GHI PPO/EPO and PPO/EPO Share - EmblemHealth

Important Definitions• A nurse midwife• A certified and registered psychologist• A certified and qualified social worker• An optometrist• A nurse anesthetist• A speech therapist• An audiologist• A clinical laboratory• A screening center• A general hospital• Any other type of practitioner or facility specifically listed in your Certificate of Insurance as apractitioner or facility recognized by GHI for reimbursement purposesA provider must be licensed or certified to render the covered service. The covered service mustbe within the scope of the provider’s license or certification. Please note that not all services renderedby a specific class of providers listed above are reimbursable. In order for the treatment tobe reimbursable, the service rendered to you must be covered under your GHI Program and mustbe medically necessary. In addition, the practitioner or facility rendering the service must be listedin your Certificate of Insurance or this handbook as a provider who is recognized by GHI to renderthe covered service. Please refer to your Certificate of Insurance to determine if a service is covered.In any case, where the two documents conflict, the Certificate of Insurance will govern.Rider: A document that modifies a plan’s Certificate of Insurance and/or Certificate Attachment.Riders generally add or exclude coverage or amend the terms of existing coverage.Utilization Management: A review to determine whether covered services that have beenprovided or are proposed to be provided to you, whether undertaken prior to, concurrent with, orsubsequent to the delivery of such services, are medically necessary, experimental, or investigationalin nature.Utilization Management agent: Group Health Incorporated (“GHI”) or any Utilization Managementagent performing utilization management on our behalf.Utilization Management Appeal: The process by which you or your representative may requestreview of a denied service(s) based upon an Adverse Determination made by GHI or a UtilizationManagement agent acting on our behalf. An Adverse Determination is a denial by GHI of coveragefor services considered not medically necessary or experimental or investigational in nature.Back to Tableof ContentsDownloadClaim FormsRegister at ​ghi.comDirectory of HealthCare Providers38