Learn More. The Peer-to-Peer request must be received by Maryland Amerigroup maryland prior authorization Care within two 2 business days of the initial notification of the denial. The intent of the Peer-to-Peer is to discuss the denial decision with the ordering clinician or attending physician. For specific details prioe authorization requirements, please refer to our Quick Reference Guide. Certain carefirst mental providers require prior authorization regardless of place of service.
EmblemHealth contracts with vendors to provide services to EmblemHealth members. These vendors are considered network providers. Preauthorization, if required, must be obtained directly from these vendors. For a listing of EmblemHealth network vendors, go to the Directory chapter.
More information about each vendor is organized by subject or specialty in the various chapters of this manual. Any activities and reporting responsibilities delegated to a subcontractor, including a practitioner, will be performed according to standards set forth by the NYSDOH.
As required, the practitioner will take any necessary corrective action s with respect to any delegated activities and responsibilities. Practitioners agree to comply with and be bound by the confidentiality provisions set forth in the above-referenced agreements.
It is important for primary care practitioners PCPs to establish a meaningful, professional, and lasting relationship with their patients. EmblemHealth encourages new members to contact their PCPs for an initial evaluation within 90 days of enrollment. If the PCP or primary caregiver anticipates the need to refer a member for services requiring a preauthorization , including the use of a non-participating provider, the request must be approved by EmblemHealth in advance for consideration of payment for the care.
A PCP may refer members with chronic, disabling, or degenerative conditions or diseases to a specialist for a set number of visits within a specified time. An EmblemHealth or managing entity medical director must approve standing referrals via the preauthorization process. Credentialed advanced nurse practitioners ANPs may act as primary caregivers, maintaining their own panels of EmblemHealth members, and issuing referrals for specialty care.
All ANPs functioning as primary caregivers must maintain a current collaborative relationship with an EmblemHealth physician who is participating in the same networks and has the same coverage arrangement for hospital admissions at an EmblemHealth-contracted hospital. For more information on how to become credentialed with EmblemHealth as a primary caregiver, see the Credentialing chapter. EmblemHealth-contracted PCPs are responsible for providing primary care services and managing all medically necessary health care services for their assigned members.
PCPs help members stay healthy by supervising and coordinating all care with medical and behavioral health practitioners, and by effectively managing appropriate use of health care resources. When EmblemHealth members first enroll, they choose where they want to receive medical care. If a member is using a behavioral health clinic that also provides primary care services, the member may select the lead provider to be their PCP.
Members who fail to select a PCP within a given time frame are assigned to a PCP and notified of the assignment in writing. PCP changes take effect immediately upon request.
This helps with continuity of care. The original record should be retained and treated as a terminated record. Practitioners treating members enrolled in Medicaid or Child Health Plus CHPlus have a maximum capacity limit of 1, members on their panel, or 2, members for a physician practicing in combination with a registered physician assistant or certified nurse practitioner.
Advanced nurse practitioners credentialed as primary caregivers will have no more than 1, members on their panel. These member-to-practitioner ratios assume the practitioner works 40 hours per week and therefore must be prorated for practitioners working less than 40 hours per week.
The ratios apply to practitioners, not to each of their practice locations. Provider Customer Service will coordinate with Member Services to notify the member. They may change PCPs for good-cause reasons such as:. The following information should be requested:. We make every effort to assist members when their practitioners terminate participation with one of our plans.
If the practitioner is a PCP and the member chooses to stay with the PCP during the day transition period, the member must notify Customer Service of the new PCP who will manage their care after the transition. If the practitioner leaving the network is a specialist and the member chooses to stay with the specialist for the day transition period, the member should obtain a referral to a new specialist for care following the day transition period.
Specialists should make note of the scope of the referral and refer the member back to the referring PCP for continuation of care. To ensure continuity of care, the specialist must communicate with the PCP, if applicable, regarding the consultation, findings, and recommended treatment plan. The scope of services rendered is limited to those related to the clinical condition for which the PCP refers the member.
EmblemHealth members can self-refer to network providers for the following services when covered by their benefit plan:. See below for more details. Medicare members may self-refer to a participating clinician for certain EmblemHealth-covered services and certain Medicare-covered services at designated frequencies and ages, including:.
Female members may self-refer to a participating women's health care specialist for the following routine and preventive health care services:. In addition to the above services to which all EmblemHealth members have direct access, there are some services that members in state-sponsored programs Medicaid and CHPlus may also self-refer.
Unless otherwise indicated, members in all state-sponsored programs may self-refer to the services outlined in in Section Additionally, New York State public healthlaw requires most medical facilities to offer voluntary HIV testing to patients of all ages. With limited exceptions,the law applies to anyone receiving treatment for a non-life-threatening condition, whether in a hospital, emergencyroom, or primary care setting such as a doctor's office or outpatient clinic. Current as of Feb.
Patients must be provided information about HIV either orally, in writing, or through other means. The patient must be informed that HIV testing will be conducted. The law no longer requires patients to give written or verbal informed consent for a HIV test. The practitioner must counsel the patient on important points to know about HIV testing.
Visit the Clinical Corner at emblemhealth. A hepatitis C screening test must be offered by PCPs regardless of the setting and without regard to board certification. This includes physicians, physician assistants, and nurse practitioners. Emergency Departments are not required by law to offer hepatitis C testing but are encouraged to do so.
Every individual born between and must be offered a hepatitis C test. If the test is reactive, the provider must offer follow-up health care, or refer to a provider who can provide follow-up care. These newborns receive all benefits and services of the plan beginning on their date of birth.
Once enrolled, the newborn is issued a member ID card. Note : Enrollment could be delayed for several reasons. If a CHPlus member gives birth, the parent must complete an application for the newborn. There is no automatic enrollment in CHPlus. The parent can contact Customer Service for information on how to apply.
EmblemHealth contracts with health care professionals and facilities with expertise in caring for medically fragile children. This ensures children with co-occurring developmental disabilities receive services from appropriate providers. For more information, see the Preauthorization Procedures section of the Utilization and Care Management chapter. Telehealth is the use of electronic information and communication technologies by a health care provider to deliver health care services to an insured individual who is located at a site different than where the health care provider is located.
For more information, see the Telehealth Medical Policy. EmblemHealth members enrolled in either a Medicaid or Medicare-Medicaid plan can access telehealth services from approved home health care agencies if the members are assessed and meet specific criteria.
Only home care agencies approved by Medicaid as providers of telehealth are authorized to provide telehealth monitoring. To be eligible, the member must have conditions needing frequent monitoring and be at risk of acute or long-term care facility admission. Congestive heart failure, asthma, cardiac conditions, chronic obstructive pulmonary disease COPD , HIV, and diabetes are the most frequent diagnoses for those currently receiving telehealth services.
However, this is not an exhaustive list of conditions for which telehealth may be indicated. Each case is assessed individually to determine the appropriateness of telehealth monitoring. Telehealth services may only be provided during an episode of home care. They must be an adjunct to nursing care and they do not replace physician-ordered nursing visits. EmblemHealth covers telehealth services if they are deemed medically necessary. Our evaluation may include a review of the original assessment or we may request a new assessment.
The home health care agency may bill using HCPCS code T for either the nursing visit or the installation, but not both. Authorization is given for 30 days.
On day 30, another 30 days may be requested. If longer than 60 days are needed, the member must be reassessed. The risk assessment tool completed by the home care agency documents the following about the member:.
EmblemHealth Neighborhood Care offers our plan members and other community members a place to receive the personalized, one-on-one support of experts in clinical, benefit, and health management solutions. Neighborhood Care does not provide medical services. Instead, they help practitioners manage patient care by supporting the primary practitioner-patient relationship.
Both in-person and telephonic contact is available at multiple locations, many of which are located with the ACPNY practice sites. For more information, visit emblemhealth. EmblemHealth will not prohibit or restrict a health care professional, acting within the lawful scope of practice, from advocating on behalf of an individual who is a patient and enrolled under EmblemHealth. Practitioners will not be prohibited from discussing the risks, benefits, and consequences of treatment or absence of treatment with the member, patient, or designated representative.
Patients will have the opportunity to refuse treatment and to express preferences about future treatment decisions. Any information provided on this Website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider.
To access benefit summaries of care plans, we entered the zip code for the Emblem headquarters in New York City. This returned basic summaries of a benefit plan. The Select Care network includes health care providers in 28 counties in New York. Select Care Basic is a catastrophic plan that is a high-deductible HMO offering three free primary care visits per year before the deductible is applied. Our results did not offer the deductible amount. Select Care Silver is described as offering mid-level out-of-pocket costs.
These plans have higher deductibles, but the deductible at each level is also the out-of-pocket care costs limit. Value plans include adult dental benefits and vision services with networks of vision providers in New York and New Jersey, as well as nationwide.
This includes two sick visits, lab services, and prescription drug coverage. The last plan is the Essential plan, which is offered only to those who qualify based on income requirements. The website states that there are four versions of the plan, but does not list further details of the plans or out-of-pocket care costs. Emblem has several types of Medicare plans, including both Medicare Advantage and supplemental insurance. At the time of our review, the website was not functioning properly.
In addition to the site errors, attempts to gain more information on the plans failed. It is likely there are several plan options with varying coverage benefits and cost beneath each of these headings. Aside from the Select Care Network, other plans offered to Small Groups include the Prime Network and the Millenium Network, but we were unable able to access it to get answers to questions about coverage for patients and specialty care due to the links not responding.
Overall, the provider portal was unable to provide more than moderate amounts of information when we visited. Emblem Health has a relatively easy online quoting system, and we requested rates for a year-old male living in the area of the Lower Manhattan company headquarters.
New York tops the list of most expensive states for health insurance premiums, so it is no surprise that these rates are quite high when compared to other states. Compared to insurers in New York, Emblem still comes out a little high on monthly premiums but does have lower deductibles than some other options.
Given that it is an HMO, which usually means lower premiums, insurance shoppers will have to decide if limited networks and reasonable deductibles balance out in terms of the monthly cost. Emblem runs HMO plans and is directly connected to the health care services provider.
That usually means fairly quick and simple internal claims processing without having to contact customer service. Like most health insurance providers, Emblem does not offer much information on the claims process. There have been a total of 61 complaints filed against the health services company in the past three years, 25 of which were closed in the past 12 months.
These numbers are low for such a large company. The complaint against the company cited failure to adequately disclose out-of-pocket costs to members for out-of-network care.
There are 83 reviews of Emblem on Yelp, most of which are negative. There are moderate amounts of positive reviews scattered throughout. Most negative reviews seem to focus on difficulty finding doctors in the provider directory that accept the insurance and difficulty reaching people for help at the company.
On Jan. ConnectiCare commercial providers have been treating certain EmblemHealth members since EmblemHeath members with the above plans will have a member ID card with a ConnectiCare logo included, like the one illustrated below:.
EmblemHealth members with the plans listed above can get medical care and services from ConnectiCare providers under their in-network benefits. For these members, EmblemHealth policies and procedures apply. Go to emblemhealth. Please note, claims need to be submitted to Emblem but will be paid according to your ConnectiCare contract. You are now leaving a ConnectiCare website. Please check the privacy statement of the website where this link takes you. Any information provided on this Website is for informational purposes only.
It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider's office. Reimbursement Policies Payment processes unique to our health plans Payment Integrity Policies How we pursue payment accuracy. Provider Manual. Provider Manual Find the specific content you are looking for from our extensive Provider Manual. Search the Provider Manual.
Dental Corner. Welcome Dental Providers Find a Dentist. What is The Bridge Program? Below are the five 5 networks that members may access. If your practice has a contract with one of these networks, you can see Bridge Program members.
Download PDF. Member's ID Card. Utilization Management. Claims Information. Preauthorization lists and UM programs follow ConnectiCare coverage guidelines.
Frequently Asked Questions. Bridge Provider:. It means: Increasing the number of our members who may come to you for care. Ensuring your staff knows how to identify these new members who can see you. Sending members to their designated utilization management programs.
How do I know if I can see members with Bridge access? What rate will I be paid? EmblemHealth Plan Inc. Where do I submit my claims? Utilization Management:. What Utilization Management rules apply? Does it matter if a member is ASO vs. Fully Insured? Find a doctor or medical office. Access the EmblemHealth Portal. Sign In. All Rights Reserved. Back to Top.
WebOct 15, · We heard your frustration in determining whether you are in-network for a specific member – especially when the member has access to multiple networks through . WebJul 6, · On Jan. 1, , EmblemHealth, our parent company in New York, expanded one of its networks to include ConnectiCare Medicare Advantage providers in Missing: reviews. Web13 rows · Aug 1, · Networks and Benefits | EmblemHealth Networks and Benefits Missing: reviews.