EmblemHealth’s mission is to provide members with access to affordable, quality health coverage in ways that respect and respond to people's fundamental needs. Our network physicians, practitioners, facilities, ancillary providers, and delegated partners play an important part in helping us achieve this goal. We look to you to be familiar with our policies and procedures and be available to our members.
This manual is an extension of your Provider Agreement and applies to all EmblemHealth plans. It details your administrative responsibilities and contractual and regulatory obligations. It shares best practices to help you guide our members as they navigate their health care while working with us and our delegated partners.
This manual changes regularly as policies are reviewed and updated, new programs are introduced, and contractual and regulatory obligations change. We promote these updates, as well as other important information, through traditional and digital channels including:
- Targeted mailings to providers impacted by specific changes
- New Policy & Alerts, Claims Corner and Clinical Corner postings to the provider pages on our website emblemhealth.com/providers
- Copies of our monthly provider newsletters, In the Know, are available via email and on our Provider Resources webpage
Please consult the online version of this manual at emblemhealth.com/providers/manual. fThe web version contains the most current and accurate content. Downloaded PDF chapters can quickly become outdated. Some content, such as code lists for services requiring preauthorization, may be directly accessed through Clinical Corner.
- The web version contains the most current and accurate content. Downloaded PDF chapters can quickly become outdated. Some content, such as code lists for services requiring preauthorization, may be directly accessed through our secure website and select "Provider Profile" or "Practice Profile" from the left navigation panel.
- Our “How Do I…?” list of frequently asked questions will provide you with important information for navigating our plan.
- Follow our Access & Availability & After-Hours Standards.
- Know how to make and receive referrals and preauthorizations using our secure provider portal.
EmblemHealth and its companies, (together referred to as EmblemHealth), arrange for the delivery of health care services in accordance with, and subject to, the terms of the certificates of coverage and benefit packages purchased either by our members or on their behalf. We do not directly provide these services or supplies. Rather, these services and supplies are provided by a network of contracted providers. The health care providers listed in the various provider directories who deliver health care services are not the employees or agents of our companies. EmblemHealth is not liable for any negligent act or omission by any of the providers listed in the directory, or any of their employees or agents, who may from time to time provide medical services to EmblemHealth members. EmblemHealth expressly disclaims any agency relationship, actual or implied, with any health care provider. Any decisions made by EmblemHealth concerning appropriateness of setting or whether any services or supply is medically necessary, pursuant to the certificate of coverage, will be deemed to be made solely for the purpose of determining whether benefits are due under the agreement between the member and EmblemHealth, and not for the purpose of recommending any medical treatment or nontreatment. EmblemHealth does not diagnose or provide treatment advice. EmblemHealth does not exercise any control or direction over the medical judgment or clinical decision of any health care provider listed in their directory and does not interfere with the physician-patient relationship between the provider and EmblemHealth member.
This provider manual links to websites as a convenience as well as an educational and informational service to our providers. These links are not intended to provide medical or professional advice. All medical information, whether from these links or from any other source, needs to be reviewed carefully by the practitioner. The opinions and information expressed therein are not necessarily EmblemHealth's. EmblemHealth does not guarantee or warrant that the links referenced in this manual, or any information therein contained, are complete, accurate, or up to date since the date of this manual's publication or last update.