EMBLEMHEALTH PROVIDER MANUAL pdf

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.
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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
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OVERVIEW
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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.
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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
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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
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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
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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
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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
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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 APPROVAL
Plan/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 pro-
vider 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 out-
side New York City.

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
Submit the prior approval request by signing on to
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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HOW TO OBTAIN PRIOR APPROVAL

Plan/Managing Entity Instructions
GHI EPO and GHI PPO
Submit the prior approval request by signing on to
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 adminis-
tered by VHMS)
Call ValueOptions at 1-888-447-2526.
EmblemHealth Behavioral
Management Program
(For members in plans

underwritten by GHI)
Call ValueOptions at 1-800-692-2489.
Montefiore
(For members in plans
underwritten by HIP and
administered by Montefiore)
Call 1-800-401-4822.
Cardiology and Radiology Services
CareCore National
Radiology
Cardiology
Call:
• 1-866-417-2345 (HIP and CompreHealth EPO/HMO)
• 1-800-835-7064 (GHI EPO/PPO, GHI HMO, and Emblem-
Health EPO/PPO)
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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HOW TO OBTAIN PRIOR APPROVAL
Plan/Managing Entity Instructions
Pharmacy Services
Express Scripts, Inc.
(Medicare PPO plans)
Call 1-866-467-8635.
ICORE Call 1-888-447-0295.
EmblemHealth Injectable
Drug Utilization Management
Program – Starts June 1, 2012
Submit the prior approval request by signing on to
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.
EmblemHealth Pharmacy
Benefit Services
Call:
• 1-866-447-9717, option3, option 2 (HIP members)
• 1-800-447-0210 (Vytra members)
• 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
Call 1-888-447-0295.
Fax 1-977-243-4812.
Monday through Friday, from 9am to 5 pm.
Radiology Services
See “Cardiology and Radiology Services.”
LABORATORY SERVICES
Although we maintain a contract with Quest Diagnostics Inc. to provide outpatient clinical
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)
Entity Address Phone E-mail/Comments
Chiropractic and Physical/Occupational Therapy
Palladian
Muscular Skeletal
Health
2732 Transit Road
West Seneca, NY 14224
1-877-774-7693
www.palladianhealth.com
Delegated for utilization
management.
Dental Services
Careington
International
Corp.
(for HIP
Preventive
Dental)
7400 Gaylord Parkway
Frisco, NY 75034
Provider Relations:
1-800-290-0523

Member Services:
1-877-548-4447
www.careington.com
Delegated for
credentialing.
Healthplex
(For HIP State
Sponsored
Programs and
HIP Prime Dental
Claims)
333 Earle Ovington
Blvd.
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.
Managing Entities
HealthCare
Partners (HCP)
501 Franklin Ave.
Suite 300
Garden City, NY 11530-
5807
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)
Entity Address Phone E-mail/Comments

Medical Injectables
ICORE National,
LLC
5850 T.G. Lee Blvd.,
Suite 510
Orlando, FL 32822
1-800-424-4088
Delegated for utilization
management.
SELECTED RESOURCES FOR MEMBERS WITH
SPECIAL NEEDS
Sign Language Interpreter Services of the Speech and
Hearing Impaired
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
servicesthroughF•E•G•S.
F•E•G•S Health and Human Services System
www.fegs.org
F•E•G•S/NYSDServicesCounselingCenter
The Harry and Jeanette Weinberg Health Related and Human Services Center
80 Vandam St.
Second Floor
New York, NY 10013
Phone/TTY: 1-212-366-0066

F•E•G•S.,anot-for-protorganization,providescomprehensivesocialandreha-
bilitative services for people who are deaf or deaf-blind and reside in the New York
metropolitanarea.ThestaffofF•E•G•Sisabletocommunicatedirectlywithits
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
111 East 59th St.
New York, NY 10022-1202
Westchester County Regional Office
170 Hamilton Ave.
White Plains, NY 10601
RESOURCES FOR CHILDREN WITH
SPECIAL NEEDS
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:
New York City: 1-800-577-BABY (1-800-577-2229) or 1-212-219-5213
Nassau County:
1-516-227-8661
Suffolk County:

1-631-853-3100
Westchester County:
1-914-813-5094
Orange County:
1-845-291-2333
Rockland County:
1-845-364-2625
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 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.
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 Treat-
ment Program. Diagnostic services are available to all children who are believed to
have physically disabling conditions or serious chronic illnesses. To receive diag-
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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
1-800-522-5006 or:
New York City:
1-212-676-2950
Nassau County: 1-516-571-0801
Suffolk County:
1-631-853-2286
Westchester County:
1-914-813-5328
Orange County: 1-845-568-5280
Rockland County:
1-845-364-2081
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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 Sunday, 8 am to 8 pm

TDD: 1-877-208-7920, Monday through Sunday, 8 am to 8 pm
GHI
1-800-624-2414
Also NYC: 1-212-501-4444
TDD: 1-877-208-7920
Monday through Friday, 8 am to 5 pm
GHI HMO
1-877-244-4466
TDD: 1-877-208-7920
Monday through Friday, 8 am to 6 pm
HIP and HIPIC
1-800-447-8255, Monday through Friday, 8 am to 6 pm
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)
1-877-444-3614, Monday through Friday, 8:30 am to 6 pm
TDD: 1-866-248-0640, Monday through Friday, 8:30 am to 5 pm
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

TDD: 1-866-248-0640, Monday through Friday, 8:30 am to 5 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
TDD: 1-866-248-0640, Monday through Friday, 8:30 am to 5 pm
Medicare HMO Pharmacy Line
(for providers and Medicare members excluding retirees and city, state and federal employees)
1-800-447-8255, Monday through Friday, 8 am to 8 pm
TDD: 1-888-447-4833, Monday through Friday, 8:30 am to 5 pm
GHI Customer Service
(for GHI retirees and city, state and federal employees)
1-800-624-2414, Monday through Friday, 8 am to 5 pm
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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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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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
www.emblemhealth.com.
• 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
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 PPO • Check eligibility at www.emblemhealth.com.
• Speak to a representative at 1-866-557-7300.
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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