EMBLEMHEALTH PROVIDER MANUAL pdf

The following listings of network urgent care centers are provided on our Web site: • For GHi, Medicare PPo and emblemHealth ePo/PPo Members • For GHi HMo Members • For HiP, CompreHealth

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EMBLEMHEALTH

PROVIDER MANUAL

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TABLE OF CONTENTS

EmblemHealth Provider Manual

OVERVIEW 1

DIRECTORY 3

YOUR PLAN MEMBERS 20

ACCESS TO CARE AND DELIVERY SYSTEM 111

MEDICAL RECORD GUIDELINES 133

CARE MANAGEMENT 145

CLINICAL PRACTICE GUIDELINES 200

QUALITY IMPROVEMENT 204

HEALTH PROMOTION AND DISEASE MANAGEMENT 212

INTEGRATIVE WELLNESS 220

PHARMACY SERVICES 224

DURABLE MEDICAL EQUIPMENT 247

RADIOLOGY & CARDIOLOGY PRIVILEGING 253

RADIOLOGY PROGRAM 266

CARDIOLOGY IMAGING SERVICES 305

RADIATION THERAPY PROGRAM 313

BEHAVIORAL HEALTH SERVICES 320

CHIROPRACTIC PROGRAM 330

PODIATRY 335

CLAIMS 345

PHYSICAL AND OCCUPATIONAL THERAPY PROGRAM 361

DISPUTE RESOLUTION- COMMERCIAL/CHILD HEALTH PLUS 374

DISPUTE RESOLUTION- MEDICAID/FAMILY HEALTH PLUS 404

DISPUTE RESOLUTION- MEDICARE 430

CREDENTIALING 446

REGULATORY MANDATORY REPORTING 461

FRAUD AND ABUSE 468

MEDICAL TRANSPORTATION PROCEDURES 479

REQUIRED PROVISIONS TO NETWORK PROVIDER AGREEMENTS 494

GLOSSARY 508

Group Health Incorporated (GHI), GHI HMO Select, Inc (GHI HMO), HIP Health Plan of New York

(HIP), HIP Insurance Company of New York, Vytra Health Plans Management Systems (VHMS) and

Click on the titles below to jump to the chapters

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This manual applies to all EmblemHealth, GHI, HIP, 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 for helping our

members navigate our delivery systems

You will also find information on our wellness programs that 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

Keep your e-mail address with us current so that you can receive electronic

communications with new and updated operational information To update your

e-mail address and your directory information, log on to your secure account from

www.emblemhealth.com

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:

• Targeted mailings to directly-impacted providers

• Postings to our Policy Alerts, Claims Corner and Clinical Corner sections of our

provider pages on www.emblemhealth.com

• Our monthly eNewsFlash and quarterly provider newsletter, News&Notes, which

are available on our Web site and can be e-mailed to you

Note: This copy of the EmblemHealth Provider Manual was last updated on

10/22/2012 Updates to the Provider Manual occur as policies are reviewed

and updated, new programs are introduced and as contractual and regulatory

obligations change Please visit www.emblemhealth.com/ProviderManual for the

most current information

Disclaimer

EmblemHealth and its companies HIP Health Plan of New York, Health Insurance Company

of New York, GHI HMO Select Health, Inc and Group Health Incorporated, Vytra Health Plans

Management Services (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 that deliver health care services are not the employees or agents of

our companies EmblemHealth shall 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

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services or supply is medically necessary, pursuant to the certificate of coverage, shall

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 you and an EmblemHealth member

Note: This provider manual links to Web sites 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

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TABLE OF CONTENTS

EMBLEMHEALTH HEADQUARTERS 4

CUSTOMER SERVICE (PROVIDERS) 4

CLAIMS CONTACTS 5

CLINICAL PHARMACY SERVICES (PRACTITIONERS) 7

RETAIL PHARMACY SERVICES (PHARMACIES) 7

BEHAVIORAL HEALTH SERVICES (PRACTITIONERS AND MEMBERS) 8

HOW TO OBTAIN PRIOR APPROVAL 9

LABORATORY SERVICES 11

URGENT CARE CENTERS 12

COMPLAINTS, GRIEVANCES AND APPEALS (PRACTITIONERS AND MEMBERS) 12

ADDITIONAL RESOURCES (PROVIDERS AND MEMBERS) .13

SELECTED RESOURCES FOR MEMBERS WITH SPECIAL NEEDS 14

SERVICES FOR THE VISUALLY IMPAIRED 15

RESOURCES FOR CHILDREN WITH SPECIAL NEEDS 15

CUSTOMER SERVICE (FOR MEMBERS) 18

PHARMACY SERVICES (FOR MEMBERS) 19

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Monday through Friday, 8 am to 5 pm

All LOBs may be accessed through our message Center at www.emblemhealth.com

emblemHealth Medicare PPo

1-866-557-7300

TDD: 1-866-248-0640

GHi

1-212-501-4444 in New York City

1-800-624-2414 outside of New York City

HiP, emblemHealth CompreHealth HMo/ePo, emblemHealth Medicare HMo

1-866-447-9717, option 1: IVR phone system

1-866-447-9717, option 2: Claims, member benefits or eligibility information

1-866-447-9717, option 3: Prior approval requests for prescription drugs or information on

pharmacy services

1-866-447-9717, option 4: Prior approval requests and questions

1-866-447-9717, option 5: Contracts, policies and procedures information

vytra

1-888-288-9872, option 1: Hospital service line

1-888-288-9872, option 2: Provider automated system (provider pin # required), eligibility,

referral generation, inquiry and claims status

1-888-288-9872, option 3: Pre-certification, report ER visit

1-888-288-9872, option 4: Speak to representative

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DIRECTORYClaiMs CoNtaCts

Plans type of Claim

eDi or Payor iD

Clearing House submission address Contact for inquiries

EmblemHealth

PO Box 2845 New York, NY 10116-2845

or 1-866-447-9717, option 2

EmblemHealth

or 1-866-447-9717, option 2

EmblemHealth

Medicare HMO All claims 55247

Emdeon

or direct submission

EmblemHealth Medicare HMO

or 1-866-447-9717, option 2

EmblemHealth

EPO/PPO All Claims 13551

Emdeon

EmblemHealth

GHI (New York

City and all

GHI Claims

GHI HMO All claims 25531

Emdeon

GHI HMO

PO Box 2845 New York, NY 10016

1-877-244-4466, or:

GHI HMO Attn: Provider Correspondence

Emdeon

HIP Health Plan of New York

or 1-866-447-9717, option 2

Emdeon

HIP Health Plan of New York

or 1-866-447-9717, option 2

Emdeon

Vytra Health Plans Attn: Claims Department

PO Box 9091 Melville, NY 11747-327

Direct submission

or:

GHI/EmblemHealth Dental Claims

PO Box 2838 New York, NY 10116

GHI Claims

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DIRECTORYClaiMs CoNtaCts

Plans type of Claim

eDi or Payor iD

Clearing House submission address Contact for inquiries

EmblemHealth

Medicare PPO All claims 13551

Emdeon

EmblemHealth Medicare PPO

Montefiore

CMO

HIP and CompreHealth claims for members managed by Mon- tefiore CMO

13174 Web MD/

NEIC

CMO

200 Corporate Drive Yonkers, NY 10701

1-877-HiP-MoNte (1-877-447-6668)

HealthCare

Partners (HCP)

HIP and CompreHealth claims for members managed by HCP

11328 Web MD/

Envoy

HealthCare Partners Attn: Claims Department

501 Franklin Avenue Suite 300

Garden City, NY 11530-5807

1-516-746-2200 or 1-888-746-2200

Palladian

Muscular

Skeletal Health

HIP sional claims for PT/OT services members managed by Palladian and claims bill- able under the Chiropractic program

profes-37268 Emdeon

Palladian Health

PO Box 270 Lancaster, NY 14086

14182

Emdeon/

Relay Health

CareCore National LLC

PO Box 61022 Anaheim, CA 92803

1-800-918-8924 or fax:

1-843-815-6579

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1-877-444-3657, Monday through Friday, 8:30 am to 6 pm

express scripts, inc (esi) (home delivery for all plan members except for state and federal

employees and retirees with GHI coverage)

• 1-800-585-5786 (GHI City of New York members)

• 1-877-866-5798 (all commercial members)

• 1-877-866-5828 (EmblemHealth Medicare HMO/PPO members)

• 1-877-866-4165 (HIP Medicaid members)

• 1-800-899-2114 (for users of TDD/TTY)

24 hours a day, 7 days a week

Pharmacy specialty Program (for all plans except GHI City of New York group plans and state

and federal employees and retirees with GHI coverage)

1-888-447-0295, Monday through Friday, 9 am to 5 pm

iCore (for all plans except GHI City of New York group plans and state and federal employees

and retirees with GHI coverage)

1-866-554-2673 , Monday through Friday, 8 am to 7 pm

retail PHarMaCy serviCes (PHarMaCies)HiP

GHi and GHi HMo

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BeHavioral HealtH serviCes (PraCtitioNers aND MeMBers)emblem Behavioral Health services Program

(For members in plans underwritten by GHI HMO, HIP and HIPIC and administered by VHMS)

1-888-447-2526

Monday through Friday, 9 am to 5 pm and 24 hours, 7 days a week for emergencies

Providers: Press 2 then choose from the following options:

1 If you do not need prior approval and are looking for eligibility, benefits or claims inquiries

2 To obtain information about your new or existing provider contract, credentialing or general

plan policies or procedures

3 for inpatient treatment, partial hospitalization and ambulatory detox prior approval

4 for outpatient treatment

5 for all other mental health questions

Montefiore

(For members in plans underwritten by HIP and administered by Montefiore)

1-800-401-4822

emblemHealth Behavioral Management Program

(For members in plans underwritten by GHI)

1-800-692-2489

Monday through Friday, 8 am to 6 pm and 24 hours, 7 days a week for emergencies

Providers: Press 1 then 5 and choose from the following options:

1 To check eligibility

2 To check benefits

3 To have a form faxed to you

4 For authorization of outpatient services

5 To review for inpatient or an alternative level of care

6 To inquire about the status of your appeal or to schedule an appeal

7 To check the status of your contract or credentialing/ recredentialing application or to

update your demographic information

8 To hear the mailing address for outpatient treatment reports or claims

emblemHealth Depression Disease Management Program

1-800-447-0769

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How to oBtaiN Prior aPProvalPlan/Managing entity instructions

CompreHealth HMO/EPO,

HIP and Medicare HMO

Submit prior approval request after signing on to

www.emblemhealth.com Call IVR system at 1-866-447-9717, option 4

• Option 1 for mental health services

• Option 2 for DME

• Option 3 for home care and end-of-life care

• Option 4 for radiology

• Option 5 for physical and occupational therapy

• Option 6 for all other requests Fax your request to 1-866-426-1509 for DME or 1-866-215-2928 for all other requests.

To speak to a representative of the EmblemHealth Prior Authorization Department, call 1-866-447-9717, option 4.

Specialists, facilities and ancillary providers must verify that prior approval has been issued by signing on to the secure provider Web site at www.emblemhealth.com, checking in the IVR system at 1-866-447-9717, option 1 or by reviewing the Concurrent Review Status Report (for hospitals and skilled nursing facilities).

EmblemHealth EPO/PPO

Submit the prior approval request by signing on to

www.emblemhealth.com Fax the Prior Authorization request to 1-212-563-8391.

Call 1-212-615-4662 in New York City or 1-800-223-9870 side New York City.

out-For questions regarding the status of a request submitted, or questions regarding the authorization process, you may call Customer Service at 1-845-340-2300 or toll free at

1-877-244-4466.

GHI HMO and Medicare PPO

www.emblemhealth.com Fax the Prior Authorization request to GHI HMO at 1-877-508-2643.

Or mail your request to:

EmblemHealth Utilization Management

55 Water Street, 12th Floor New York, NY 10041 Urgent or expedited prior approval requests required after business hours (which are Monday – Friday, 8:30 am – 5 pm) should be made by calling 1-877-244-4466 For Medicare PPO, call 1-866-557-7300.

For questions regarding the status of a request submitted or the authorization process, call Customer Service at 1-845-340-2300

or toll free at 1-877-244-4466.

(See “ additional Prior approval Procedures for GHi ePo/PPo and GHi HMo Practitioners ” for more information.)

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GHI EPO and GHI PPO

www.emblemhealth.com Call the Coordinated Care Intake department at 1-800-223-9870, option 6.

(See “ additional Prior approval Procedures for GHi ePo/PPo and GHi HMo Practitioners ” for more information.)

Health Care Partners Call 1-800-877-7587.

Or, fax your request to 1-888-746-6433.

Montefiore CMO Call 1-888-666-8326.

For behavioral health services, call 1-800-401-4822.

Vytra Health Plan

Call 1-888-288-9872, option 3.

Prior approval requirements and procedures may be different for Vytra ASO accounts, so please contact the administrator listed on the Vytra member’s ID card for more information.

Behavioral Health services

Emblem Behavioral Health

Services Program

(For members in plans

underwritten by GHI HMO,

HIP and HIPIC and

(For members in plans

underwritten by HIP and

• 1-866-417-2345 (HIP and CompreHealth EPO/HMO)

• 1-800-835-7064 (GHI EPO/PPO, GHI HMO, and Health EPO/PPO)

Emblem-Chiropractic services

all emblemHealth plans

Send all requests to Palladian via the Web Fax your request to Palladian at:

• 1-716-712-2802 (HIP and CompreHealth EPO/HMO)

• 1-716-712-2803 (Vytra ASO)

• 1-716-712-2817 (GHI EPO/PPO and GHI HMO and EmblemHealth EPO/PPO)

You may also call 1-877-774-7693.

outpatient Physical and occupational therapy

GHI HMO and HIP

fee-for-service plans

Send all requests to Palladian via the Web Or, your may fax your request to Palladian at 1-716-809-8324 You may also call 1-877-774-7693.

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Pharmacy services

express scripts, inc

(Medicare PPO plans) Call 1-866-467-8635.

EmblemHealth Injectable

Drug Utilization Management

Program – Starts June 1, 2012

www.icorehealthcare.com Call ICORE 1-800-424-4084 (Monday - Friday, 8 am to

6 pm EST) Submit both the prior approval request and the replacement drug order from ICORE by using the appropriate fax form available at www.emblemhealth.com/iCore

• 1-877-444-3657 (GHI EPO/PPO members)

• 1-877-444-7037 (EmblemHealth Medicare PPO members)

• 1-877-362-5670 (EmblemHealth plan members)

Specialty Pharmacy Program

services to our members, other laboratories are also available for specialty tests

A list of our network laboratories is provided on our Web site

Quest Diagnostics

Quest Diagnostics Patient Services Locator:

Quest Diagnostics Customer Service department:

Quest Diagnostics Web site:

1-800-377-7220 1-800-631-1390

www.questdiagnostics.com

Contracted laboratories will provide a collection box and courier service to and

from the practitioner’s office for specimen collection If specimens need to be

drawn outside of the practitioner’s office, members should be directed to the

near-est contracted laboratory Patient Service Center and given the requisition form to

hand carry

STAT Laboratory Services

Selected tests are available on a STAT (emergency) basis Specimens requiring

STAT services should not be given to your routine Route Service Representative

Instead, practitioners should call the Quest Diagnostics Logistics department for

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STAT specimen pick-up at the number listed below Practitioners may also consult

their local Quest Diagnostics laboratory for more information

STAT results are reported by telephone as soon as available Written and/or

elec-tronic reports will follow per your routine medical report delivery system

Please contact your local Quest Diagnostics laboratory to request a STAT service or

pick-up

New York (excluding Long Island): Logistics department: 1-800-223-0570, option 1

Long Island (Nassau and Suffolk Counties): Logistics department: 1-800-877-7588,

option 2

New Jersey: STAT laboratory direct number: 1-800-648-4738

URGENT CARE CENTERS

For urgent conditions that do not meet the layperson’s definition of an emergency,

all EmblemHealth plan members have access to network urgent care centers

For more information on urgent care centers, please visit the Care Management

chapter

The following listings of network urgent care centers are provided on our Web site:

• For GHi, Medicare PPo and emblemHealth ePo/PPo Members

• For GHi HMo Members

• For HiP, CompreHealth and Medicare HMo Members

COMPLAINTS, GRIEVANCES AND APPEALS

(PRACTITIONERS AND MEMBERS)

For process terminology, filing instructions and applicable time frames for disputing

determinations that result in a denial of payment and/or covered services, please

go to the following chapters:

• Dispute resolution – Commercial/Child Health Plus

• Dispute resolution – Medicaid/Family Health Plus

• Dispute resolution - Medicare

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aDDitioNal resourCes (ProviDers aND MeMBers)

Chiropractic and Physical/occupational therapy

Palladian

Muscular skeletal

Health

2732 Transit Road West Seneca, NY 14224 1-877-774-7693

Provider Relations:

1-800-290-0523 Member Services:

1-877-548-4447

www.careington.com

Delegated for credentialing.

Ste 300 Uniondale, NY 11553- 3608

General Line:

1-516-794-3000 Provider Relations &

Medical Management:

1-516-542-2600 Claims:

1-888-468-2183 option 3

Member Services:

1-800-468-9868

www.healthplex.com

Delegated for credentialing, utilization management and claims processing.

General Line:

1-800-877-7587 Customer Service:

(Providers and Members):

1-516-746-2200 or 1-888-746-2200

Delegated for credentialing, utilization management, claims processing and first call resolution.

Montefiore CMo 100 Corporate Drive Yonkers, NY 10701 1-877-HiP-MoNte (1-877-447-6668)

Delegated for credentialing, utilization management and claims processing.

radiology services

CareCore

National, llC

PO Box 61022 Anaheim, CA 92803

General line:

1-800-918-8924 Customer Service (Providers):

1-800-918-8924 ext

11879 (phone) 1-843-815-6579 (fax) vision services

Davis vision

(For GHI

members only)

159 Express St

Plainview, NY 11803 1-800-999-5431 Delegated for credentialing

and claims processing.

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aDDitioNal resourCes (ProviDers aND MeMBers)

Medical injectables

iCore National,

llC

5850 T.G Lee Blvd., Suite 510

Plan providers (or members or their representatives) can contact the Customer

Service Department via phone at 1-646-447-6534 or TeleTypewriter (TTY) at

1-800-874-9426 to request a sign language interpreter for a provider appointment

If the member calls, s/he will be asked to have the provider contact EmblemHealth

to arrange for the interpreter If the member is communicating through one of

EmblemHealth’s TTY devices, the Interview Unit can contact the provider while the

member is “holding” to verify the appointment The Interview Unit will contact the

member to confirm the interpreter arrangements We primarily arrange these

constituency through the use of sign language, tactile communication, lip reading,

or any other form of communication in which the consumer feels most

comfort-

able F•E•G•S’s Interpreter Referral Services provides skilled interpreters through-out the New York City metropolitan area in a wide range of settings

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SERVICES FOR THE VISUALLY IMPAIRED

lighthouse international

www.lighthouse.org

Lighthouse International is a leading worldwide resource on vision impairment and

vision rehabilitation Through its work in vision rehabilitation services, education,

research and advocacy, Lighthouse International enables people of all ages who are

blind or partially sighted to lead independent and productive lives

New york City Headquarters

Early Intervention Program (EIP)

New York State law requires that all primary referral sources (e.g., primary care

phy-sicians (PCPs), specialists, hospitals, etc.) shall, within two working days of

identify-ing a child under 3 years of age with either a risk factor for developmental delay or

an actual developmental delay or disability, refer that child to the Local Early

Inter-vention Agency (LEIA) corresponding to the child’s county of residence In most

cases, the LEIA is the County Department of Health Parental consent is required

for referral The EIP has two components:

• The Infant Child Health Assessment Program (ICHAP) serves as the “child find”

component Only children with a risk factor for developmental delay should be

referred to this component Referred children are tracked to insure that their

pediatricians/PCPs conduct periodic developmental assessments and if such

assessments indicate developmental delay, the program facilitates referrals to the

EIP component

• The Early Intervention Program (EIP) provides for evaluation and developmental

services when a child has or is suspected of having a developmental delay

Ser-vices are provided by the LEIA’s network of approved EIP providers The LEIA is

under no obligation to use providers in the child’s health plan network When the

services rendered are covered by a third party, the LEIA is authorized to bill the

third party on behalf of the servicing provider

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For information please call the new York State Growing Up Healthy Hotline at

1-800-522-5006 You may also call the LEIAs at:

Preschool Supportive Health Services Program (PSHSP)

When children between 3 and 4 years of age are identified as having or are at risk

of developmental disability, pediatricians/PCPs shall, with parental consent, refer

the children to the Committee on Special Preschool Education serving the school

district in which the children reside This program ensures that such children are

evaluated and receive needed special education and that disability-related health

services are provided by PSHSP providers approved by the Committee on

Pre-school Special Education The program is under no obligation to use providers in

the child’s health plan network The school district bills the state for services

ren-dered to Medicaid managed care members When the services renren-dered to

non-Medicaid members are covered by a third party, the school district is authorized to

bill the third party on behalf of the servicing provider

School Supportive Health Services Program (SSHSP)

When children between 5 and 21 years of age are identified as at risk for or having

a developmental disability, pediatricians/PCPs shall, with parental consent, refer the

children to the Committee on Special Education serving the school district in which

the children reside This program ensures that such children are evaluated and

receive needed special education and that disability-related health services are

pro-vided by SSHSP providers approved by the Committee on Special Education The

program is under no obligation to use providers in the child’s health plan network

The school district bills the state for services rendered to Medicaid managed care

members When the services rendered to non-Medicaid members are covered by

a third party, the school district is authorized to bill the third party on behalf of the

servicing provider

Physically Handicapped Children’s Program (PHCP)

PHCP provides financial assistance for medical care and support services to

chil-dren that have severe, long-term health problems and chronic disabilities Eligible

conditions include birth defects, physical handicaps and other conditions that can

be improved with treatment and early intervention

PHCP has two components: the Diagnosis and Evaluation Program and the

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nostic services, families do not have to satisfy local financial eligibility criteria, but

prior authorization from the local PHCP must be obtained Diagnostic services are

provided through approved specialty centers or medical specialists If the child is

covered by health insurance or Medicaid, these funding sources must be billed first

If the child has neither insurance nor Medicaid, then the authorized services are

paid for directly by the PHCP

The treatment component reimburses health care providers for services rendered

to eligible children Inpatient hospital care, physician office visits, durable medical

equipment and pharmaceuticals are examples of items covered by the program

PHCP will cover the cost of medically needed care and supplies not covered by

some health insurance plans, such as over the counter drugs/supplies and

transpor-tation

Application for the Treatment Program must be made to the county in which the

child resides There are some variations between counties for conditions covered

and financial eligibility Financial criteria are designed to assist families with low

incomes or inadequate private health insurance All services provided under PHCP

must have prior authorization from the county health department

For more information, please call the new York State Growing Up Healthy Hotline at

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emblemHealth Medicare HMo

1-800-447-8255, Monday through Sunday, 8 am to 8 pm

TDD: 1-888-447-4833, Monday through Sunday, 8 am to 8 pm

emblemHealth Medicare PPo

1-866-557-7300, Monday through Sunday, 8 am to 8 pm

TDD: 1-877-208-7920, Monday through Sunday, 8 am to 8 pm

HiP and HiPiC

Medicare HMO: 1-800-447-8255 From November 1 to March 31, open daily 8 am to 8 pm From

April 1 to October 31, open daily 8 am to 6 pm.

TDD: 1-888-447-4833, Monday through Friday, 8:30 am to 5 pm

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PHarMaCy serviCes (For MeMBers)emblemHealth

(for all EmblemHealth, GHI and HIP members excluding GHI retirees and city, state and federal

employees with GHI coverage)

Medicare PPO Prescription Drug Plan

(for Medicare PPO members excluding retirees and city, state and federal employees)

1-877-444-7241, 7 days a week, 8 am to 8 pm

Medicare PPo Pharmacy line

(for providers and Medicare members excluding retirees and city, state and federal employees)

1-866-557-7300, option 1, Monday through Friday, 8 am to 8 pm

Medicare HMo Pharmacy line

(for providers and Medicare members excluding retirees and city, state and federal employees)

GHi Customer service

(for GHI retirees and city, state and federal employees)

TTY/TDD: 1-212-721-4962, Monday through Friday

If calling from New York City, members may also call 1-212-615-4444.

express scripts, inc (esi)

(home delivery)

1-877-534-3682 (GHI City of NY group members)

1-877-866-5798 (Commercial members)

1-877-866-5828 (EmblemHealth Medicare HMO/PPO members)

1-877-866-4165 (HIP Medicaid members)

1-800-899-2114 (TDD/TTY users)

24 hours a day, 7 days a week

Physicians may call 1-800-305-5287 for instructions on how to fax a prescription to ESI In

addition, members can speak to a registered pharmacist for medication counseling.

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YOUR PLAN MEMBERS

TABLE OF CONTENTS

MEMBER IDENTIFICATION CARDS 22

COPAYMENT POLICY AND PROCEDURES 23

Preventive Services Covered Under the Affordable Health Care Act .24

COMMERCIAL PRODUCT SUMMARY 24

MEDICAID AND MEDICARE PRODUCT SUMMARIES 26

Medicare Products 27

Maximum Out-of-Pocket Reductions .27

Wellness Exams .27

MEDICARE SPECIAL NEEDS PLANS 33

SNPs Meet Our Members’ Special Needs 33

The SNP Interdisciplinary Team 33

NY BRIDGE PLAN 34

RIGHTS AND RESPONSIBLITIES OF EMBLEMHEALTH PLAN MEMBERS 35

MEMBER PRIVACY RIGHTS 38

Confidentiality of Personal Information 38

Member Consent 39

The Health Insurance Portability and Accountability Act (HIPAA) 39

Confidentiality of HIV-related Information 40

Routine Consent 40

Authorization to Release Information 40

Access to Medical Records 40

Notice of Privacy Practices 42

NONDISCRIMINATION 46

CULTURAL COMPETENCY 46

APPENDIx A: HEALTH PLAN MEMBER ID CARDS 48

Practitioner Benefit Plan Participation 53

EMBLEMHEALTH HDHP PROGRAMS: CONSUMERDIRECT EPO AND

CONSUMERDIRECT PPO 53

APPENDIx B: MEDICAID MANAGED CARE AND FAMILY HEALTH PLUS

MODEL CONTRACT, APPENDIx K 54

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APPENDIx C: SUMMARY OF MEDICAID MANAGED CARE BENEFIT AND

PROGRAM CHANGES RESULTING FROM THE MEDICAID REDESIGN

TEAM AND 2011-2012 BUDGET 94

APPENDIx D: BENEFIT SUMMARIES 102

APPENDIx E: MEDICARE PREVENTIVE SERVICES 102

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YOUR PLAN MEMBERS

MEMBER IDENTIFICATION CARDS

Members and their spouses and dependents age 19 and older are sent an

identification (ID) card The card provides both members and providers with

important health plan information, including covered riders and copayments For

CompreHealth HMO/EPO and HIP plans, each dependent child under age 19 will

receive his or her own personal ID card For EmblemHealth EPO/PPO,

GHI HMO, and GHI plans, dependent children under 19 years of age will not receive

an ID card All Child Health Plus members will receive their own ID cards

We issue unique non-Social Security Number (SSN)-based member ID numbers

to our non-Medicaid members to protect their confidentiality This practice also

protects our members from potential identity theft and fraud All Medicaid and

Family Health Plus members receive their own personal ID card with unique

Medicaid Client Identification Number (CIN)-based alpha numeric ID numbers

Sample member ID cards appear in appendix a of this chapter

Ask to see a member’s ID card at each appointment, emergency visit or inpatient

stay A member’s eligibility can change at any time for a number of reasons,

including termination of employment or enrollment in a different health plan

The provision of service should not be conditioned on the presentation of a

member ID card, since delays in processing applications for enrollment can impact

when members receive their ID card in the mail Conversely, the presentation of an

ID card does not guarantee eligibility and/or payment of benefits

Providers should verify member eligibility as outlined on the following page

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YOUR PLAN MEMBERS

CoNFirM MeMBer eliGiBility Plan Members instructions (Choose one of the bulleted options) HIP, EmblemHealth

CompreHealth EPO/HMO and

EmblemHealth Medicare HMO

• Check eligibility at www.emblemhealth.com

• Call the IVR phone system at 1-866-447-9717, option 1

(Have your user ID and PIN ready.)

• Speak to a representative at 1-866-447-9717, option 2.

• PCPs may check the Member Roster available at

• Providers with eMedNY access may check HIP enrollment

of Medicaid and Family Health Plus members on ePACES.

Vytra • Check eligibility at www.vytra.com

• Call the IVR phone system at 1-888-288-9872, option 2

(Have your user ID and PIN ready.)

• Speak to a representative at 1-888-288-9872, option 4.

GHI HMO • Check eligibility at www.emblemhealth.com to perform a

member eligibility search.

• Call the IVR phone system at 1-877-244-4466, option 2.

• PCPs may check the Member Roster available at

• Check a copy of the enrollment form

• Speak to a representative at 1-877-244-4466.

GHI • Check eligibility at www.emblemhealth.com

• Speak to a representative at 1-212-501-4444 in New York City (1-800-624-2414 outside New York City).

EmblemHealth EPO/PPO • Check eligibility at www.emblemhealth.com

EmblemHealth Medicare PPO • Check eligibility at www.emblemhealth.com

COPAYMENT POLICY AND PROCEDURES

Some plan members may have required copayment (copay) charges Copays

should be collected from members by the provider’s office at the time of service

The copay, in conjunction with an office visit, is part of the provider’s remuneration

and its collection is the provider’s responsibility

In the event that the copay is not collected from the member, the provider may

not seek reimbursement of the copay from EmblemHealth If the contracted fee

under the participating provider agreement with the EmblemHealth companies is

less than the copay amount, the participating provider is not permitted to collect

the difference between the contracted fee and the copay and must refund such

difference to the member if it was collected

Patient-specific copay information is listed on the member’s ID card It can also be

obtained from our Web sites after login in the member’s Summary of Benefits or

from our Customer Service departments as listed in the “Directory” chapter

Important things to note:

• Copays may not be collected from Medicare members for the preventive care

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YOUR PLAN MEMBERS

services as defined by CMS and listed in appendix e

• Members enrolled in Dual Eligible PPO SNP, Dual Eligible HMO SNP and GuildNet

Gold plans may not be charged cost sharing greater than what would have been

charged if the member was enrolled in NYS Medicaid

• Medicaid and Family Health Plus members do not have copays for the following

services:

• Emergency room visits for needed emergency care

• Family planning services, drugs and supplies

• Mental health clinic visits

• Chemical dependency clinic visits

• Drugs to treat mental illness

• Drugs to treat tuberculosis

• Prescription drugs for residents of adult care facilities

• The following Medicaid and Family Health Plus members do not have copays for

any services:

• Children under age 21

• Pregnant women (through 60 days postpartum)

• Permanent residents of nursing homes

• Residents of community-based residential facilities licensed by the Office

of Mental Health or the Office of Mental Retardation and Developmental

Disability

• Those who are financially unable to make copays at any time and who tell the

provider they are unable to pay

• Medicaid and Family Health Plus members cannot be denied health care services

based on their inability to pay the copay at the time of service However,

providers may bill these members or take other action to collect the owed

copay amount

• Medicaid members only have pharmacy copays and an annual $200 maximum

copay obligation

• There are no plan copay requirements for Child Health Plus members

• Copays may not exceed the amount payable under the participating

provider agreement

Preventive Services Covered Under the Affordable Health Care Act

The Affordable Health Care Act dictates that any person who has a new insurance

plan or policy as of September 23, 2010 must have certain preventive services

covered without having to pay a copay or coinsurance or meet a deductible Our

2011 Preventive Health Guidelines booklet helps members learn more about the

screenings, tests and immunizations that they and their family need every year

COMMERCIAL PRODUCT SUMMARY

The table that follows summarizes the plans (lines of business or products) through

which our Commercial members receive their health care benefits and services

Health benefits are usually tailored to individual employer groups, with varied levels

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YOUR PLAN MEMBERS

Note: Certain Vytra plans require members to use a designated radiologist for

all radiology services If the plan requires this, the radiologist’s name and phone

number will be printed on the member’s ID card

CoMMerCial PlaNs suMMary

Plan

type

PCP required

referrals required

Network Cost sharing*

Products

GHi: HMO, HMO Value Plan, Healthy NY, Direct Pay, Direct Access

HiP: HIPaccess ® I, Classic® HMO, Healthy NY, HMO Direct, Prime®

HMO, Vytra HMO

Direct, Prime® POS

GHi: Direct Pay POS

deductible and coinsurance

emblemHealth: EPO, InBalance EPO, ConsumerDirect EPO, CompreHealth EPO

GHi: EPO, EPO Share, EPO HDHP, Brooklyn HealthWorks, Healthy

NY EPO , HCTC EPOHiP: Prime® EPO, Select® EPO

deductible and coinsurance

emblemHealth: PPO, InBalance PPO, ConsumerDirect PPO GHi: PPO, PPO Share, SBAP

HiP: Prime® PPO, Select® PPO

*Only copays (if applicable) should be taken at the time of service

**No referrals are required for Access I & II

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YOUR PLAN MEMBERS

MEDICAID AND MEDICARE PRODUCT

SUMMARIES

The tables that follow summarize the plans (lines of business or products) through

which our Medicaid and Medicare members receive their health care benefits and

specialist referrals req’d

Coverage

in-Network Cost sharing

service area*

Networks available Comments

HiP

Medicaid HMO Yes Yes** Yes Yes*** Copays

8 county Prime

State-sponsored managed care product

8 county = New York City (Bronx, Kings, New York, Queens, Richmond), Nassau, Suffolk,

Westchester

IN = network

OON = out of network

*Members are covered for urgent and emergency care HIP covers in all 50 United States, Canada,

Mexico, Puerto Rico, the US Virgin Islands, Guam and the Northern Mariana Islands Medicaid

and Family Health Plus members are covered for urgent and emergent care in all 50 United

States, Washington D.C., Canada, Puerto Rico, the US Virgin Islands, Guam, American Samoa, the

Northern Mariana Islands and American territorial waters.

**Except for self-referral services and services that Medicaid members can get from Medicaid FFS

providers (For a list of these services, see the “ Direct access (self-referral) services ” section of

the “Access to Care and Delivery Systems” chapter.)

***Members can access certain services from county departments of health, academic dental

centers and, for Medicaid members, Medicaid FFS providers (See the “ access to Care and

Delivery systems ” chapter for a list of these services.)

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YOUR PLAN MEMBERS

Note: The New York State budget for fiscal year 2011–2012 includes many Medicaid

program changes recommended by Governor Cuomo’s Medicaid Redesign Team

(MRT) One of the major changes is mandatory enrollment of Medicaid Restricted

Recipient Program (RRP) beneficiaries into managed care These Medicaid and

Family Health Plus recipients are restricted to certain provider types (dentists,

hospitals, pharmacies, behavioral health professionals, etc.) based on a history of

overuse or inappropriate use of specific services Recipients are further restricted

to using a specific provider of that type and can only change physicians for “good

cause” reasons You can identify these members by the “R” after the plan name on

the upper right of their ID card (e.g., “HIP FHPlus-R” and “HIP MA-R”; see cards in

Appendix A of this chapter) Refer to appendix C: summary of Medicaid Managed

Care Benefit and Program Changes resulting from the Medicaid redesign team

and 2011–2012 Budget in this chapter for more information about RRP

Medicare Products

HIP underwrites Medicare HMO products, and GHI underwrites Medicare PPO

products Effective January 1, 2012, we made minor changes to our Medicare

products One new plan was introduced, and the following regulatory requirements

have been adopted

Maximum Out-of-Pocket Reductions

Reduction of the maximum out-of-pocket (MOOP) threshold for Medicare Parts

A and B services covered under our Medicare HMO and PPO plans has been

introduced This includes the in-network MOOP under our Medicare HMO plans

and both the in-network and combined (in- and out-of-network) MOOPs under our

Medicare PPO plans

A statement of members’ out-of-pocket spending to date will appear on their

Explanation of Benefits Members will continue to be notified by mail upon reaching

the MOOP for their plan This notice will also list services with $0 cost-sharing

available to the member for the remainder of the calendar year Sign in to your

account at www.emblemhealth.com to confirm MOOPs for your Medicare HMO

and PPO patients

Wellness Exams

Medicare Part B services now include an annual wellness exam in addition to the

“Welcome to Medicare” physical exam

• “welcome to Medicare” Physical exam: Our Medicare plans cover a one-time

“Welcome to Medicare” physical exam This exam includes a health review,

education and counseling about preventive services (including screenings and

vaccinations) and referrals for care, if necessary Note: Members must have the

“Welcome to Medicare” physical exam within 12 months of enrolling in Medicare

Part B When making their appointment, they should let you know they are

scheduling their “Welcome to Medicare” physical exam

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YOUR PLAN MEMBERS

• annual wellness visit: A Health Risk Assessment (HRA) is to be used as part

of the Annual Wellness Visits (AWV) Members enrolled in Medicare Part B for

over 12 months are eligible for an annual wellness visit to develop or update a

personalized prevention plan based on their health needs and risk factors This

is covered once every 12 months Note: Following their “Welcome to Medicare”

physical exam, members must wait 12 months before having their first annual

wellness visit However, once members have been enrolled in Medicare Part B

for at least 12 months, they do not need to have had a “Welcome to Medicare”

physical exam to be covered for annual wellness visits Providers may bill for this

service using HCPCS codes G0438 and G0439 for initial and subsequent visits,

respectively

• No Cost-sharing: CMS has released National Coverage Determinations for

preventive services that are to be offered without cost-sharing All of the

services are listed in appendix e For HMO members, including Dual Eligible and

Medicaid Advantage, Medicare-required covered services that are not available

in network and receive prior approval from our plan, or the member’s assigned

managing entity, as applicable, will be allowed at $0 cost-sharing as well For

PPO Dual Eligible and Medicaid Advantage members, all of the services outlined

in appendix e are covered at $0 cost-sharing For PPO High Option, I, II and

III members, all of the services listed in appendix e are covered at the

out-of-network cost-sharing percentage

view benefit summaries and copies of members’ evidences of Coverage for each

of these Medicare plans

• EmblemHealth Medicare Advantage HMO

• EmblemHealth Medicare Advantage PPO

• EmblemHealth Medicare Special Needs Plan (SNP)

• EmblemHealth Medicare Prescription Drug Plan (PDP)

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YOUR PLAN MEMBERS

The table below summarizes our Medicare suite of products

MeDiCare ProDuCt suMMary For 2012 Product Name Product type req’dPCP

Coverage Cost sharingin-Network service area Networks available Comments

IN OON emblemHealth Medicare HMo

Direct-pay Medicare plan Replaces the Medical Group Tiered PCP option that was available under the HIP VIP plan.

Offers lower copays for a smaller PCP network

coinsurance 8 county Prime

Direct-pay Medicare plan

No copays for most services, including office visits and hospital stays Current members who have selected the High Option Rider must complete

a new enrollment form to receive these benefits If they do not, they will remain in the VIP (HMO) plan, and will

be charged a copay

or coinsurance for services.

8 county Prime Employer Group

plan.

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YOUR PLAN MEMBERSMeDiCare ProDuCt suMMary For 2012

Product Name Product type req’dPCP

IN OON emblemHealth Medicare HMo (continued)

Dual Eligible

(HMO SNP) HMO Yes Yes Yes Yes* Part D only 8 county** Prime

Special needs plan Members have certain fee-for- service (partial) Medicaid benefits in addition to Medicare plan benefits Medicaid Advantage

is a subset of the Medicare Advantage SNP.

of Medicaid wraparound benefits plus additional long- term-care benefits emblemHealth Medicare PPo

coinsurance 9 county

Medicare Choice PPO

Direct Pay Medicare Advantage plan No Part D coverage

Medicare Choice PPO

Direct Pay Medicare Advantage prescription drug plan No drug coverage in the

“donut hole.”

Medicare Choice PPO

Direct Pay Medicare Advantage prescription drug plan Offers coverage of generic drugs in the “donut hole.”

No copays for most services including office visits and hospital stays.

Employer Group MAPD plan Each group contracts individually with the plan for benefit design Pharmacy benefits included.

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Product Name Product type req’dPCP

IN OON emblemHealth Medicare PPo (continued)

Employer Group MAPD plan Each Group contracts individually with the plan for benefit design Pharmacy benefits excluded.

Dual Eligible

Medicare Choice PPO

Direct Pay Medicare Advantage

prescription drug plan Special needs plan limited to individuals with both Medicare and Medicaid coverage Individuals with full Medicaid coverage receive additional benefits Medicaid Advantage is a subset of the Medicare Advantage SNP.

emblemHealth Medicare aso

determined

New York City and Dutchess, Orange and Westchester counties

Medicare Choice PPO

N/A

GuildNet Gold ASO No No Yes Yes Part D only 6 county

Medicare Choice PPO

Third party administration MAPD plan Plans customized to meet client’s health plan needs Individuals must have Medicare and full Medicaid coverage.

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Product Name Product

type

PCP req’d

Coverage in-Network

Cost sharing service area

Networks available Comments

IN OON emblemHealth Medicare aso (continued)

Third party administration MAPD plan Plans customized to meet client’s health plan needs Individuals must have Medicare and full Medicaid coverage.

Part D drug coverage GHI Medicare PDP and HIP Standard and Enhanced PDP consolidated and rebranded as EmblemHealth Medicare PDP.

table legend

9 county = New York City (Bronx, Kings, New York, Queens, Richmond), Nassau,

Rockland, Suffolk, Westchester

8 county = New York City (Bronx, Kings, New York, Queens, Richmond), Nassau,

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YOUR PLAN MEMBERS

*Members can access certain services from county departments of health,

academic dental centers and for Medicaid members, Medicaid FFS providers (See

the “access to Care and Delivery system” chapter for a list of these services.)

**Members are covered for urgent and emergency care HIP covers in all 50 United

States, Canada, Mexico, Puerto Rico, the US Virgin Islands, Guam and the Northern

Mariana Islands Medicare members have worldwide urgent and emergency

coverage Note: Medicaid and Family Health Plus members are covered for urgent

and emergent care in all 50 United States, Washington D.C., Canada, Puerto Rico,

the US Virgin Islands, Guam, American Samoa, the Northern Mariana Islands and

American territorial waters

MEDICARE SPECIAL NEEDS PLANS

SNPs Meet Our Members’ Special Needs

Medicare Special Needs Plans (SNPs) are specially designated Medicare Advantage

plans, with custom designed benefits to meet the needs of a specific population

Enrollment in a SNP is limited to Medicare beneficiaries within the target SNP

population The target populations for the EmblemHealth SNPs are individuals that

live within the plan service area, are eligible for Medicare Part A and Part B, and are

eligible for Medicaid

EmblemHealth’s SNPs consist of:

• Dual eligible HMo sNP

• Dual eligible HMo sNP (MltC)

• Dual eligible PPo sNP

Each of these plans has a Medicaid Advantage plan as a subset of the Medicare

SNP

Our SNP goals are to:

• Improve access to medical, mental health, social services, affordable care and

preventive health services

• Improve coordination of care through an identified point of contact

• Improve transitions of care across health care settings and providers

• Assure appropriate utilization of services

• Assure cost-effective service delivery

• Improve beneficiary health outcomes

The SNP Interdisciplinary Team

The SNP interdisciplinary team provides the framework to coordinate and deliver

the plan of care and to provide appropriate staff and program oversight to

achieve the SNP goals The Care Management staff assumes an important role in

developing and implementing the individualized care plan, coordinating care and

sharing information with the interdisciplinary care team and with the member, their

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YOUR PLAN MEMBERS

Practitioners providing care to our SNP members are important members of

the SNP interdisciplinary team As such, they participate in one of our regularly

scheduled care coordination or case rounds meetings to discuss their plan of care

and the health status of the SNP-enrolled patient These practitioners also share

their progress with the team to ensure we are meeting our SNP program goals

The summary table on the next page outlines the key components of the SNPs,

such as Medicaid eligibility level, service area and whether referrals are needed

You may review the full training program on the SNP Model of Care at our

Counties in which the Plan is available

referrals required?

Primary Care Provider selection required?

Must use Plan Providers?

Dual Eligible

HMO SNP

Any level of Medicaid

Bronx, Kings, New York, Queens, Richmond, Nassau, Suffolk, Westchester

Dual Eligible

HMO SNP

(MAP MLTC)

Full Medicaid benefits

Bronx, Kings, New York, Queens, Richmond, Nassau, Suffolk, Westchester

Dual Eligible

PPO SNP

Any level of Medicaid

Bronx, Kings, New York, Queens, Richmond, Rockland, Westchester

*Each of these plans has a Medicaid Advantage plan as a subset of the Medicare

SNP

NY BRIDGE PLAN

In March 2010, Congress passed a health care reform law called the Patient

Protection and Affordable Care Act This law created a temporary program that will

run from October 1, 2010, until January 1, 2014, to provide coverage for individuals

who have a pre-existing medical condition

This new program is called the Pre-Existing Condition Insurance Plan (PCIP) and

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YOUR PLAN MEMBERS

the NY Bridge Plan The plan is an EPO, is administered by GHI and utilizes the

same network as GHI’s other EPO plans, with additional network providers available

in upstate New York counties

The NY Bridge Plan covers a broad range of services, including primary and

specialty care, inpatient and outpatient hospital care, vision care, prescription drugs

and assistance from professional nurses and caseworkers to help members manage

chronic conditions and maintain overall health Once a person is enrolled, there is

no waiting period, and coverage for medical services begins immediately

Here are some highlights regarding cost sharing:

• No deductibles

• $20 office visit copay

• $500 inpatient per occurrence copay

• $100 emergency room copay

To be eligible to apply, a person must:

• Be a legal US resident

• Be a resident of New York State

• Have one or more pre-existing medical condition(s)

• Have not had health care coverage for the last six months

There is no minimum age to qualify — even newborns may be enrolled if they meet

the eligibility requirements However, once a person turns 65 years of age and

has Medicare coverage, that person is no longer eligible for the NY Bridge Plan

Applicants who transfer from another state’s PCIP program are eligible if they are

residents of New York and have less than a 63-day lapse in coverage from their

prior PCIP coverage

RIGHTS AND RESPONSIBLITIES OF

EMBLEMHEALTH PLAN MEMBERS

The rights and responsibilities listed below indicate what members can expect of

EmblemHealth and what responsibilities our members have to EmblemHealth

emblemHealth plan members have the right to:

• Obtain from the member’s physician, during practice hours, comprehensive

information about the member’s diagnosis, treatment and prognosis, regardless

of cost or benefit coverage, in terms the member can reasonably be expected to

understand When it is not medically advisable to give such information to the

member, or when the member is a minor or is incompetent, the information will

be made available to a person designated to act on that person’s behalf

• Receive from the member’s physician information necessary to allow the member

to give informed consent prior to the start of any procedure or treatment and

refuse to participate in, or be a patient for, medical research In deciding whether

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YOUR PLAN MEMBERS

to participate, the member has the right to a full explanation

• Refuse treatment, to the extent permitted by law, and be informed of the medical

consequences of refusing it

• Understand their rights and receive information about their plan’s services,

practitioners and providers If for any reason the member does not understand

these rights or how to interpret them, EmblemHealth and our network providers

will provide the member with assistance

• Treatment without discrimination, including discrimination based on race, color,

religion, gender, national origin, disability, sexual orientation or source of payment

• Participate with physicians in making decisions about the member’s health care

• A non-smoking environment

• Receive considerate and respectful care in a clean and safe environment

• Receive, upon request, a list of the physicians and other health care providers in

the EmblemHealth plan provider network

• Change physicians.*

• Be assured that EmblemHealth network health care providers have the

qualifications set forth in the Professional Standards established by the

EmblemHealth credentialing committee, which are available upon request

• Know the names, positions and functions of any network provider’s staff and

refuse their treatment, examination or observation

• Have all lab reports, x-rays, specialists’ reports and other medical records

completed and placed in the member’s chart so they may be available to the

member’s physician at the time of consultation

• Be informed about all medication given to the member, as well as the reasons for

prescribing the medication and its expected effects

• Receive all information needed to give informed consent for an order not to

resuscitate The member also has the right to designate an individual to give this

consent if the member is too ill to do so

• Request a second opinion from an EmblemHealth network physician

• Privacy concerning the member’s medical care This means, among other

things, a person not directly involved in the member’s care may not be present

without the member’s permission during any portion of the member’s discussion,

consultation, examination or treatment

• Expect that all communications, records and other information pertaining to the

member’s care or personal condition will be kept confidential, except if disclosure

is required by law or permitted by the member

• Request that copies of the member’s complete medical records be forwarded to

a physician or hospital of the member’s choice, and at the member’s expense

• Be withheld information if in the reasonable exercise of a physician’s judgment

it is believed that the release of such information could harm the member or

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YOUR PLAN MEMBERS

control or sexually transmitted diseases if the minor’s consent is not obtained

• Have a person of the member’s choice accompany the member in any meeting or

discussion with medical or administrative personnel

• Consult by appointment, during business hours, with responsible administrative

officials at EmblemHealth and the member’s network physician’s office to make

specific recommendations for the improvement of the delivery of health services

• File an appeal or external review related to a determination about care and

services rendered For additional information on filing an appeal the member may

review the section on “If You Disagree with a Decision or Service” in the Member

Handbook and/or call EmblemHealth’s Customer Service department at

1-877-842-3625 TTD is 1-866-248-0640

• Accept or refuse medical treatment, including life-sustaining treatment, in the

event of catastrophic illness or injury (as provided by state and federal laws)

As the member’s health insurer, it is EmblemHealth’s duty to make the member

aware of his or her rights in these matters Included with the membership kit

are materials on advance directives with written instructions, such as a living

will or health care proxy containing the member’s wishes relating to health care

should the member become incapacitated Members should carefully read their

plan materials, e.g subscriber agreement, member handbook, etc To request

replacement copies of these materials, please call 1-877-842-3625 TTD is

1-866-248-0640

• Receive information about the organization, its services, its practitioners and

providers, and its member rights and responsibilities

• Make recommendations regarding EmblemHealth’s Member Rights and

Responsibilities policies

* Medicaid members in the Restricted Recipient Program (RRP) can only change

physicians for “good cause” reasons

emblemHealth plan members have the responsibility to:

• Provide EmblemHealth and our network physicians and other providers with

accurate and relevant information about the member’s medical history and health

so that appropriate treatment and care can be rendered

• Keep scheduled appointments or cancel them, giving as much notice as possible

in accordance with the provider’s guidelines for cancellation notification

• Update the member’s record with accurate personal data including changes

in name, address, phone number, health insurance carriers and number of

dependents within 30 days of the change

• Treat with consideration and courtesy all EmblemHealth personnel and the

personnel of any hospital or health facility to which the member is referred

• Be actively involved in the member’s own health care by seeking and obtaining

information, by discussing treatment options with the member’s physician and by

making informed decisions about the member’s health care

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YOUR PLAN MEMBERS

• Participate in understanding the member’s health issues and to follow through

with treatment plans agreed upon by all parties involved in the member’s health

care: the member, EmblemHealth and participating physicians

• Follow plans and instructions for care that the member agreed to with his or her

practitioner

• Understand the member’s health problems and participate in developing mutually

agreed upon treatment goals, to the degree possible

• Understand EmblemHealth’s benefits, policies and procedures as outlined

in the member’s Contract or Certificate of Coverage and in the handbook,

including policies related to prior authorization for all services that require such

authorization

• Pay premiums on time and copays at the time services are rendered (if applicable)

• Abide by the policies and procedures of the member’s network physician’s office

MEMBER PRIVACY RIGHTS

The protection and security of our members’ personal information is a major

objective of EmblemHealth Our Notice of Privacy Practices describes how medical

information about our members may be used and disclosed and how our members

can get access to this information Our member handbook tells members how to

give consent to the collection, use and release of personal health information, how

to obtain access to their medical records and what we do to protect access to their

personal information

Confidentiality of Personal Information

As members consider joining an EmblemHealth plan, we want them to know that

we make the protection of personal information a high priority Our members

entrust us with information that is personal, sensitive and highly confidential

Our employees and other authorized individuals working for us are accountable

for exercising a high degree of care in safeguarding the confidentiality of that

information

Indeed, our employees and other authorized individuals are prohibited from:

• Accessing or trying to access personal information, except on a “need to know”

basis and only when authorized to do so

• Disclosing personal information to any person or organization within or outside

the Plan, unless that person or organization has a “need to know” and is

authorized by us to receive that information

Tiêu đề	EmblemHealth Provider Manual
Trường học	University of Example
Chuyên ngành	Health Insurance and Provider Management
Thể loại	Hồ sơ hướng dẫn nhà cung cấp
Năm xuất bản	2023
Thành phố	New York

Định dạng
Số trang	536
Dung lượng	8,38 MB