Provider Manual

Chapter 3: Credentialing

 

 

In this chapter you will find credentialing and recredentialing requirements, including the managed care law requiring provisional credentialing, and the practitioner appeal process for changes in participation. EmblemHealth permits the delegation of credentialing to certain large organizations that are subject to strict oversight protocols. Check with your practice administrator to see if delegation protocols apply to your organization.

 

 

To see the credentialing requirements for our Behavioral Health Network, please see Beacon Health Option’s provider manual. The following provider types should contact Beacon Health Options to address participation:

  • Caregiver/Family Supports and Services – behavioral health primary diagnosis
  • Community Self-Advocacy Training and Support – behavioral health primary diagnosis
  • Habilitation – behavioral health primary diagnosis
  • HCBS/SPA services – behavioral health primary diagnosis
  • NYS-designated providers of Children’s Specialty Services – behavioral health primary diagnosis
  • NYS-determined Essential Community Behavioral Health providers for children – behavioral health primary diagnosis
  • OMH and OASAS licensed or certified providers
  • Psychologists
  • Prevocational Services
  • Psychiatrists
  • Respite – behavioral health primary diagnosis
  • School-based mental health clinics
  • Social Workers
  • Supported Employment

Credentialing is an important process that ensures that health care professionals have the requisite qualifications and training needed to deliver care. The credentialing process also ensures the verification and review of individuals with adverse actions against them, such as sanctions, malpractice or fraud. When applicable, written notice will be sent to practitioners whose credentials are being reviewed.

Minimum qualification requirements for participation include, but are not limited to:

  • A valid license to practice
  • City of New York – non-members
  • Appropriate training or board certification
  • Clinical privileges in good standing (as applicable)
  • Current malpractice insurance coverage
  • Acceptable history with regards to malpractice

 

Note: Providers who are sanctioned or excluded by the New York State Department of Health's (DOH) Medicaid Program will be excluded from participation in all our benefit plans.

Also Note: All providers, professional and facility, inside and outside of New York, who treat our Medicaid, HARP and Child Health Plus members MUST be registered with the DOH for the Medicaid Program. Registration does not obligate providers to see FFS Medicaid members. The DOH offers an option for participation to be limited to Medicaid Managed Care.

During the credentialing process, practitioners maintain the following rights:

  • The right to review information obtained in support of their credentialing applications, excluding references, recommendations or other peer review protected material.
  • The right to correct erroneous information in written form to the credentialing department within 10 days of receipt of EmblemHealth's notification.
  • The right to be informed of the status of his/her credentialing/recredentialing application. Requests may be made to EmblemHealth via written or telephone inquiry.

Per New York State law, initial applications are reviewed by the Credentialing department within 90 days of receiving a fully completed application, and the applicant is notified within that time period if credentialing has been approved or if additional time is needed. We will make our best effort to obtain any missing documentation from third parties in a timely manner.

Decision

Following completion of the application and all applicable verifications, the Credentialing/ Recredentialing Committee (CRC) will consider all information gathered on the provider and evaluate in light of the criteria. At that time, the CRC decides to approve or disapprove the provider's application. The provider is advised accordingly.

The provider will generally be credentialed for a three year period. However, the CRC may recommend credentialing for a period less than three years based on the results of its review. If so, the provider is advised of the decision and the reason for the shorter approval period.


If a provider has been disapproved but had been providing care to plan members, the CRC will direct appropriate plan and medical group staff to develop a transition plan for developing alternative providers or may recommend immediate cessation of referrals to the provider.

New York State and Federal regulations require EmblemHealth to maintain the accuracy of its provider file data, to ensure its Provider Directories meet basic information requirements and accuracy.

Through the initial credentialing and periodic recredentialing processes, EmblemHealth validates the accuracy of a provider’s service location data by reviewing against the provider’s data in CAQH ProView™ and performing telephone outreach.

CAQH ProView, formerly the Universal Credentialing Datasource®, was founded in 2002 to address the biggest challenge with provider credentialing. Data collection had been the most inefficient step of the credentialing process, placing unnecessary burden on providers. Previously, providers completed separate credentialing forms for each payer.

EmblemHealth’s data validation process leverages the data in CAQH ProView as the “source of truth” for service location data. Only service locations listed on CAQH Proview are eligible for validation, enrollment at initial credentialing or continued participation at recredentialing. Service locations not listed in CAQH ProView will be subject to validation by phone call and possible termination if unreachable or non-responsive.

To avoid a failed validation, denial of enrollment or possible break in service, please ensure your CAQH profile is up to date with all service addresses and telephone numbers where you take appointments.

In accordance with New York State Public Health Law, EmblemHealth allows newly licensed or recently relocated out-of-state practitioners to apply for provisional credentialing, which would take effect prior to completion of the full 90-day credentialing process. This provisional status is available only to practitioners who apply within six months of licensing or out-of-state relocation, who join a group practice that already participates with EmblemHealth's HMO networks and whose group practice agrees to any necessary repayment noted below. Provisionally credentialed practitioners may not be assigned to members as a primary care provider.

Should an application for provisional credentials be denied, EmblemHealth will consider any work performed by the provisional practitioner to be an out-of-network service, and the practitioner (or their group practice) shall repay to EmblemHealth the difference between the in- and out-of-network fees payable under each member's coverage plan. Under no circumstances may the practitioner (or group practice) attempt to recover this difference from the member, except to collect copayment or coinsurance that would otherwise be payable had the member received services from a health care professional in the EmblemHealth network.

EmblemHealth requires all practitioners to undergo recredentialing every three years.

Practitioners must maintain the same minimum qualification requirements as applicable for the initial credentialing. In addition, the recredentialing process will evaluate each practitioner on:

  • Access/availability
  • Under/over utilization data
  • Quality of care
  • Primary and secondary prevention
  • Disease management
  • Member satisfaction
  • Site/medical record audit scores
  • Member concerns
  • Peer review
  • Continuity of care

Six months prior to the credential’s expiration, practitioners will receive a letter from either EmblemHealth’s Recredentialing Department or Aperture CVO (our contracted credentials verification organization). The letter will direct them to update their application on file with the Council for Affordable Quality Healthcare’s (CAQH) Universal Provider Datasource (UPD).

Practitioners should make any changes to their information on the CAQH UPD, update the malpractice claims history accordingly, and include updated copies of their curriculum vitae, State License, Drug Enforcement Agency certification and proof of malpractice insurance coverage with the application.

Practitioners with a complete application on file with CAQH UPD can advise EmblemHealth or Aperture CVO to retrieve all documentation from that source. More information on our relationship with CAQH can be found in this chapter in the section on Council for Affordable Quality Healthcare Universal Provider Database.

To ensure continued participation with EmblemHealth, it is important to return all recredentialing materials as soon as possible. Failure to respond in a timely manner may result in termination from EmblemHealth's provider networks. Reapplication to our provider networks will then be subject to network need.

The Recredentialing Department will review the updated application for completeness and present it to EmblemHealth's CRC for a determination. Occasionally, an EmblemHealth staff member may call the practitioner's office for missing or additional information. The practitioner will then be notified of continued participation or termination.

On July 30, 2010, New York State passed into law updates to the definition of and requirements for midwives and midwifery. (See §6951 at http://public.leginfo.state.ny.us/menuf.cgi.) The law changes the requirement that midwives must enter into formal written agreements with obstetricians, gynecologists or health care facilities, including hospitals; instead they are now required to have a collaborative relationship with these entities.

As of November 1, 2010, EmblemHealth requires midwives to have a collaborative relationship with a participating physician that practices obstetrics and gynecology. Midwives must document this collaborative relationship and must make this information available to their patients. Failure to comply with this directive may result in professional misconduct charges as set forth in the law. Participating midwives, or those applying for participation with EmblemHealth, must furnish proof of their collaborative relationship with a participating obstetrics and gynecology physician.

EmblemHealth has adopted the policy guidance from the New York State Medicaid program to ensure appropriate designation of participating practitioners as breast feeding, education and lactation counselors. Physicians, nurse practitioners, midwives, physician assistants and registered nurses seeking this credential must have the following minimum requirements, as defined in the EmblemHealth Credentialing Policy:

  • Current and valid medical license
  • Current and valid DEA certificate (as applicable)
  • Current malpractice coverage within acceptable limits
  • Hospital privileges in good standing with a plan-contracted facility
  • Acceptable work history
  • Acceptable malpractice history
  • Acceptable adverse action history

In addition to these minimum credentialing requirements, applicants must also be International Board Certified Lactation Consultants (IBCLCs) credentialed by the International Board of Lactation Consultant Examiners (IBLCE).

The professional services of a nurse practitioner (NP) may be covered in network if he or she is contracted, meets qualifications for NPs and is legally authorized to provide services in the state where the services are performed. Payments are allowed for assistant-at-surgery services and services provided in all areas and settings permitted under applicable state licensure laws.

Note: No separate payment will be made to the nurse practitioner when a facility or other provider charges or is paid any amount for such professional services. A facility or other provider includes a hospital, skilled nursing facility, comprehensive outpatient rehabilitation facility, ambulatory surgical center, community mental health center, rural health center or federally qualified health center.

Qualifications for NPs

An NP must meet all three of the following qualifications:

  • Be a registered professional nurse who is authorized by the state in which the services are provided to practice as an NP in accordance with state law
  • Be certified as an NP by a recognized national certifying body that has established standards for NPs
  • Possess a master’s degree in nursing

The following organizations are recognized national certifying bodies for NPs at the advanced practice level:

Covered Services

Services are covered if they meet all four of the following criteria:

  • Considered physician’s services if provided by a doctor of medicine or osteopathy (MD/DO)
  • Performed by a person who meets all NP qualifications and is legally authorized to perform the services in the state in which they are performed
  • Performed in collaboration with a MD/DO
  • Not otherwise precluded from coverage because of statutory exclusions

In general, NPs are paid for covered services at 85 percent of what a physician is paid.

Nurse Practitioners as Attending Physicians

Services provided by an NP that are medical in nature must be reasonable and necessary, be included in the plan of care, and would be performed by a physician in the absence of the NP. If the services performed by an NP can be performed by a registered nurse in the absence of a physician, they are not considered attending physician services and are not separately billable.

Services Otherwise Excluded From Coverage

NP services may not be covered if they are otherwise excluded from coverage even though an NP may be authorized by state law to perform them. For example, the Medicare law excludes from coverage routine foot care and services that are not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body part. Therefore, these services are precluded from coverage even though they may be within an NP’s scope of practice under state law.

Sending Your Application

To submit a request for NP credentialing, print and complete a Credentialing Application Addendum for Nurse Practitioner form, and mail to the applicable address below.

For New York City, Nassau county and Suffolk county, as well as New Jersey and Connecticut applicants, please send your completed application and agreements to:

EmblemHealth
55 Water Street
New York, NY 10041
Attn: Physician Contracting, 7th floor

For all other counties in New York State, as well as all other out-of-state applicants, please send your completed application and agreements to:

EmblemHealth
5015 Campuswood Drive
East Syracuse, NY 13057
Attn: Physician Contracting

Note: All applications must include the signed agreement for the networks you would like to join.

The professional services of a physician assistant (PA) may be covered in network if he or she is contracted, meets qualification for PAs and is legally authorized to provide services in the state where the services are performed. Payments are allowed for assistant-at-surgery services and services provided in all areas and settings permitted under applicable state licensure laws.

Note: No separate payment will be made to the physician assistant when a facility or other provider charges or is paid any amount for such professional services. A facility or other provider includes a hospital, skilled nursing facility, comprehensive outpatient rehabilitation facility, ambulatory surgical center, community mental health center, rural health center or federally qualified health center.

Qualifications for PAs

A PA must be licensed by the state to practice as a PA and meet one of following two qualifications:

  • Graduated from a PA educational program accredited by the Accreditation Review Commission on Education for the Physician Assistant (or its predecessor agencies, the Commission on Accreditation of Allied Health Education Programs [CAAHEP] and the Committee on Allied Health Education and Accreditation [CAHEA])
  • Passed the national certification examination administered by the National Commission on Certification of Physician Assistants (NCCPA)

Covered Services

Services are covered if they meet all four of the following criteria:

  • Considered physician’s services if provided by a doctor of medicine or osteopathy (MD/DO)
  • Performed by a person who meets all PA qualifications and is legally authorized to perform the services in the state in which they are performed
  • Performed under the general supervision of an MD/DO
  • Not otherwise precluded from coverage because of statutory exclusions

Types of PA Services That May Be Covered

PAs may provide services billed under all levels of CPT evaluation and management codes, and diagnostic tests, if provided under the general supervision of a physician. Examples of services PAs may provide include services traditionally reserved for physicians, such as examinations (including the initial preventive physical examination), minor surgery, setting casts for simple fractures, interpreting X-rays, and other activities that involve an independent evaluation or treatment of the patient’s condition. In general, PAs are paid for covered services at 85 percent of what a physician is paid.

Services Otherwise Excluded From Coverage

PA services may not be covered if they are otherwise excluded from coverage even though a PA may be authorized by state law to perform them.

Physician Supervision

The PA’s physician supervisor (or a physician designated by the supervising physician or employer as provided under state law or regulations) is primarily responsible for the overall direction and management of the PA’s professional activities and for assuring that the services provided are medically appropriate for the patient. The physician supervisor (or physician designee) need not be physically present when a service is provided by the PA to a patient and may be contacted by telephone, if necessary, unless state law or regulations require otherwise.

Sending Your Application

To submit a request for PA credentialing, print and complete a Credentialing Application Addendum for Registered Physician Assistant form, and mail to the applicable address below.

For New York City, Nassau county and Suffolk county, as well as New Jersey and Connecticut applicants, please send your completed application and agreements to:

EmblemHealth
55 Water Street
New York, NY 10041
Attn: Physician Contracting, 7th floor

For all other counties in New York State, as well as all other out-of-state applicants, please send your completed application and agreements to:

EmblemHealth
5015 Campuswood Drive
East Syracuse, NY 13057
Attn: Physician Contracting

Note: All applications must include the signed agreement for the networks you would like to join.

State-Designated Providers

State designation of providers will suffice for the EmblemHealth’s credentialing process. When contracting with NYS-designated providers, EmblemHealth will not separately credential individual staff members in their capacity as employees of these programs. EmblemHealth will still conduct program integrity reviews to ensure that provider staff are not disbarred from Medicaid or any other way excluded from Medicaid reimbursement. EmblemHealth will still collect and accept program integrity-related information from these providers, as required in the Medicaid Managed Care Model Contract, and will require that such providers not employ or contract with any employee, subcontractor, or agent who has been debarred or suspended by the federal or state government, or otherwise excluded from participation in the Medicare or Medicaid program.

Organizational providers contracting with EmblemHealth must apply for credentialing. They must go through the recredentialing process in much the same way as individual practitioners.

Minimum qualification requirements for facility participation include, but are not limited to:

  • Current accreditation or an acceptable site visit
  • Appropriate licensure
  • Current Medicare and Medicaid certification status
  • Malpractice insurance coverage
  • Acceptable history with regards to malpractice

Organizational providers requiring credentialing include:

  • Ambulatory surgery facilities
  • Clinical laboratories
  • Comprehensive outpatient rehabilitation facility (CORF) providers
  • Dialysis centers
  • Federally qualified health centers/NYS Article 28 Certified Health and Treatment Centers
  • Freestanding imaging centers
  • Freestanding outpatient alcohol/drug abuse centers
  • Freestanding outpatient mental health centers
  • Home health agencies
  • Home infusion agencies
  • Hospices
  • Hospitals
  • Outpatient diabetes self-management training (DSMT) providers
  • Outpatient physical therapy and speech language pathology (OPT/SLP) providers
  • Portable X-ray suppliers
  • Psychiatric hospitals
  • Rural health clinics
  • School-based health centers (effective 1/1/21 or other official start date of the Medicaid carve-in)
  • Skilled nursing facilities
  • Substance abuse residential rehabilitation services
  • Urgent care facilities

Site Visits

Site visits are completed for non-accredited entities, as applicable. Although the Centers for Medicare and Medicaid Services (CMS) or state review or certification does not serve as accreditation of an institution, a CMS or state review can be accepted in lieu of the required site visit. The actual report from the institution must be retrieved to verify that the review was performed and that the report meets acceptable standards; however, a letter from CMS which shows that the facility was reviewed and indicates that it passed inspection is acceptable in lieu of the survey report.

Decision

Following completion of the application and all applicable verifications, the CRC will consider all information gathered on the organizational provider and evaluate in light of the criteria. At that time, the CRC decides to approve or disapprove the application. The provider is advised accordingly.

The organizational provider will generally be credentialed for a three year period. However, the CRC may recommend credentialing for a period less than three years based on the results of its review. If so, the provider is advised of the decision and the reason for the shorter approval period.

If an organizational provider has been disapproved but had been providing care to plan members, the CRC will direct appropriate plan and medical group staff to develop a transition plan for identifying alternative providers or may recommend immediate cessation of referrals to the provider.

EmblemHealth has a process for the periodic recredentialing of organizational providers previously approved by the CRC. All organizations are recredentialed every three years.

Scope

All organizations participating in the HMO networks and the Medicare Advantage network that were required to obtain initial approval from the CRC are also subject to the recredentialing process.

Review Criteria

The review criteria for recredentialing are the same as the credentialing criteria.

Decision

The decision-making process for recredentialing is the same as for initial credentialing.

Acceptable accrediting bodies include, but are not limited to:

  • The Joint Commission (TJC)
  • Det Norske Veritas (DNV)
  • The Accreditation Association for Ambulatory Health Care (AAAHC)
  • The Commission on Accreditation of Rehabilitation Entities (CARF)
  • The Council on Accreditation, the Community Health Accreditation Program (CHAP)
  • The Continuing Care Accreditation Commission
  • American Association of Diabetes Educators (AADE)
  • American College of Radiology (ACR)
  • American Institute of Ultrasound in Medicine (AIUM)
  • Intersocietal Commission on Accreditation of Nuclear Laboratories (ICANL)
  • American Association of Clinical Endocrinologists (AACE)
  • Nuclear Medicine Technology Certification Board (NMTCB)

EmblemHealth's Credentialing/ Recredentialing Committee (CRC) is charged with examining the qualifications of participating clinicians and facilities against the professional standards established by our Quality Improvement Committee (QIC).

The CRC performs the initial approval and credentialing of clinicians and facilities for participation with EmblemHealth. The CRC is assisted by the Credentialing department, which is responsible for reviewing and verifying completeness of every provider's application. Primary source verification is done of the provider's licensure and accreditation, where applicable. CMS requires primary source verification of education and training records and board certification. They reassess said clinicians and organizational providers every three years (at minimum) to assure that all credentialed clinicians and organizations remain qualified and continue to meet the established criteria.

Members of the CRC include an EmblemHealth designee or our Medical Director (acting as the Committee Chair), at least one physician from each primary care specialty and any high volume specialists as designated by the Committee Chair. The Committee Chair ensures that the CRC has a meaningful range of participating practitioners serving on the Committee with additional specialties added on an ad-hoc basis. All practitioners in the voting membership of the Committee must maintain a current credentials file with EmblemHealth.

The Committee Chair leads discussions concerning potential quality issues and explains and/or clarifies credentialing policy and procedure when required. The CRC is required to conduct a review of the credentialing file prior to credentialing or recredentialing an applicant.

For Medicare Advantage health care services, the provider shall cooperate with the plan's credentialing and recredentialing process. The credentials of medical professionals covered by an agreement with one of EmblemHealth's companies will either be reviewed by EmblemHealth directly or where delegated, the credentialing process will be reviewed and approved by EmblemHealth who must audit the credentialing process on an ongoing basis.

EmblemHealth is part of The Alliance, a collaboration between health plans which allows practitioners who participate in two or more plans to use a single application for credentialing. Alliance-based applications are performed by Aperture CVO and the results are shared with all participating and applicable health plans.

EmblemHealth participates in the Council for Affordable Quality Healthcare (CAQH) Universal Provider Datasource (UPD).

EmblemHealth requires all applicants for all networks to complete the Council for Affordable Quality Health Care (CAQH) Proview credentialing application form. If you do not have a CAQH number, please register with CAQH ProView. If you have any  questions abouthow to obtain a CAQH number, please call  CAQH at 1-888-599-1771.

The following events may affect the credentialing of a practitioner or practitioner's employee and shall be immediately reported to EmblemHealth:

  • Any voluntary or involuntary diminishment, suspension, termination or relinquishing of licensing and/or hospital privileges initiated by a hospital.
  • Any voluntary or involuntary diminishment, suspension, revocation, or relinquishing of a DEA certificate.
  • The initiation of any proceeding by a state licensing authority.
  • The initiation of any legal or criminal proceeding pertaining to practitioner or any individual employed by practitioner.
  • Any proceeding which could affect Medicaid or Medicare participation of either practitioner or any licensed employee of the practitioner.
  • Any report made to the National Practitioner Data Bank (NPDB) or other reporting agency concerning a licensed professional employed by the practitioner.
  • Any notice given regarding the commencement of a professional liability action involving the practitioner or any entity, other than a publicly traded company, in which the practitioner has an ownership interest.
  • Any member complaint concerning the covered services rendered.

In the event that a practitioner is de-credentialed for quality issues by the CRC, the Recredentialing Committee or an Ad Hoc Appellate Board, EmblemHealth is required by law to report such misconduct to the appropriate data collection service(s). Reporting shall occur within 30 days from the decision date, unless the practitioner requests an appeal.

Reportable Actions

Actions reportable to the National Practitioners Data Bank (NPDB) include:

  • Any professional review based on reasons related to professional competence or conduct which adversely affects EmblemHealth participation for a period longer than 30 days.
  • Voluntary surrender or restriction of clinical privileges while under, or to avoid, investigation.

Actions reportable to the Healthcare Integrity and Protection Data Bank (HIPDB) include:

  • Health care related civil judgments entered in federal or state court.
  • Any other adjudicated actions or decisions that the CMS Secretary shall establish by regulation.

Actions reportable to the applicable state office with oversight of professional conduct, e.g., New York State Office of Professional Medical Conduct (NYSOPMC) includes:

  • Termination of credentials based upon member complaints or peer review findings.

In the event that a practitioner is de-credentialed for quality issues by the CRC, the Recredentialing Committee or an Ad Hoc Appellate Board, EmblemHealth is required by law to report such misconduct to the appropriate data collection service(s). Reporting shall occur within 30 days from the decision date, unless the practitioner requests an appeal.

Reportable Actions

Actions reportable to the National Practitioners Data Bank (NPDB) include:

  • Any professional review based on reasons related to professional competence or conduct which adversely affects EmblemHealth participation for a period longer than 30 days.
  • Voluntary surrender or restriction of clinical privileges while under, or to avoid, investigation.

Actions reportable to the Healthcare Integrity and Protection Data Bank (HIPDB) include:

  • Health care related civil judgments entered in federal or state court.
  • Any other adjudicated actions or decisions that the CMS Secretary shall establish by regulation.

Actions reportable to the applicable state office with oversight of professional conduct, e.g., New York State Office of Professional Medical Conduct (NYSOPMC) includes:

  • Termination of credentials based upon member complaints or peer review findings.

The CRC and PRS have the authority to terminate practitioners from servicing EmblemHealth members. The committee and subcommittee make such a determination based on, in the case of the CRC, quality or credentials issues arising at recredentialing or, in the case of the PRS, complaints about quality of care. The procedures for termination and appeal are managed through our Credentialing department and apply to actions by either the CRC or PRS.

Actions that may cause termination include, but are not limited to:

  • Engaging in acts of gross incompetence or gross negligence on a single occasion, or negligence or incompetence on more than one occasion.
  • Refusing to provide a client or patient service or medical care because of race, creed, color or national origin.
  • Practicing beyond the scope of the profession.
  • Failing to return or provide copies of records upon request.
  • Being sexually or physically abusive.
  • Abandoning or neglecting a patient in need of immediate care.
  • Performing unnecessary work or unauthorized services.
  • Practicing under the influence of alcohol or other drugs.
  • Promoting the sale of services, goods, appliances or drugs in a manner that exploits the patient.
  • Refusing to provide medical care because of race, creed, color or national origin.
  • Guaranteeing a cure.
  • Performing professional services not authorized by the patient.
  • Willfully harassing, abusing or intimidating a patient.
  • Ordering excessive tests or treatments.
  • Permitting or aiding an unlicensed person to perform activities which require a license.
  • Practicing the profession with a suspended or inactive license.
  • Revealing personally identifiable facts, data or information without consent of the patient, except as authorized or required by law.
  • Any conviction of a criminal offense related to a participating provider or that provider's managing employee involvement in any Medicare, Medicaid or Title XX services program.
  • Any provider denied credentialing for program integrity-related reasons such as being on a government program-excluded provider list and/or having existing fraud, licensing or OPMC issues.
  • Voluntary surrender or restriction of clinical privileges while under, or to avoid, investigation.
  • A finding of mental or physical impairment.
  • A finding of imminent harm to patient health, safety and welfare.
  • The voluntary or involuntary termination of a contract, employment or other affiliation to avoid the imposition of disciplinary measures.
  • Determination of fraud.
  • Determination of misconduct.
  • Releasing confidential information without authorization or as otherwise legally permitted.
  • Being convicted of a crime.
  • For other reasons, such as business decisions that are other than quality of care concerns.

The CRC and PRS make decisions, except for termination for egregious reasons, at regularly scheduled meetings. The practitioner will receive a termination notice explaining the reasons for the proposed action, a termination date and a detailed explanation of the appeal process. Termination shall be effective no earlier than 60 days from the practitioner's receipt of the termination notice.

Throughout the process, the CRC and PRS make every effort to ensure that the practitioner has adequate opportunity to contribute to any discussion on recredentialing or quality of care.

Decisions of the practitioner's termination shall be effective not less than 60 days after the receipt by the practitioner of the termination notice.

Appeal of Disciplinary Decisions

The practitioner may appeal any formal CRC/PRS disciplinary action to a CRC Ad Hoc Appellate Board. Written notice of appeal must be sent to CRC within 30 days of receiving the termination notice. If no appeal is submitted within 30 days, the action will be reported to NPDB.

If an appeal is requested, the practitioner will be contacted and, once a date is confirmed, will be notified by certified mail of the date and time of the appeal hearing. Said hearing shall take place no later than 30 days from the date of receipt of the provider's request for a hearing.

The notice of hearing must be accompanied by copies of all documents, reports, cases or materials on which the Ad Hoc Appellate Board intends to rely. The practitioner may submit additional information (in writing) for consideration by the Ad Hoc Appellate Board within 30 days of filing the appeal. Additional materials must be received before the scheduled date of the hearing.

The practitioner has the right to appear before the Ad Hoc Appellate Board through counsel.

This hearing may be postponed only once, unless there are extenuating circumstances. If the practitioner elects to postpone the second hearing without extenuating circumstances, the Ad Hoc Appellate Board will convene as scheduled and make a decision based upon the information available.

If the Ad Hoc Appellate Board upholds the original Committee's decision, EmblemHealth will proceed with reporting the action to appropriate regulatory agencies.

Ad Hoc Appellate Board

The Ad Hoc Appellate Board shall be compiled by EmblemHealth and shall contain three credentialed practitioners, at least one of whom specializes in the field appropriate to the review. The panel may consist of more than three provided that the number of clinical peers constitutes one-third or more of the total membership. Members of the CRC may serve on this board. However, no physician can vote on both an initial decision and an appeal for the same practitioner.

The Ad Hoc Appellate Board decision may include reinstatement, provisional reinstatement with conditions set by the Board or termination. The Hearing Panel will render a decision in a timely manner. The practitioner will be notified by mail within five business days of the decision. A decision for termination shall be effective not less than 30 days after the practitioner's receipt of the Hearing Panel's decision.

EmblemHealth will permit members to continue an on-going course of treatment for a transition period of up to ninety (90) days, and post-partum care, subject to the provider's agreement, pursuant to PHL §4403(6)(e).

Termination For Egregious Reasons

EmblemHealth can initiate an immediate termination in the event of:

  • Knowledge of a member's imminent harm by a clinician.
  • Determination of fraud by EmblemHealth's Special Investigations Unit (SIU).
  • Action by the NYSOPMC or other recognized regulatory agency, such as license suspension or revocation, or CMS sanction.

A termination for any of the above reasons is reported to the NPDB and is not eligible for a hearing or a review.

EmblemHealth will immediately remove any provider from the network who is unable to provide health care services due to a disciplinary action.

Practitioner's Rights

We recognize that practitioners have the following rights which may not justify termination or decredentialing:

  • To advocate on behalf of our members.
  • To file a complaint against EmblemHealth.
  • To appeal any decision made by EmblemHealth.
  • To provide information or file a report to PHL § 4406-c regarding prohibitions made by EmblemHealth.
  • To request a hearing or review.

Practitioners with certain types of credentialing may be eligible to provide in-house radiology imaging through our Radiology Privileging Program. Additional certification may be required. See the Radiology Privileging chapter for more details. The Radiology Privileging Program applies to members with the following benefit plans and to practitioners who provide care to these members:

  • EmblemHealth EPO/PPO
  • GHI
  • Vytra

GHI HMO members and practitioners are not eligible for this program. Protocols for HIP, EmblemHealth CompreHealth EPO (Retired August 1, 2018) and EmblemHealth Medicare HMO appear in the HIP Outpatient Diagnostic Imaging Self-Referral Payment Policy chapter.

The Americans with Disabilities Act (ADA) is a federal statute that requires public accommodations to provide goods and services to people with disabilities on an equal basis as that provided to the general public. Structural barriers to access should be removed only when the correction is readily achievable, which is defined by the law as easily accomplished and able to be carried out without much difficulty or expense. EmblemHealth is required to report aggregate statistics by geographic area and specialty on the percentage of providers that practice in ADA-compliant facilities.

A new EmblemHealth ADA Accessibility Attestation Form needs to be completed and submitted to EmblemHealth each time a provider joins a new office or has moved to a new location. Please note that the information provided here will in no way affect your affiliation with EmblemHealth.

All providers who participate in either the EmblemHealth Dual Assurance Network or Associated Dual Assurance Network must have a signed ADA Accessibility Attestation Form on file with EmblemHealth for each service location.

Providers must notify EmblemHealth within 10 business days of any change in their ability to meet the ADA Accessibility standards as outlined in the signed ADA Accessibility Attestation Form.