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Provider Manual

EmblemHealth Provider Manual
The EmblemHealth Provider Manual provides convenient access to EmblemHealth, GHI and HIP plan policies and procedures, which may affect your patients' coverage and how you work with us.

Updated: 6/2013

Additional Resources/Administrative Guidelines

Find information that affects you and your patients below. This resource page is organized according to the EmblemHealth Provider Manual. Within each section, you may link to the relevant chapter of the Provider Manual or to additional resources on our Web site and on the internet.

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Directory

Contact information for parties within EmblemHealth, our delegated relationships and other external resources

View Directory chapter

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Quest Diagnostics
Designated AIDS Centers (DACs)

Urgent Care Centers

Network Laboratory Services for All Plan Members
HIP Optical Directory
Compare Hospitals
New York State Nursing Home Profile
Quick Reference Cards

YOUR PLAN MEMBERS

Information on our networks and the benefit plans within them as well as our members rights and responsibilities, including privacy rights and sample ID cards

View Your Plan Members chapter

More about privacy rights:

Prescribing eHealth Initiative Best Practices and Guidance

ACCESS TO CARE AND DELIVERY SYSTEM

Policies and procedures for the provision of medical care to our members, including:

Participation requirements
Role of primary care providers
Provider termination procedures

View Access To Care And Delivery System chapter

Visit Clinical Corner for practice guidance resources.

MEDICAL RECORD GUIDELINES

Policies on how to maintain member medical records, including

Medical record standards
Contractual requirements regarding retention and disclosure of information

View Medical Record Guidelines chapter

CARE MANAGEMENT

Our philosophy, policies and procedures for the coordinated care of our members, including referral and prior approval requirements, case management programs, and utilization review guidelines

View Care Management chapter

Visit Clinical Corner for practice guidance resources.

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CLINICAL PRACTICE GUIDELINES

Evidence-based recommendations to assist practitioners in providing medical care

View Clinical Practice Guidelines chapter

Visit Clinical Corner for practice guidance resources.

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Domestic violence resources:

Quality Improvement

Summarizes our quality improvement programs established to improve the medical and mental health care outcomes for our members

HEDIS/QARR

View Quality Improvement chapter

Quality Improvement Program Overview

HEALTH PROMOTION AND DISEASE MANAGEMENT

Quality improvement programs available to help members with identified conditions and diseases.

View Health Promotion and Disease Management chapter

INTEGRATIVE WELLNESS

Plan and community programs that promote healthy living, particularly to frail seniors and at-risk members.

View Integrative Wellness chapter

Dignified Decisions – End of Life Care Program Referral Form for Hospice

Pharmacy Services

Prescription drug coverage, including:

Pharmacy benefit designs
Medication Therapy Management program
Home delivery

View Pharmacy Services chapter

Visit Clinical Corner for formulary updates.

Injectables and Specialty Pharmacy Program

Information on the EmblemHealth Injectables and Specialty Pharmacy Program

Medical benefit injectables
Self-administered specialty drugs
EmblemHealth Injectable Drug Utilization Management Program
Prior approval procedures
HIP Drug Replacement Program order forms
Code list

View Injectables and Specialty Pharmacy Program chapter

DURABLE MEDICAL EQUIPMENT

Policies for the prescription of durable medical equipment for members

View Durable Medical Equipment chapter

HIP OUTPATIENT DIAGNOSTIC IMAGING SELF-REFERRAL PAYMENT POLICY

Our diagnostic imaging payment policy as it applies to services performed in an office setting (POS 11). The policy designates which imaging procedures will be reimbursed (subject to the member’s benefit plan) according to practitioner specialty.

View HIP Outpatient Diagnostic Imaging Self-Referral Payment Policy chapter

RADIOLOGY PRIVILEGING

Radiology privileging protocols to improve quality of care and make imaging services available when rendered by physicians other than radiologists

View Radiology Privileging chapter

Radiology Program

Diagnostic imaging management program for outpatient radiology services for all members, including prior approval and radiology scheduling procedures

View Radiology Program chapter

CARDIOLOGY IMAGING PROGRAM

Diagnostic imaging management program for outpatient cardiology for selected HIP members, including:

Prior approval procedures
Cardiology imaging scheduling procedures

View Cardiology Imaging Program chapter

Radiation Therapy Program

Policies and procedures for the EmblemHealth Radiation Therapy Program

Cancer Clinical Pathways
Place of service for select outpatient radiation therapy services
Prior approval procedures
Urgent requests/non-urgent requests
Formal dispute resolution
CPT code list

View Radiation Therapy chapter

Behavioral Health Services

Policies and procedures for mental health and substance abuse services, including:

Prior approval procedures
Post-discharge protocol
Mental Health Parity Law

View Behavioral Health Services chapter

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Chiropractic Program

Network and utilization management program for chiropractic services provided to designated members

View Chiropractic Program chapter

Podiatry

Special reimbursement program for podiatry services provided by designated providers

View Podiatry chapter

Claims

Policies and procedures for submitting your claims:

Recent managed care laws
Electronic claims submission
Where to file claims or documentation for plan members

View Claims chapter

Visit Claims Corner for updated information so that you may pay your claims quickly and accurately

PHYSICAL AND OCCUPATIONAL THERAPY PROGRAM

Utilization management program for physical and occupational therapy provided in partnership with Palladian Muscular Skeletal Health.

View Physical and Occupational Therapy Program chapter

DISPUTE RESOLUTION

Processes for members and practitioners to dispute a determination that results in a denial of payment and/or covered service.

View Dispute Resolution — Commercial/Child Health Plus chapter

View Dispute Resolution — Medicaid/Family Health Plus chapter

View Dispute Resolution — Medicare chapter

Credentialing

Credentialing and recredentialing requirements:

New managed care law requiring provisional credentialing
Practitioner appeal process for changes in participation

View Credentialing chapter

Regulatory Mandatory Reporting

Outlines mandatory reporting requirements for New York State and New York City

View Regulatory Mandatory Reporting chapter

Communicable Disease Reporting and Resources

Fraud and Abuse

Identifying and preventing fraudulent claims

View Fraud and Abuse chapter

Medical Transportation Procedures

Information on Medicaid policies for transporting or reimbursing Medicaid, Family Health Plus and Medicare Advantage members

View Medical Transportation Procedures chapter

Required Provisions To Network Provider Agreements

Mandatory contract language required by the State of New York and the Centers for Medicare & Medicaid Services, including:

Managed Care Law of 2009
NYS DOH Standard Clauses
Special Provisions Related to Medicaid and Family Health Plus Members
Medicare Advantage Addendum

View Required Provisions to Network Provider Agreements chapter

Glossary

Definitions of terms used in the manual

View Glossary

Press | Privacy/Security Policies | Legal | Glossary | Site Map | News & Media | Careers

URAC - Health Care Quality Accreditation

The Leapfrog Group's Patient-Safety Improvement Efforts

Health Care Fraud-EmblemHealth Special Investigation Unit (SIU)

GHI and HIP are EmblemHealth companies. ©2013 EmblemHealth. All Rights Reserved. Last Updated 6-7-2013. Effective September 23, 2010, federal health reform may require changes to your coverage, depending on your plan. Get more information.