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DIRECTORY TABLE OF CONTENTS . . . . . . . . . . . . . . . . . . . .HEADQUARTERS EMBLEMHEALTH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. . . . . . . . . . . . . . . . .SERVICE CUSTOMER . . . . . . . . . (PROVIDERS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. . . . . . . . . . . . CONTACTS CLAIMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. . . . . . . . . . . . . . PHARMACY CLINICAL . . . . . . . . . . . . . .SERVICES . . . . . . . . . . . (PRACTITIONERS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9. . . . . . . . . . . .PHARMACY RETAIL . . . . . . . . . . . . . SERVICES . . . . . . . . . . . (PHARMACIES) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9. . . . . . . . . . . . . . . . . . HEALTH BEHAVIORAL . . . . . . . . . .SERVICES . . . . . . . . . . . (PRACTITIONERS . . . . . . . . . . . . . . . . . . . AND . . . . . .MEMBERS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 .... . . . . . . .TO HOW . . . .OBTAIN . . . . . . . . .PRIOR . . . . . . . APPROVAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 .... . . . . . . . . . . . . . . . . SERVICES LABORATORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 .... . . . . . . . . . . CARE URGENT . . . . . . .CENTERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 .... . . . . . . . . . . . . . . . . GRIEVANCES, COMPLAINTS, . . . . . . . . . . . . . . . .AND . . . . . .APPEALS . . . . . . . . . .(PRACTITIONERS . . . . . . . . . . . . . . . . . . . AND . . . . . .MEMBERS) . . . . . . . . . . . . . . . . . . . . . . .14 .... . . . . . . . . . . . . . . . RESOURCES ADDITIONAL . . . . . . . . . . . . . . (PROVIDERS . . . . . . . . . . . . . . AND . . . . . .MEMBERS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 .... . . . . . . . . . . . . RESOURCES SELECTED . . . . . . . . . . . . . . FOR . . . . . MEMBERS . . . . . . . . . . . .WITH . . . . . . SPECIAL . . . . . . . . . .NEEDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 .... . . . . . . . . . . . .FOR SERVICES . . . . .THE . . . . .VISUALLY . . . . . . . . . . .IMPAIRED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 .... . . . . . . . . . . . . . . FOR RESOURCES . . . . . CHILDREN . . . . . . . . . . . . .WITH . . . . . . SPECIAL . . . . . . . . . .NEEDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 .... . . . . . . . . . . . . . .SERVICE CUSTOMER . . . . . . . . . (FOR . . . . . . MEMBERS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 .... . . . . . . . . . . . . . .SERVICES PHARMACY . . . . . . . . . . . (FOR . . . . . . MEMBERS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 .... Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 4 DIRECTORY This chapter contains contact information for parties within EmblemHealth, our delegated relationships and other external resources. EMBLEMHEALTH HEADQUARTERS EmblemHealth 55 Water Street New York, NY 10041-8190 CUSTOMER SERVICE (PROVIDERS) CUSTOMER SERVICE (PROVIDERS) EmblemHealth 1-877-842-3625, seven days a week (excluding major holidays), 8 am to 8 pm TTY/TDD: 711 All LOBs may be accessed through our message Center at www.emblemhealth.com EmblemHealth Medicare HMO 1-877-344-7364, seven days a week (excluding major holidays), 8 am to 8 pm TTY/TDD: 711 EmblemHealth Medicare PPO 1-866-557-7300, seven days a week (excluding major holidays), 8 am to 8 pm TTY/TDD: 711 GHI 1-800-624-2414, seven days a week (excluding major holidays), 8 am to 8 pm Also NYC: 1-212-501-4444 TTY/TDD: 711 GHI HMO 1-877-244-4466, seven days a week (excluding major holidays), 8 am to 8 pm TTY/TDD: 711 HIP and HIPIC 1-800-447-8255, seven days a week (excluding major holidays), 8 am to 8 pm HIP and EmblemHealth CompreHealth EPO 1-866-447-9717, Monday through Friday, 9 am to 5 pm Vytra 1-888-288-9872 Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 5 DIRECTORY CLAIMS CONTACTS CLAIMS CONTACTS Clearing House Submission Address Contact for Inquiries All claims (except 55247 anesthesiolog y) Emdeon or direct submission EmblemHealt h PO Box 2845 New York, NY 10116-2845 www.emblem health.com or 1-866-447-97 17 EmblemHealt h Anesthesiolog 55247 CompreHealt y claims h EPO Emdeon or direct submission EmblemHealt h PO Box 2787 New York, NY 10116-2787 www.emblem health.com or 1-866-447-97 17 55247 Emdeon or direct submission EmblemHealt h Medicare HMO PO Box 2803 New York, NY 10116-2830 www.emblem health.com or 1-866-447-97 17 13551 Emdeon or direct submission EmblemHealth Medicare PPO PO Box 2830 New York, NY 10116-2830 13551 Emdeon or direct submission EmblemHealt h www.emblem PO Box 2832 health.com New York, NY 10116-2832 13551 Emdeon or direct submission GHI Claims PO Box 2832 www.emblem New York, NY health.com 10116-2832 Emdeon or direct submission www.emblem health.com, 1-877-244-44 66 or: GHI HMO GHI HMO PO Box 2845 Attn: New York, NY Provider 10016 Corresponde nce PO Box 2844 New York, NY Plans Type of Claim EmblemHealt h CompreHealt h EPO EmblemHealt h Medicare All claims HMO EmblemHealth Medicare PPO All claims EmblemHealt All claims h EPO/PPO GHI (New York City and all other areas All claims outside of New York State) GHI HMO All claims EDI or Payor ID 25531 Back to Table of Contents www.emblem health.com EmblemHealth Provider Manual Last Updated: 09/03/2014 6 DIRECTORY CLAIMS CONTACTS Plans Type of Claim EDI or Payor ID Clearing House Submission Address Contact for Inquiries 10016-2844 HIP HIP Select Care Network-Based Plans Vytra All claims (except 55247 anesthesiolog y) Anesthesiolog 55247 y claims All claims All claims 55247 22264 GHI / Not EmblemHealt Dental claims applicable h Dental GHI GHI employee 13551 claims Montefiore CMO HIP and CompreHealt h EPO claims for members 13174 managed by Montefiore CMO Emdeon or direct submission HIP Health Plan of New York PO Box 2845 New York, NY 10116-2845 www.emblem health.com or 1-866-447-97 17 Emdeon or direct submission HIP Health Plan of New York PO Box 2787 New York, NY 10116-2787 www.emblem health.com or 1-866-447-97 17 Emdeon or direct submission EmblemHealt h PO Box 2845 New York, NY 10116-2845 www.emblemhe alth.com or 1-866-447-971 7 Emdeon or direct submission Vytra Health Plans Attn: Claims Department PO Box 9091 Melville, NY 11747-327 1-888-288-98 72 Direct submission www.emblem health.com or: GHI/Emblem Health Dental Claims PO Box 2838 New York, NY 10116 www.emblem health.com or 1-212-615-4E MC Emdeon or direct submission GHI Claims PO Box 2861 www.emblem New York, NY health.com 10116-2861 Web MD/NEIC CMO 200 Corporate Drive Yonkers, NY 10701 Back to Table of Contents 1-877HIP-MONTE (1-877-447-6 668) EmblemHealth Provider Manual Last Updated: 09/03/2014 7 DIRECTORY CLAIMS CONTACTS Plans Type of Claim EDI or Payor ID HealthCare Partners (HCP) HIP and CompreHealt h EPO claims 11328 for members managed by HCP Palladian Muscular Skeletal Health HIP professional claims for PT/OT services members managed by 37268 Palladian and claims billable under the Chiropractic program CareCore National, LLC HIP and GHI claims billable as part of the Radiology program 14182 Clearing House Submission Address Contact for Inquiries Web MD/Envoy HealthCare Partners Attn: Claims Department 501 Franklin Avenue Suite 300 Garden City, NY 11530-5807 1-516-746-22 00 or 1-888-746-22 00 Emdeon Palladian Health www.palladia PO Box 270 nhealth.com Lancaster, NY 14086 Emdeon/Rela y Health CareCore National LLC PO Box 61022 Anaheim, CA 92803 Back to Table of Contents 1-800-918-89 24 or fax: 1-843-815-65 79 EmblemHealth Provider Manual Last Updated: 09/03/2014 8 DIRECTORY CLINICAL PHARMACY SERVICES (PRACTITIONERS) CLINICAL PHARMACY SERVICES (PRACTITIONERS) EmblemHealth (all plans managed by EmblemHealth with the exception of City of New York) 1-877-362-5670, Monday through Friday, 8 am to 6 pm EmblemHealth (City of New York plans) 1-888-447-8175, Monday through Friday, 8 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) 1-877-866-5798 (all commercial members with the exception of City of New York) 1-877-534-3682 (City of New York commercial members) 1-800-585-5786 (City of New York Medicare members) 1-877-866-5828 (EmblemHealth Medicare HMO/PPO members) 1-877-866-4165 (EmblemHealth Medicaid members) 1-800-899-2114 (for users of TDD/TTY) 24 hours a day, 7 days a week Pharmacy Specialty Program 1-888-447-0295, Monday through Friday, 9 am to 5 pm ICORE 1-866-554-2673, Monday through Friday, 8 am to 7 pm RETAIL PHARMACY SERVICES (PHARMACIES) 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 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 Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 9 DIRECTORY BEHAVIORAL HEALTH SERVICES (PRACTITIONERS AND MEMBERS) 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. 2. 3. 4. 5. 6. 7. To check eligibility To check benefits To have a form faxed to you For authorization of outpatient services To review for inpatient or an alternative level of care To inquire about the status of your appeal or to schedule an appeal 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 HOW TO OBTAIN PRIOR APPROVAL HOW TO OBTAIN PRIOR APPROVAL Plan/Managing Entity Instructions Submit prior approval request after signing on to www.emblemhealth.com. Call IVR system at 1-866-447-9717 CompreHealth EPO, HIP and Medicare HMO 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 Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 10 DIRECTORY HOW TO OBTAIN PRIOR APPROVAL Plan/Managing Entity Instructions EmblemHealth Prior Authorization Department, call 1-866-447-9717. Specialists, facilities and ancillary providers must verify that prior approval has been issued by signing on to the secure provider Web site at www.emblemhealth.com, checking in the IVR system at 1-866-447-9717 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 outside 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.) 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. Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 11 DIRECTORY HOW TO OBTAIN PRIOR APPROVAL Plan/Managing Entity Instructions (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. 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 administered by VHMS) Call ValueOptions at 1-888-447-2526. EmblemHealth Behavioral Management Program (For members in plans underwritten Call ValueOptions at 1-800-692-2489. by GHI) Montefiore (For members in plans underwritten by HIP and administered by Montefiore) Call 1-800-401-4822. Cardiology and Radiology Services Call: CareCore National Radiology Cardiology 1-866-417-2345 (HIP and CompreHealth EPO) 1-800-835-7064 (GHI EPO/PPO, GHI HMO, and EmblemHealth EPO/PPO) Chiropractic Services Send all requests to Palladian via the Web at www.palladianhealth.com. Fax your request to Palladian at: 1-716-712-2802 (HIP and CompreHealth EPO) 1-716-712-2803 (Vytra ASO) 1-716-712-2817 (GHI EPO/PPO and GHI HMO and EmblemHealth EPO/PPO) All EmblemHealth plans 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 at www.palladianhealth.com. Or, your may fax your request to Palladian at 1-716-809-8324. You may also call 1-877-774-7693. Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 12 DIRECTORY LABORATORY 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 can be found at www.emblemhealth.com/~/media/Files /PDF/Providers/EH_Network_Laboratory_Services.pdf. 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 nearest 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 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 electronic 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 Long Island (Nassau and Suffolk Counties): Logistics department: 1-800-877-7588 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. To find a list of network urgent care centers, use the Find a Doctor tool on our website at www.emblemhealth.com/find-a-doctor. You may also call Member Customer Service to obtain this information. Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 13 DIRECTORY Vytra plan members should visit www.vytra.com or call Vytra's Customer Service line at 1-866-409-0999. For more information on urgent care centers, please visit the Urgent Care Centers section of the Care Management chapter. 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 ADDITIONAL RESOURCES (PROVIDERS AND MEMBERS) ADDITIONAL RESOURCES (PROVIDERS AND MEMBERS) Entity Address Phone E-mail/Comments 2732 Transit Road West Seneca, NY 14224 1-877-774-7693 www.palladianhealth. com Delegated for utilization management. 7400 Gaylord Parkway Frisco, NY 75034 Provider Relations: 1-800-290-0523 Member Services: 1-877-548-4447 www.careington.com Delegated for credentialing. 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 Member Services: 1-800-468-9868 www.healthplex.com Delegated for credentialing, utilization management and claims processing. 501 Franklin Ave. Suite 300 Garden City, NY General Line: 1-800-877-7587 Customer Service: Delegated for credentialing, utilization Chiropractic and Physical/Occupational Therapy Palladian Muscular Skeletal Health Dental Services Careington International Corp. (For HIP Preventive Dental) Healthplex (For HIP State Sponsored Programs and HIP Prime Dental Claims) Managing Entities HealthCare Partners (HCP) Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 14 DIRECTORY ADDITIONAL RESOURCES (PROVIDERS AND MEMBERS) Entity Address Phone E-mail/Comments 11530-5807 (Providers and Members): 1-516-746-2200 or 1-888-746-2200 management, claims processing and first call resolution. 100 Corporate Drive Yonkers, NY 10701 1-877-HIP-MONTE ( 1-877-447-6668 ) Delegated for credentialing, utilization management and claims processing. 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) Davis Vision (For GHI members only) 159 Express St. Plainview, NY 11803 1-800-999-5431 Delegated for credentialing and claims processing Comprehensive Professional Systems (For HIP members only) 11 Hanover Square New York, NY 10005 1-212-675-5745 EmblemHealth conducts claims processing Eye Care Advantage (For HIP members only) 1953 Grand Avenue Baldwin, NY 11510 1-516-623-3700 EmblemHealth conducts claims processing General Vision (For HIP members only) 520 Eighth Avenue New York, NY 10018 1-800-847-4661 EmblemHealth conducts claims processing 5850 T.G. Lee Blvd., Suite 510 Orlando, FL 32822 1-800-424-4088 Delegated for utilization management. Montefiore CMO Radiology Services CareCore National, LLC Vision Services Medical Injectables ICORE National, LLC 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 Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 15 DIRECTORY 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-profit organization, provides comprehensive social and rehabilitative 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 comfortable. F•E•G•S's Interpreter Referral Services provides skilled interpreters throughout the New York City metropolitan area in a wide range of settings. 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 Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 16 DIRECTORY Early Intervention Program (EIP) New York State law requires that all primary referral sources (e.g., primary care physicians (PCPs), specialists, hospitals, etc.) shall, within two working days of identifying 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 Intervention 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. Services 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. 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 Preschool 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. 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 provided by SSHSP providers approved by the Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 17 DIRECTORY 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 children 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 Treatment Program. Diagnostic services are available to all children who are believed to have physically disabling conditions or serious chronic illnesses. To receive diagnostic 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 transportation. 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 CUSTOMER SERVICE (FOR MEMBERS) CUSTOMER SERVICE (FOR MEMBERS) Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 18 DIRECTORY EmblemHealth 1-877-842-3625, seven days a week (excluding major holidays), 8 am to 8 pm TTY/TDD: 711 EmblemHealth Medicare HMO 1-877-344-7364, seven days a week (excluding major holidays), 8 am to 8 pm TTY/TDD: 711 EmblemHealth Medicare PPO 1-866-557-7300, seven days a week (excluding major holidays), 8 am to 8 pm TTY/TDD: 711 GHI EPO/PPO 1-800-624-2414, seven days a week (excluding major holidays), 8 am to 8 pm Also NYC: 1-212-501-4444 TTY/TDD: 711 GHI HMO 1-877-244-4466, seven days a week (excluding major holidays), 8 am to 8 pm TTY/TDD: 711 HIP and HIPIC 1-800-447-8255, seven days a week (excluding major holidays), 8 am to 8 pm Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 19 DIRECTORY PHARMACY SERVICES (FOR MEMBERS) 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 TTY/TDD: 711 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 TTY/TDD: 711 Medicare PPO Pharmacy Line (for providers and Medicare members excluding retirees and city, state and federal employees) 1-866-557-7300, Monday through Friday, 8 am to 8 pm TTY/TDD: 711 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 TTY/TDD: 711 GHI Customer Service (for GHI retirees and city, state and federal employees) 1-800-624-2414, Monday through Friday, 8 am to 5 pm If calling from New York City, members may also call 1-212-615-4444 TTY/TDD: 711 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) 711 (TTY/TDD 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. Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 20
