
  • Obesity and Weight Management in Adults
  • Obesity and Weight Management in Children and Adolescents
  • Osteoporosis
  • Pediatric and Adolescent Preventive Services
  • Preconception Care
  • Prenatal/Postpartum Care
  • Sexually Transmitted Diseases (STDs)
  • Smoking Cessation
  • Stroke Prevention
  • Tuberculosis
  • Urinary Incontinence

 

Behavioral Health Services

Beacon Health Options manages behavioral health services for members served by Emblem Behavioral Health Services Program (for plans underwritten by HIP and HIPIC and administered by VHMS) and Behavioral Management Program (for plans underwritten by GHI).

 

Please access the Beacon Health Options Treatment Guidelines listed below at https://www.beaconhealthoptions.com/pcp-toolkit/.

 

Diagnosed Based

Program Based

Treatment Based

  • Electroconvulsive Therapy (ECT) (PDF)
    Adopted from APA 8/11/05 Reviewed 9/19/11

 

Medically Fragile Children

For the Medicaid children carve-in effective July 1, 2018, and the foster care children carve-in in 2019, EmblemHealth
will incorporate the following into its guidance:

 

Office of Health Insurance Programs Principles

A “medically fragile child” (MFC) is defined as an individual who is under 21 years of age and has a chronic debilitating condition or conditions, who may or may not be hospitalized or institutionalized, and meets one or more of the following criteria:
(1) is technologically dependent for life or health-sustaining functions,
(2) requires a complex medication regimen or medical interventions to maintain or to improve their health status,
(3) is in need of ongoing assessment or intervention to prevent serious deterioration of their health status or medical complications that place their life, health, or development at risk. Chronic debilitating conditions include, but are not limited to:

  • bronchopulmonary dysplasia
  • cerebral palsy
  • congenital heart disease
  • microcephaly
  • pulmonary hypertension
  • muscular dystrophy

 

With respect to medically fragile children, and children in foster care EmblemHealth:
A. Will, in accordance with the requirements of C/THP and EPSDT as described in Section 10.4 of the DOH Model Contract, cover all services that assist a medically fragile child in reaching their maximum functional capacity, taking into account the appropriate functional capacities of children of the same age. EmblemHealth will continue to cover services until that child achieves age-appropriate functional capacity.

 

B. Shall not base determinations solely based upon review standards applicable to (or designed for) adults to medically fragile children. Adult standards include, but are not limited to, Medicare rehabilitation standards and the “Medicare 3-hour rule.” Determinations have to take into consideration the specific needs of the child and the circumstances pertaining to their growth and development.

 

C. Will accommodate unusual stabilization and prolonged discharge plans for medically fragile children, as appropriate. Areas that plans must consider when developing and approving discharge plans include, but are not limited to:

  •  
    • sudden reversals of condition or progress, which may make discharge decisions uncertain or more prolonged than for other children or adults
    • necessary training of parents or other adults to care for a medically fragile child at home
    • unusual discharge delays encountered if parents or other responsible adults decline or are slow to assume full responsibility for caring for a medically fragile child
    • the need to await an appropriate home or home-like environment rather than discharge to a housing shelter or other inappropriate setting for a medically fragile child
    • the need to await construction adaptations to the home (such as the installation of generators or other equipment)
    • and lack of available suitable specialized care (such as unavailability of pediatric nursing home beds or
      pediatric ventilator units).

 

EmblemHealth will develop a person-centered discharge plan for the child, taking the above situations into consideration.

 

D. Will identify an available provider of needed covered services, as determined through a person-centered care plan, to effect safe discharge from a hospital or other facility. Payment will not be denied to a discharging hospital or other facility due to lack of an available post-discharge provider as long as they have worked with EmblemHealth to identify an appropriate provider. EmblemHealth will approve the use of out-of-network (OON) providers if we do not have a participating provider to address the child’s needs.

 

E. EmblemHealth will ensure that a medically fragile child receives services from appropriate providers that have the expertise to effectively treat the child. EmblemHealth contracts with providers with demonstrated expertise in caring for medically fragile children. Network providers shall refer to appropriate network community and facility providers to meet the needs of the child or seek EmblemHealth’s authorization for out-of-network providers when participating providers cannot meet the child’s needs. EmblemHealth will authorize services as fast as the enrollee’s condition requires and in accordance with established time frames in the Medicaid Managed Care Model Contract.

 

EmblemHealth expects those who treat medically frail and foster children to comply with this guidance.