GHI PPO/EPO and PPO/EPO Share - EmblemHealth

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Choosing Your Health Care ProvidersGreat Doctors. More Choices.At GHI, we know that nothing is more important than access to quality doctors and health carefacilities. That’s why we work hard to attract and keep the best doctors and hospitals in eachnetwork. You’ll find that your network includes:• More than half the Top Docs from New York magazine’s list and great hospitals like MemorialSloan-Kettering, Montefiore Medical Center, Lenox Hill Hospital, North Shore-Long IslandJewish Health System, and Albany Medical Center.• Access regionally to more than 92,000 doctors at more than 150,000 locations in New York, NewJersey and Connecticut, and to more than one million providers across all 50 states.To make it easy to find the right doctor near where you live and work, visit www.ghi.com 24/7 andclick on “Find a Doctor.”It’s Easy to “Find a Doctor” at www.ghi.com.All GHI Network Providers are listed on our Web site. Visit www.ghi.com and click on “Find aDoctor” to view the most up-to-date listing of GHI Network Providers.To use the system, enter your Member ID number in the box under “Already a GHI Customer?”and click “Next.” The system will then show what network you have access to. Follow theprompts to locate a provider by name or location. You can refine your search by distance, gender,language, office hours, and more. You can even get driving directions to the provider’s office.Click on a particular provider’s name to see all the networks that provider is affiliated with.Scheduling an Appointment With a Network ProviderWhen you schedule an appointment, you should always confirm that the provider participateswith GHI. The logos on your Member ID card may help you and your providerdetermine participation status. When making an appointment with a New Jersey provider,ask if the provider belongs to the QualCare network to verify that he or she is a GHI NetworkProvider. Similarly, when making an appointment with a Connecticut provider, ask if theprovider is in the MultiPlan network. When making an appointment with a provider locatedoutside the NY/NJ/CT area, ask if the provider is a GHI “CBP” provider or “MultiPlan”network provider.You can also call GHI at 1-212-501-4444 in New York City or 1-800-624-2414 outside theNew York City area for a listing of Network Providers.Back to Tableof ContentsDownloadClaim FormsRegister at ghi.comDirectory of HealthCare Providers8
Choosing Your Health Care ProvidersIn general, GHI defines a provider as a medical practitioner or facility recognized by GHI forreimbursement purposes. The section of this handbook entitled “Important Definitions” containsadditional details on how GHI defines a provider.Choosing Network Providers Cuts Expenses and PaperworkWhen you use a GHI Network Provider, you control your out-of-pocket expenses and avoid unnecessarypaperwork. GHI’s Network Providers have agreed to accept GHI’s allowances or negotiatedrates as payment in full for covered services.You pay only the applicable copayments, deductibles, and/or coinsurance for covered services, asdescribed in your Certificate of Insurance and Certificate Attachment. Plus, you do not file anyclaim forms when you use a Network Provider—that’s the provider’s responsibility.Your GHI health insurance program gives you direct and easy access to GHI’s extensive networkof participating physicians and other health care providers conveniently located where you liveand work. All GHI Network Providers must pass GHI’s rigorous credentialing process.The following provider types are part of GHI’s provider network:• Primary care physicians• Specialist physicians• Mental health and chemical dependency providers and facilities• Hospitals• Ancillary care providers• Vision care providers• Pharmacies nationwideNo Referral NeededYou are free to schedule an appointment with any Network Provider—including specialists—without a referral from your primary care physician. Please note that the GHI provider networkchanges over time. Before scheduling an appointment or receiving covered services, be sure toconfirm that the provider still participates in the GHI network selected for your program. GHIcannot guarantee the continued participation of a Network Provider or your acceptance as apatient by a particular Network Provider.Back to Tableof ContentsDownloadClaim FormsRegister at ghi.comDirectory of HealthCare Providers9
Page 1 and 2: This is your PPO/EPO andPPO/EPO Sha
Page 3 and 4: WelcomeThank You for Selecting GHI
Page 6 and 7: Types of Plans: PPO and EPOWhat Kin
Page 8 and 9: Member EligibilityDependent Childre
Page 12 and 13: Choosing Your Health Care Providers
Page 14 and 15: Claims and ReimbursementYour GHI Ex
Page 16 and 17: Claims and ReimbursementWhat You Pa
Page 18 and 19: Your BenefitsWhat Benefits Are Incl
Page 20 and 21: Your BenefitsDirect Access to Obste
Page 22 and 23: Utilization Management: How It CanA
Page 24 and 25: Coordinated CareSome Utilization Ma
Page 26 and 27: Coordinated CareGHI will notify you
Page 28 and 29: Filing a Grievance or AppealAppeali
Page 30 and 31: Filing a Grievance or AppealYou wil
Page 32 and 33: Member Rights and Responsibilities
Page 34 and 35: Member ServicesCall Member Services
Page 36 and 37: Important DefinitionsThis handbook
Page 38 and 39: Important Definitionspresent and on
Page 40 and 41: Important Definitions• A nurse mi
Page 42 and 43: Important Contact InformationHearin
Page 44 and 45: Important Contact InformationGHI Pr
Page 46 and 47: Employee Assistance Program (EAP)Yo
Page 48 and 49: Healthy DiscountsOffering Big Disco
Page 50 and 51: Health ManagerYour Personal “Heal
Page 52 and 53: GHI Notice of Privacy Practices--Gi
Page 54 and 55: GHI Notice of Privacy Practicesduly
Page 56 and 57: GHI Notice of Privacy Practicesonly

GHI PPO/EPO and PPO/EPO Share - EmblemHealth

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