i EMBLEMHEALTH PROVIDER MANUAL ii 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 EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies. Click on the titles below to jump to the chapters. 1 BACK TO TABLE OF CONTENTS DIRECTORY EmblemHealth Provider Manual Last updated: 10/11 OVERVIEW 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 Last page viewed 2 OVERVIEW BACK TO TABLE OF CONTENTS DIRECTORY EmblemHealth Provider Manual Last updated: 10/11 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. Last page viewed 3 BACK TO TABLE OF CONTENTS DIRECTORY EmblemHealth Provider Manual Last updated: 6/12 DIRECTORY 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 Last page viewed 4 DIRECTORY BACK TO TABLE OF CONTENTS DIRECTORY EmblemHealth Provider Manual Last updated: 6/12 EMBLEMHEALTH HEADQUARTERS EmblemHealth 55 Water Street New York, NY 10041-8190 CUSTOMER SERVICE (PROVIDERS) EmblemHealth 1-877-842-3625 TDD: 1-866-248-0640 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 Monday through Friday, 8 am to 5 pm GHI 1-212-501-4444 in New York City 1-800-624-2414 outside of New York City TDD: 1-866-248-0640 Monday through Friday, 8 am to 5 pm GHI HMO 1-877-244-4466 TDD: 1-877-208-7920 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 Monday through Friday, 9 am to 5 pm 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 Last page viewed 5 DIRECTORY BACK TO TABLE OF CONTENTS DIRECTORY EmblemHealth Provider Manual Last updated: 6/12 CLAIMS CONTACTS Plans Type of Claim EDI or Payor ID Clearing House Submission Address Contact for Inquiries EmblemHealth CompreHealth HMO/EPO Professional 55247 Emdeon or direct submis- sion EmblemHealth PO Box 2845 New York, NY 10116-2845 www.emblemhealth.com or 1-866-447-9717, option 2 EmblemHealth CompreHealth HMO/EPO Anesthesiol- ogy 55247 Emdeon or direct submis- sion EmblemHealth PO Box 2787 New York, NY 10116-2787 www.emblemhealth.com or 1-866-447-9717, option 2 EmblemHealth Medicare HMO All claims 55247 Emdeon or direct submis- sion EmblemHealth Medicare HMO PO Box 2803 New York, NY 10116-2830 www.emblemhealth.com or 1-866-447-9717, option 2 EmblemHealth EPO/PPO All Claims 13551 Emdeon or direct submis- sion EmblemHealth PO Box 2832 New York, NY 10116-2832 www.emblemhealth.com GHI (New York City and all other areas outside of New York State) All Claims 13551 Emdeon or direct submis- sion GHI Claims PO Box 2832 New York, NY 10116-2832 www.emblemhealth.com GHI HMO All claims 25531 Emdeon or direct submis- sion GHI HMO PO Box 2845 New York, NY 10016 www.emblemhealth.com 1-877-244-4466, or: GHI HMO Attn: Provider Correspondence PO Box 2844 New York, NY 10016-2844 HIP Professional 55247 Emdeon or direct submis- sion HIP Health Plan of New York PO Box 2845 New York, NY 10116-2845 www.emblemhealth.com or 1-866-447-9717, option 2 HIP Anesthesiol- ogy 55247 Emdeon or direct submis- sion HIP Health Plan of New York PO Box 2787 New York, NY 10116-2787 www.emblemhealth.com or 1-866-447-9717, option 2 Vytra All Claims 22264 Emdeon or direct submis- sion Vytra Health Plans Attn: Claims Department PO Box 9091 Melville, NY 11747-327 1-888-288-9872 GHI / EmblemHealth Dental Dental Not appli- cable Direct submis- sion www.emblemhealth.com or: GHI/EmblemHealth Dental Claims PO Box 2838 New York, NY 10116 www.emblemhealth.com or 1-212-615-4EMC GHI GHI employee claims 13551 Emdeon or direct submis- sion GHI Claims PO Box 2861 New York, NY 10116-2861 www.emblemhealth.com Last page viewed 6 DIRECTORY BACK TO TABLE OF CONTENTS DIRECTORY EmblemHealth Provider Manual Last updated: 6/12 CLAIMS CONTACTS Plans Type of Claim EDI or Payor ID Clearing House Submission Address Contact for Inquiries EmblemHealth Medicare PPO All claims 13551 Emdeon or direct submis- sion EmblemHealth Medicare PPO PO Box 2830 New York, NY 10116-2830 www.emblemhealth.com Montefiore CMO HIP and CompreHealth claims for members man- aged 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 man- aged 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 profes- sional claims for PT/OT ser- vices members managed by Palladian and claims bill- able under the Chiropractic program 37268 Emdeon Palladian Health PO Box 270 Lancaster, NY 14086 www.palladianhealth.com CareCore National, LLC HIP and GHI claims bill- able as part of the Radiology program 14182 Emdeon/ Relay Health CareCore National LLC PO Box 61022 Anaheim, CA 92803 1-800-918-8924 or fax: 1-843-815-6579 Last page viewed 7 DIRECTORY BACK TO TABLE OF CONTENTS DIRECTORY EmblemHealth Provider Manual Last updated: 6/12 CLINICAL PHARMACY SERVICES (PRACTITIONERS) EmblemHealth (for HIP, EmblemHealth and CompreHealth plans) 1-866-447-9717, option 3, option 2 Monday through Friday, 8:30 am to 6 pm GHI 1-877-444-7037, Monday through Friday, 8:30 am to 6 pm GHI HMO 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 1-800-992-6227, Monday through Friday, 8:30 am to 6 pm GHI and GHI HMO 1-877-444-3786, Monday through Friday, 8:30 am to 6 pm CompreHealth EPO/HMO 1-877-362-5670, Monday through Friday, 8:30 am to 6 pm EmblemHealth EPO/PPO 1-877-793-6253, Monday through Friday, 8:30 am to 6 pm Last page viewed 8 DIRECTORY BACK TO TABLE OF CONTENTS DIRECTORY EmblemHealth Provider Manual Last updated: 6/12 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 Last page viewed [...]... benefits Providers should verify member eligibility as outlined on the following page Last page viewed Back To Table of Contents DIRECTORY Last updated: 6/12 EmblemHealth Provider Manual 22 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... members’ Evidences of Coverage for each of these Medicare plans • EmblemHealth • EmblemHealth • EmblemHealth • EmblemHealth Medicare Medicare Medicare Medicare Advantage HMO Advantage PPO Special Needs Plan (SNP) Prescription Drug Plan (PDP) Last page viewed Back To Table of Contents DIRECTORY Last updated: 6/12 EmblemHealth Provider Manual 28 YOUR PLAN MEMBERS The table below summarizes our Medicare... 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 Last page viewed Back To Table of Contents DIRECTORY Last updated: 6/12 EmblemHealth Provider Manual 15 DIRECTORY For information please... Back To Table of Contents DIRECTORY Last updated: 6/12 EmblemHealth Provider Manual 17 DIRECTORY Customer Service (For Members) EmblemHealth 1-877-842-3625 TDD: 1-877-208-7920 Monday through Friday, 8 am to 5 pm 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... open daily 8 am to 6 pm TDD: 1-888-447-4833, Monday through Friday, 8:30 am to 5 pm Last page viewed Back To Table of Contents DIRECTORY Last updated: 6/12 EmblemHealth Provider Manual 18 DIRECTORY Pharmacy Services (For Members) EmblemHealth (for all EmblemHealth, GHI and HIP members excluding GHI retirees and city, state and federal employees with GHI coverage) 1-877-444-3614, Monday through Friday,... updated: 6/12 EmblemHealth Provider Manual 13 DIRECTORY Additional Resources (Providers and Members) Entity Address Phone E-mail/Comments 1-800-424-4088 Delegated for utilization management Medical Injectables ICORE National, LLC 5850 T.G Lee Blvd., Suite 510 Orlando, FL 32822 Selected Resources For Members With Special Needs Sign Language Interpreter Services of the Speech and Hearing Impaired Plan providers... Roster available at www .emblemhealth. com • 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 • Speak to a representative at 1-877-842-3625 EmblemHealth Medicare... 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... 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... Commercial/Child Health Plus • Dispute Resolution – Medicaid/Family Health Plus • Dispute Resolution - Medicare Last page viewed Back To Table of Contents DIRECTORY Last updated: 6/12 EmblemHealth Provider Manual 12 DIRECTORY Additional Resources (Providers and Members) Entity Address Phone E-mail/Comments Chiropractic and Physical/Occupational Therapy Palladian 2732 Transit Road Muscular Skeletal West Seneca, NY . i EMBLEMHEALTH PROVIDER MANUAL ii TABLE OF CONTENTS EmblemHealth Provider Manual OVERVIEW 1 DIRECTORY 3 YOUR PLAN. DIRECTORY EmblemHealth Provider Manual Last updated: 10/11 OVERVIEW This manual applies to all EmblemHealth, GHI, HIP, and Vytra plans and it replaces all provider