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NYS Mandates
Delegated Entities
Grievance and Appeals
Member Billing
Pre Auth and referral
100
Name at least 3 type of New York State Mandates. C-MORE file is only in PowerPoint.
CME_158500 -NYS Diabetes mandate -Breast Pumps mandate -Women’s Preventive Services (WPS) Mandate. -Well Woman Mandate -Autism spectrum Disorder (ASD) Mandate -Timothy's law -NYS Ambulance Mandate -Enteral Mandate -Infertility Mandate
100
What is this type of HMO contracts with individual physicians to care for members in their own private offices and are free to contract with more than one plan.
IPA which stands for Independent Practice Association or Individual Physician’s Association CME_013145
100
What do you call a written request by a provider to reverse an initial adverse determination for an admission, extension of stay, or other health care service that was received?
Pay and educate
100
Can the member’s due date be changed?
No cmore 012005
100
A plan or managing entity Medical Director must approve standing referrals via the prior approval process
FALSE CME_025036
200
When is the effective date of Autism spectrum Disorder (ASD) Mandate?
November 1, 2012 Cmore#:024296
200
What are the CAIPA medical center number?
14PA and 14PY CME_013145
200
If a party want to file a complaint what are the 3 processes?
In Writing In person In telephone
200
If the caller is the parent or guardian of a Child Health Plus member, how long should they expect full processing of the application and the first debit to the bank account?
sixty (60) to ninety (90) days from the time the application is received cmore -013610
200
A PCP may refer members with chronic, disabling and/or degenerative conditions to a specialist for a set number of visits within a specified time period.
TRUE CME_025036
300
What do you call to something that refers to any pervasive developmental disorder as defined in the Diagnostic and Statistical Manual of Mental Disorders?
Autism Spectrum Disorder Cmore#024296
300
Who is EmblemHealth's radiology vendor contracted to provide comprehensive, customized diagnostic imaging management?
Evicore CME_013202
300
what is the HIP timeframe for the investigation and response for the complaint?
30 calendar days
300
How long do all Direct Pay bills go out?
two weeks before the 1st of the month cmore-012005
300
What is the maximum number of units and the visit duration of Radiation Therapy?
40 visits and 180 days CME_025036
400
How can you find the State Mandate reference documents in C-MORE?
Browse Content (No C-MORE document reference, you can test it in C-MORE) (^_^)b
400
Who do members contact for benefit information and HCP for claims, referrals and prior approval information when a member selects an HCP PCP?
EmblemHealth CME_158296
400
Is a verbal or written request to conduct an initial clinical review based on the claimant’s request that the denied services were medically necessary and emergent
Member Retrospective Utilization Review-
400
How long should we receive the initial premium for new HIX CHPlus members?
within 10 days of the month of coverage cmore-001651
400
This is a clinical description of medical services recommended by a referring physician.
SCRIPTS CME_025036
500
Is the Value plan and standardized Medicare supplement contracts under NYS Mandated Ambulance Coverage is covered?
C_more# 010009
500
What is the phone number of our delegated entity Orthonet?
1-888-678-4663 CME_013145
500
This is a verbal or written request from or on behalf of a Medicaid or Family Health Plus (FHP) member to review an action made by the plan.
Action Appeal
500
Until what time can members can hand-carry their payment into the Walk-In Unit?
no later than 4:55pm CME_012005
500
Why does the non-par provider contact EmblemHealth to establish a pre-cert notification if a member’s benefits include the entitlement of in-network and out-of-network services?
This is to ensure that the member does not receive a financial penalty for the service covered in accordance to the benefit plan. CME_025036