Overview

This manual applies to all EmblemHealth, GHI, HIP, HIPIC and Vytra plans, and it replaces all provider manuals published before November 2009. It includes detailed information about your administrative responsibilities, contractual and regulatory obligations, and best practices for interacting with our plans and helping our members navigate our delivery systems.

You will also find information on our wellness programs, which foster disease prevention and healthier living. These services support our mission of providing a choice of products and services, so that our members have access to the medical care they need when they need it at prices they can afford. More Information on our member’s Protections for Out-of-Network Emergency Services and Surprise Bills can be found on emblemhealth.com.

Keep your email address with us current so that you can receive electronic communications with new and updated operational information. To update your email address and directory information, sign in to our secure provider websiteat www.emblemhealth.com/providers.

This manual is an extension of your Provider Agreement and is amended as our operational policies change. We regularly communicate these updates and other important information through available communication channels, including:

Note: This copy of the EmblemHealth Provider Manual was last updated on October 27, 2015. Updates to the Provider Manual occur as policies are reviewed and updated, new programs are introduced and contractual and regulatory obligations change. Please visit www.emblemhealth.com/ProviderManual for the most current information. To receive email notifications of updates, select a chapter or chapter section and click the "Subscribe" button at the top right of the page.

Disclaimer
EmblemHealth and its companies Group Health Incorporated (GHI), HIP Health Plan of New York, HIP Insurance Company of New York and Vytra Health Plans Managed Systems (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 independent contractors. 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 will not be 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 exercise any control or directory 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.

Note: 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.