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This

Glossary

Care

Management

Prior

Approval

Procedures

Practitioners

and

Facilities

The

physician

or

organization

providing

or

requesting

the

service

is

responsible

for

obtaining

prior

approvals

As

part

of

an

ongoing

effort

to

decrease

physicians

administrative

burden

and

ensure

prompt

access

to

care

for

our

members

we

regularly

review

and

update

our

prior

approval

policies

Please

subscribe

to

this

chapter

and

its

sections

to

receive

email

notification

of

updates

The

following

require

prior

approval

for

all

members

unless

noted

otherwise

Standing

Referrals

A

PCP

may

refer

members

with

chronic

disabling

or

degenerative

conditions

or

diseases

to

a

specialist

for

a

set

number

of

visits

within

a

specified

time

period

An

EmblemHealth

or

managing

entity

medical

director

must

approve

standing

referrals

via

the

prior

approval

process

Specialists

as

PCPs

A

specialist

may

substitute

as

a

PCP

for

a

member

with

a

lifethreatening

condition

or

disease

or

degenerative

and

disabling

condition

or

disease

either

of

which

requires

specialized

medical

care

over

a

prolonged

period

of

time

when

authorized

by

the

managing

entitys

medical

director

Whenever

possible

the

specialist

who

will

be

acting

as

a

PCP

should

be

dually

boardcertified

A

treatment

plan

must

be

agreed

upon

among

the

PCP

the

managing

entitys

medical

director

and

the

specialist

Specialty

Care

Centers

A

member

with

a

lifethreatening

condition

or

disease

or

degenerative

and

disabling

condition

or

disease

either

of

which

requires

specialized

medical

care

over

a

prolonged

period

of

time

may

request

a

referral

to

a

specialty

care

center

Such

referral

will

require

prior

approval

by

the

managing

entitys

medical

director

A

treatment

plan

must

be

agreed

upon

among

the

PCP

the

managing

entitys

medical

director

and

the

provider

Use

of

OutofNetwork

Providers

All

requests

to

see

outofnetwork

providers

are

reviewed

against

the

members

benefits

the

plans

provider

network

and

the

medical

necessity

of

treatment

by

an

outofnetwork

provider

Members

with

a

Point

of

Service

PPO

or

Access

II

contract

may

elect

to

receive

specialty

care

from

an

outofnetwork

specialist

without

a

PCP

referral

if

they

elect

to

use

their

outofnetwork

benefits

including

appropriate

outofpocket

expenses

If

the

service

requires

prior

approval

the

member

is

responsible

for

obtaining

prior

approval

from

the

managing

entity

For

more

details

regarding

when

outofnetwork

providers

can

be

used

please

see

the

Commercial

Networks

Medicaid

Network

and

Medicare

Networks

sections

of

the

Provider

Networks

and

Member

Benefit

Plans

chapter

In

addition

see

the

Continuity

of

Care

Use

of

OutofNetwork

Provider

section

in

this

chapter

to

see

accommodations

that

will

be

made

for

new

members

Prior

approval

is

required

for

members

who

do

not

have

outofnetwork

benefits

Prior

approval

is

also

needed

for

referrals

to

an

outofnetwork

provider

when

a

network

does

not

include

an

available

provider

with

the

appropriate

training

and

experience

to

meet

the

needs

of

the

members

or

when

medically

necessary

services

are

not

available

through

network

providers

See

the

How

to

Obtain

a

Prior

Approval

section

of

this

chapter

for

more

information

on

how

to

request

prior

approval

If

a

specialist

is

not

available

in

the

network

and

prior

approval

has

been

granted

by

the

managing

entity

listed

on

the

members

ID

card

the

member

may

receive

care

from

an

outofnetwork

specialist

at

no

additional

cost

to

the

member

For

Medically

Fragile

Children

and

foster

children

EmblemHealth

will

authorize

services

in

accordance

with

established

time

frames

in

the

Medicaid

Managed

Care

Model

Contract

OHIP

Principles

for

Medically

Fragile

Children

Under

EPSDT

HCBS

and

CFCO

rules

and

with

consideration

for

extended

discharge

planning

EmblemHealth

will

execute

Single

Case

Agreements

SCAs

with

nonparticipating

providers

to

meet

clinical

needs

of

children

when

innetwork

services

are

not

available

EmblemHealth

will

pay

at

least

the

FFS

fee

schedule

for

months

for

all

SCAs

Submitting

an

Compliant

Prior

Approval

or

Referral

Request

When

submitting

a

prior

approval

or

referral

request

use

the

date

that

you

are

entering

the

prior

approval

or

referral

request

NOT

the

date

of

service

to

determine

whether

to

use

or

codes

Unless

there

are

any

new

CMS

guidelines

the

following

requirements

apply

with

no

exceptions

For

prior

approval

or

referral

requests

entered

before

October

use

codes

only

Those

submitted

with

codes

will

not

be

accepted

and

must

be

modified

to

use

codes

For

prior

approval

or

referral

requests

entered

on

or

after

October

use

codes

only

Those

submitted

with

codes

will

not

be

accepted

and

must

be

modified

to

use

codes

Prior

approval

or

referral

requests

submitted

with

a

combination

of

and

codes

will

not

be

accepted

and

must

be

modified

to

use

either

or

codes

based

on

date

of

entry

of

prior

approval

request

For

more

information

on

submitting

compliant

claims

please

see

the

Claims

chapter

ContinuityTransition

of

Care

New

Members

Upon

enrollment

the

member

shall

select

a

PCP

from

whom

the

member

may

request

continuation

of

care

When

appropriate

EmblemHealth

will

permit

new

members

to

continue

seeing

their

current

outofnetwork

practitioner

for

up

to

days

or

as

otherwise

required

to

accommodate

the

needs

of

medically

fragile

children

and

foster

children

covered

by

Medicaid

If

on

the

effective

date

of

enrollment

a

member

has

a

lifethreatening

disease

or

condition

or

a

degenerative

and

disabling

disease

or

condition

the

member

may

continue

to

see

their

current

outofnetwork

practitioner

for

up

to

days

In

the

case

of

pregnancy

if

the

member

has

entered

into

her

second

trimester

she

may

continue

to

see

the

nonparticipating

practitioner

through

delivery

and

postpartum

care

for

up

to

days

for

care

related

to

the

delivery

for

Medicaid

members

All

transitions

of

care

and

continuity

of

services

must

be

reviewed

and

approved

by

EmblemHealth

or

the

members

assigned

managing

entity

A

condition

in

the

midst

of

ongoing

course

of

treatment

with

an

outofnetwork

provider

Second

and

third

trimester

of

pregnancy

up

to

days

postpartum

directly

related

to

the

delivery

for

Medicaid

members

If

transitions

of

care

andor

continuity

of

care

is

approved

it

will

be

for

a

period

of

up

to

days

from

the

effective

date

of

enrollment

when

the

eligibility

criteria

are

met

A

single

case

agreement

for

continued

services

with

an

outofnetwork

health

care

provider

must

be

agreed

upon

by

EmblemHealth

and

the

provider

The

provider

must

do

all

of

the

following

Accept

our

reimbursement

rates

as

payment

in

full

Adhere

to

our

Quality

Improvement

program

Provide

medical

information

related

to

the

enrollees

care

Otherwise

adhere

to

our

policies

and

procedures

including

those

regarding

referrals

and

obtaining

prior

approvals

and

a

treatment

plan

approved

by

our

applicable

Prior

Authorization

department

See

the

How

to

Obtain

Prior

Approval

section

in

this

chapter

This

transitional

method

does

not

require

EmblemHealth

to

provide

coverage

for

benefits

not

otherwise

covered

or

diminish

or

impair

preexisting

condition

limitations

contained

in

the

member

agreement

ContinuityTransition

of

Care

Benefits

Exhausted

or

Ended

We

collaborate

with

the

members

and

their

providers

and

practitioners

to

assure

that

members

receive

the

services

needed

within

the

benefit

limitations

of

their

contracts

When

benefits

end

for

members

the

Utilization

Management

department

will

assist

if

applicable

in

the

transition

of

their

care

Continuity

of

Care

When

Providers

Leave

the

Network

When

a

members

health

care

practitioner

leaves

EmblemHealth

the

member

will

be

given

the

option

of

continuing

an

ongoing

course

of

treatment

with

his

or

her

current

practitioner

for

a

transitional

period

of

up

to

days

If

the

member

has

entered

the

second

trimester

of

pregnancy

the

transitional

period

includes

the

provision

of

postpartum

care

through

days

postpartum

directly

related

to

the

delivery

Members

who

wish

to

continue

seeing

their

current

health

care

practitioner

for

a

limited

time

must

contact

or

have

their

provider

contact

the

appropriate

Anticipated

Care

department

see

the

How

to

Obtain

Prior

Approval

section

in

this

chapter

EmblemHealth

will

permit

a

member

to

continue

with

their

current

practitioner

as

long

as

the

reason

for

leaving

is

not

related

to

imminent

harm

to

patients

to

a

determination

of

fraud

or

to

a

final

disciplinary

action

by

a

state

licensing

board

that

impairs

the

health

professionals

ability

to

practice

The

practitioner

must

agree

to

all

of

the

following

Continue

to

accept

reimbursement

at

the

rates

applicable

prior

to

the

start

of

the

transitional

period

as

payment

in

full

Adhere

to

EmblemHealths

quality

assurance

requirements

and

provide

us

with

necessary

medical

information

related

to

such

care

Otherwise

adhere

to

our

policies

which

include

but

are

not

limited

to

procedures

regarding

referrals

obtaining

prior

approval

for

services

and

obtaining

an

approved

treatment

plan

Services

That

Require

Approval

for

HIP

Network

Plans

On

July

a

revised

prior

approval

list

went

into

effect

for

benefit

plans

in

the

following

networks

Enhanced

Care

Prime

Network

HIP

Premium

Network

HIP

Prime

Network

NY

Metro

Network

Retired

August

Select

Care

Network

VIP

Prime

Network

Vytra

Network

What

requires

prior

approval

Services

that

require

prior

approval

are

now

consistent

for

the

networks

listed

above

unless

the

service

is

not

covered

by

the

members

benefit

plan

When

submitting

a

prior

approval

request

there

may

be

minor

exceptions

in

timing

for

example

the

number

of

referral

visits

allowed

before

a

prior

approval

request

must

be

made

A

Prior

Approval

Lookup

Tool

to

simplify

determination

of

what

procedures

need

preservice

review

and

approval

became

operational

on

January

Sign

in

to

our

secure

website

to

access

the

Lookup

Tool

Who

conducts

the

preservice

review

Preservice

reviews

are

administered

by

the

managing

entity

on

the

member

ID

card

or

by

the

vendor

managing

a

utilization

program

on

our

behalf

The

following

services

require

prior

approval

in

accordance

with

the

members

benefit

plan

All

inpatient

confinements

Emergency

admissions

Elective

hospital

admissions

Skilled

nursing

facility

admissions

Rehabilitation

facility

admissions

Inpatient

hospice

admission

Services

and

procedures

provided

in

an

ambulatory

or

outpatient

surgery

center

For

exceptions

effective

June

see

Services

That

Do

Not

Require

Prior

Approval

All

procedures

outpatient

ambulatory

surgery

and

inpatient

that

require

an

assistant

surgeon

or

cosurgeon

Reconstructive

surgery

or

other

procedures

that

may

be

considered

cosmetic

including

but

not

limited

to

Blepharoplastycanthopexycanthoplasty

Breast

reconstructionbreast

enlargement

Breast

reductionmammoplasty

Cervicoplasty

Chemical

peels

Cosmetic

procedures

see

EmblemHealths

cosmetic

surgery

procedures

medical

policy

located

in

Clinical

Corner

under

Provider

Resources

Excision

of

excessive

skin

due

to

weight

loss

Gastroplastygastric

bypass

Gender

reassignment

surgery

Hair

transplant

Injection

of

filling

material

Lipectomy

or

excess

fat

removal

Otoplasty

Pectus

excavatum

repair

Rhinoplastyrhytidectomy

Surgical

treatment

of

gynecomastia

Sclerotherapy

or

surgery

for

varicose

veins

Outpatient

cardiac

and

pulmonary

rehabilitation

Nonemergent

services

when

rendered

by

nonparticipating

providers

in

accordance

with

the

members

benefit

plan

All

procedures

considered

experimental

and

investigational

see

the

EmblemHealth

Medical

Technologies

Database

located

in

Clinical

Corner

under

Provider

Resources

All

home

health

care

services

including

home

uterine

monitoring

home

hospice

and

home

sleep

study

services

Home

infusion

therapy

Some

types

of

durable

medical

equipment

DME

see

Durable

Medical

Equipment

chapter

Dental

implants

and

oral

appliances

Elective

nonemergent

transportation

by

ambulance

ambulette

or

medical

van

and

all

transfers

via

air

ambulance

see

the

Medical

Transportation

Procedures

chapter

Genetic

testing

including

BRCA

and

BRCA

GeneticBRAC

Analysis

Rearrangement

Testing

BART

Genetic

testing

for

colorectal

cancer

Genetic

testing

for

long

QT

syndrome

Genetic

testing

BRAC

Analysis

Rearrangement

Testing

BART

Genetic

testing

comparative

genomic

hybridization

CGH

microarray

for

chromosomal

imbalance

various

manufacturers

Genetic

testing

cystic

fibrosis

Genetic

testing

familial

hypertrophic

cardiomyopathy

Genetic

testing

KRAS

sequence

variant

analysis

for

predicting

response

to

colorectal

cancer

drug

therapy

Assisted

reproductive

infertility

treatments

including

preimplantation

genetic

testing

All

major

organ

transplant

evaluations

and

transplants

including

but

not

limited

to

kidney

liver

heart

lung

and

pancreas

and

bone

marrow

replacement

and

stem

cell

transfer

after

highdose

chemotherapy

Services

covered

by

vendoradministered

utilization

programs

which

may

require

prior

approval

See

Prior

Approval

Requests

for

VendorAdministered

Utilization

Management

Programs

for

services

and

entities

responsible

for

authorizing

services

All

inpatient

behavioral

health

services

for

psychiatric

care

including

alcohol

and

substance

abuse

detoxification

and

rehabilitation

see

the

Behavioral

Health

Services

chapter

Chiropractic

services

see

the

Chiropractic

Program

chapter

Outpatient

PTOT

see

the

Physical

Therapy

and

Occupational

Therapy

chapter

Outpatient

diagnostic

radiology

services

see

the

Radiology

Program

and

Cardiology

Imaging

Program

chapters

Radiation

therapy

see

the

Radiation

Therapy

Program

chapter

Specialty

drugs

see

the

Injectables

and

Specialty

Pharmacy

Program

chapter

Spine

surgery

and

pain

management

therapies

see

the

EmblemHealth

Spine

Surgery

and

Pain

Management

Therapies

Program

chapter

Prior

approval

is

not

required

for

emergency

admissions

However

EmblemHealth

must

be

notified

within

hours

The

services

will

be

reviewed

for

medical

necessity

following

notification

and

submission

of

clinical

information

Services

That

Require

Prior

Approval

for

EmblemHealth

EPOPPO

All

nonemergency

inpatient

hospital

admissions

acute

rehabilitation

behavioral

health

and

skilled

nursing

facility

care

Assistant

surgeon

does

not

apply

to

Medicare

members

Prior

approval

should

be

requested

at

the

time

the

surgery

is

authorized

to

determine

the

necessity

of

the

request

Services

and

procedures

provided

in

an

ambulatory

or

outpatient

surgery

center

For

exceptions

effective

July

see

Services

That

Do

Not

Require

Prior

Approval

Air

ambulance

Land

ambulance

nonemergent

Ambulette

Diagnostic

heart

catheterization

contact

eviCore

at

Durable

medical

equipment

customized

or

rental

See

the

Durable

Medical

Equipment

chapter

for

more

information

Note

Prior

approval

required

only

for

DME

in

excess

of

for

Medicare

Advantage

Home

health

care

nursing

PT

OT

ST

home

infusion

therapy

Hospice

covered

under

Medicaid

Managed

Care

and

traditional

Medicare

Prior

approval

requirement

does

not

apply

to

Medicare

Advantage

Hyperbaric

oxygen

therapy

Lymphedema

therapy

Midwifery

services

Neuropsychological

and

psychological

testing

Outpatient

cardiac

and

pulmonary

rehabilitation

Podiatry

procedures

hammer

toe

repair

hallux

valgas

correction

excision

of

Mortons

neuroma

resection

of

calcaneal

spurplantar

fasciotomy

resection

of

Haglunds

deformity

Radiation

therapy

see

the

Radiation

Therapy

Program

chapter

for

more

information

Skilled

nursing

facility

admissions

Sleep

studies

Subacute

behavioral

health

services

partial

hospitalization

ambulatory

detoxification

outpatient

electroconvulsive

therapy

Transplant

evaluation

and

services

Services

covered

by

vendoradministered

utilization

programs

which

may

require

prior

approval

See

Prior

Approval

Requests

for

VendorAdministered

Utilization

Management

Programs

for

services

and

entities

responsible

for

authorizing

services

All

inpatient

behavioral

health

services

for

psychiatric

care

including

alcohol

and

substance

abuse

detoxification

and

rehabilitation

see

the

Behavioral

Health

Services

chapter

Chiropractic

services

see

the

Chiropractic

Program

chapter

Outpatient

PTOT

see

the

Physical

Therapy

and

Occupational

Therapy

chapter

Outpatient

diagnostic

radiology

services

see

the

Radiology

Program

and

Cardiology

Imaging

Program

chapters

Radiation

therapy

see

the

Radiation

Therapy

Program

chapter

Any

prosthetic

orthotic

or

equipment

that

must

be

designed

and

built

to

meet

the

specific

needs

of

a

patient

eg

power

wheelchairs

braces

prosthetic

limbs

Please

note

that

mastectomy

supplies

HCPCS

codes

and

do

not

require

prior

approval

Any

equipment

intended

for

shortterm

home

use

eg

oxygen

and

its

delivery

devices

hospital

beds

wheelchairs

and

scooters

In

general

Medicare

coverage

rules

apply

Prior

Approval

Requests

for

VendorAdministered

Utilization

Management

Programs

EmblemHealth

has

engaged

a

number

of

vendors

to

conduct

utilization

management

for

certain

segments

of

our

member

populations

Full

descriptions

may

be

found

in

the

following

chapters

Cardiology

Imaging

Program

Chiropractic

Program

Injectables

and

Specialty

Pharmacy

Program

Physical

and

Occupational

Therapy

Program

Radiation

Therapy

Program

Radiology

Program

If

a

member

is

not

covered

by

the

vendor

program

prior

approval

must

be

obtained

from

the

managing

entity

indicated

on

the

members

ID

card

or

on

our

website

Prior

Approval

for

Procedures

Supplies

and

Drugs

for

Erectile

Dysfunction

Treatment

In

May

the

NYSDOH

suspended

all

coverage

for

erectile

dysfunction

ED

prescription

drugs

for

the

Medicaid

and

Healthy

New

York

programs

as

well

as

for

direct

pay

members

Effective

February

health

plans

were

required

to

employ

procedures

attendant

to

legislation

to

exclude

from

coverage

procedures

and

supplies

for

the

treatment

of

ED

for

sex

offenders

enrolled

in

Medicaid

No

guidance

has

been

received

from

the

New

York

State

Department

of

Financial

Services

NYSDFS

on

how

the

ED

ban

will

be

implemented

for

the

Healthy

New

York

program

or

direct

pay

members

Medicaid

members

may

be

prescribed

ED

drugs

approved

by

the

FDA

for

the

treatment

of

nonEDrelated

conditions

In

these

cases

use

of

ED

drugs

may

be

approved

but

only

if

The

member

is

not

on

the

Sex

Offender

Registry

The

Prior

Approval

Request

outlined

below

is

followed

The

NYSDOH

created

a

prior

approval

program

for

Medicaid

members

for

the

provision

of

ED

procedures

and

supplies

so

that

the

members

eligibility

can

be

confirmed

The

physician

must

submit

a

prior

approval

request

to

EmblemHealth

or

to

the

entity

listed

on

the

back

of

the

members

ID

card

for

the

excluded

ED

services

A

prior

approval

clinical

manager

or

a

designated

prior

approval

nurse

will

send

an

inquiry

to

the

NYSDOH

for

confirmation

of

the

members

eligibility

to

receive

the

requested

procedures

and

supplies

If

the

NYSDOH

response

acknowledges

the

members

eligibility

the

request

will

be

reviewed

for

medical

necessity

If

appropriate

a

physicians

prior

approval

PPA

number

is

issued

Once

the

physician

has

obtained

prior

approval

the

member

can

obtain

the

service

requested

If

the

request

is

denied

because

it

is

deemed

medically

unnecessary

a

medical

necessity

denial

letter

will

be

sent

to

the

physicianmember

If

the

NYSDOH

response

acknowledges

that

the

member

is

not

eligible

for

coverage

the

case

will

be

denied

as

not

a

covered

benefit

and

the

physicianmember

will

receive

a

benefit

denial

letter

The

practitionermember

has

the

right

to

appeal

and

the

right

to

request

a

fair

hearing

and

an

external

appeal

if

the

service

request

is

denied

for

any

reason

Go

to

the

NYSDOHs

website

to

obtain

more

information

regarding

the

procedures

that

require

prior

approval

Prior

Approval

for

Anticipated

Care

of

Maternity

Patients

The

OBGYN

physicians

office

must

notify

EmblemHealths

Prior

Authorization

department

or

the

managing

entity

listed

on

the

members

ID

card

of

the

estimated

date

of

confinement

EDC

of

maternity

patients

after

the

first

prenatal

visit

so

a

prior

approval

can

be

recorded

This

notification

is

the

responsibility

of

the

OBGYN

physicians

office

Once

the

member

has

delivered

it

is

the

facilitys

responsibility

to

notify

the

plan

or

the

managing

entity

of

the

actual

delivery

It

is

the

responsibility

of

the

admitting

facility

to

notify

the

plan

of

all

emergency

admissions

Prior

Approval

for

Midwifery

Services

The

services

of

a

midwife

are

covered

for

all

our

benefit

plans

Prior

approval

is

required

for

all

HIP

CompreHealth

EPO

Retired

August

Medicare

HMO

and

GHI

HMO

lines

of

business

For

GHI

PPO

EmblemHealth

EPOPPO

ConsumerDirect

and

InBalance

plans

Vytra

ASO

plans

and

the

Vytra

plan

for

the

City

of

New

York

prior

approval

is

only

required

if

the

midwife

is

not

a

plan

participant

Note

If

a

provider

and

a

midwife

bill

for

the

same

services

on

the

same

dates

only

the

first

claim

submitted

will

be

adjudicated

and

the

second

claim

will

be

treated

as

a

duplicate

submission

See

Midwifery

Services

in

the

Credentialing

chapter

Additional

Prior

Approval

Procedures

for

GHI

Practitioners

Where

possible

prior

approval

requests

should

be

made

on

the

secure

provider

website

at

wwwemblemhealthcom

otherwise

the

written

request

must

document

needed

identification

information

Depending

on

the

complexity

of

the

request

clinical

information

sufficient

to

make

a

medical

necessity

determination

should

be

documented

In

most

cases

a

copy

of

a

recent

office

note

or

consultation

summarizing

the

medical

needs

of

your

patient

will

help

us

rapidly

process

the

request

Information

that

can

facilitate

prior

approval

determinations

includes

the

following

elements

as

relevant

to

each

individual

case

Patient

characteristics

such

as

age

gender

height

weight

vital

signs

or

other

historical

and

physical

findings

pertinent

to

the

condition

proposed

for

treatment

Precise

information

confirming

the

diagnosis

or

indication

for

the

proposed

medical

service

Details

of

treatment

for

the

index

condition

or

any

related

condition

including

names

doses

and

duration

of

treatment

for

pharmacotherapy

andor

detailed

surgical

notes

for

surgical

therapy

Appropriate

laboratory

or

radiology

results

Office

or

consultation

notes

related

to

the

proposed

medical

service

Peerreviewed

medical

literature

national

guidelines

or

consensus

statements

of

relevant

expert

panels

Applicable

and

ICD

diagnosis

codes

Complete

facility

and

service

information

Note

diagnosis

codes

were

implemented

in

our

systems

effective

October

Services

That

Do

Not

Require

Prior

Approval

Effective

November

CPT

Codes

That

Do

Not

Require

Prior

Approval

Effective

November

CPT

Code

CPT

Description

Place

of

Service

POS

anesth

n

blockinj

prone

fna

wo

image

implant

hormone

pellets

tis

trnfr

fccmnaghf

tis

trnfr

fccmnaghf

mohs

stage

hnhfg

removal

of

breast

lesion

partial

mastectomy

pmastectomy

wln

removal

mast

simple

complete

exc

neck

tum

deep

cm

remove

wrist

tendon

lesion

incise

finger

tendon

sheath

strapping

of

ankle

andor

ft

shoulder

arthroscopysurgery

shoulder

arthroscopysurgery

shoulder

arthroscopysurgery

shoulder

arthroscopysurgery

autgrft

implnt

knee

wscope

knee

arthroscopysurgery

knee

arthroscopysurgery

knee

arthroscopysurgery

resect

inferior

turbinate

ablate

inf

turbinate

submuc

removal

of

ethmoid

sinus

larynscop

wtumr

exc

scope

diagnostic

laryngoscopy

endobronchial

us

addon

dx

bronchoscopewash

bronchoscopy

wbiopsys

bronchoscopylung

bx

each

percut

bx

lungmediastinum

place

catheter

in

artery

ins

cath

abdlext

art

routine

venipuncture

insert

picc

cath

removal

tunneled

cv

cath

removal

tunneled

cv

cath

embolization

uterine

fibroid

fempopl

revas

wather

bone

marrow

aspiration

bone

marrow

biopsy

biopsyremoval

lymph

nodes

ra

tracer

id

of

sentinl

node

io

map

of

sent

lymph

node

removal

of

tonsils

removal

of

adenoids

lap

rmvl

gastr

adj

all

parts

surg

dx

exam

anorectal

remove

inex

hem

groups

needle

biopsy

of

liver

laparo

cholecystectomygraph

diag

laparo

separate

proc

prp

ihern

init

reduc

yr

rpr

ventral

hern

init

reduc

hernia

repair

wmesh

lap

ing

hernia

repair

init

lap

ventabd

hernia

repair

renal

biopsy

perq

injection

for

bladder

xray

insert

bladder

catheter

cystometrogram

wvp

cystometrogram

wvpup

electrouroflowmetry

first

us

urine

capacity

measure

cystoscopy

ureter

catheter

cystoscopy

wbiopsys

cystoscopy

and

treatment

cystoscopy

and

treatment

cystoscopy

and

treatment

cystouretero

or

pyeloscope

cystouretero

wlithotripsy

circum

days

or

older

excise

lesion

testis

suspension

of

testis

removal

of

hydrocele

removal

of

sperm

ducts

revise

spermatic

cord

veins

exam

of

vulva

wscope

repair

bladder

defect

bxcurett

of

cervix

wscope

endocervical

curettage

conization

of

cervix

biopsy

of

uterus

lining

dilation

and

curettage

catheter

for

hysterography

reopen

fallopian

tube

endometr

ablate

thermal

hysteroscopy

biopsy

hysteroscopy

remove

myoma

hysteroscopy

ablation

hysteroscopy

sterilization

laparoscopy

remove

adnexa

laparoscopy

excise

lesions

laparoscopy

tubal

cautery

laparoscopy

tubal

block

removal

of

ovarian

cysts

chorion

biopsy

obstetrical

care

abortion

abortion

biopsy

of

thyroid

removal

of

thyroid

scan

proc

cranial

extra

spinal

fluid

tap

diagnostic

low

back

disk

surgery

destroy

nerve

neck

muscle

revise

armleg

nerve

carpal

tunnel

surgery

internal

nerve

revision

corneal

trnspl

endothelial

prep

corneal

endo

allograft

incise

inner

eye

adhesions

implant

eye

shunt

after

cataract

laser

surgery

removal

of

lens

lesion

cataract

surgery

complex

revise

two

eye

muscles

revise

eye

muscle

revise

eye

muscles

revise

eye

muscles

addon

repair

tear

ducts

probe

nasolacrimal

duct

create

eardrum

opening

microsurgery

addon

new

eye

exam

treatment

cmptr

ophth

img

optic

nerve

cptr

ophth

dx

img

post

segmt

oral

function

therapy

tympanometry

reflex

thresh

acoustic

immitance

testing

eval

aud

rehab

status

cardioversion

electric

ext

insert

intracoronary

stent

electrocardiogram

complete

cardiovascular

stress

test

ecg

monitreprt

up

to

hrs

right

heart

cath

left

hrt

cath

wventrclgrphy

ablate

heart

dysrhythm

focus

ablate

heart

dysrhythm

focus

tilt

table

evaluation

intracardiac

ecg

ice

lower

extremity

study

vascular

study

vascular

study

penile

vascular

study

respiratory

flow

volume

loop

exhaled

air

analysis

pulm

function

test

by

gas

hot

or

cold

packs

therapy

Diab

manage

trn

per

indiv

Removal

of

impacted

wax

md

Arthro

loose

body

chondro

POS

Office

POS

Home

POS

Inpatient

hospital

POS

Outpatient

hospital

POS

Ambulatory

surgical

center

CPT

Codes

That

Do

Not

Require

Prior

Approval

this

list

is

retired

as

of

Nov

CPT

Code

CPT

Description

Place

of

Service

POS

anesth

n

blockinj

prone

fna

wo

image

implant

hormone

pellets

tis

trnfr

fccmnaghf

tis

trnfr

fccmnaghf

mohs

stage

hnhfg

removal

of

breast

lesion

partial

mastectomy

pmastectomy

wln

removal

mast

simple

complete

exc

neck

tum

deep

cm

remove

wrist

tendon

lesion

incise

finger

tendon

sheath

strapping

of

ankle

andor

ft

shoulder

arthroscopysurgery

shoulder

arthroscopysurgery

shoulder

arthroscopysurgery

shoulder

arthroscopysurgery

shoulder

arthroscopysurgery

arthroscop

rotator

cuff

repr

autgrft

implnt

knee

wscope

knee

arthroscopysurgery

knee

arthroscopysurgery

knee

arthroscopysurgery

resect

inferior

turbinate

ablate

inf

turbinate

submuc

removal

of

ethmoid

sinus

larynscop

wtumr

exc

scope

diagnostic

laryngoscopy

endobronchial

us

addon

dx

bronchoscopewash

bronchoscopy

wbiopsys

bronchoscopylung

bx

each

percut

bx

lungmediastinum

place

catheter

in

artery

ins

cath

abdlext

art

ins

cath

abdlext

art

routine

venipuncture

insert

picc

cath

removal

tunneled

cv

cath

removal

tunneled

cv

cath

embolization

uterine

fibroid

iliac

revasc

wstent

fempopl

revas

wtla

fempopl

revas

wather

fempopl

revasc

wstent

fempopl

revasc

stnt

ather

bone

marrow

aspiration

bone

marrow

biopsy

biopsyremoval

lymph

nodes

biopsyremoval

lymph

nodes

ra

tracer

id

of

sentinl

node

io

map

of

sent

lymph

node

removal

of

tonsils

removal

of

adenoids

lap

rmvl

gastr

adj

all

parts

surg

dx

exam

anorectal

remove

inex

hem

groups

needle

biopsy

of

liver

laparoscopic

cholecystectomy

laparo

cholecystectomygraph

diag

laparo

separate

proc

prp

ihern

init

reduc

yr

rpr

ventral

hern

init

reduc

hernia

repair

wmesh

rpr

umbil

hern

reduc

yr

lap

ing

hernia

repair

init

lap

ventabd

hernia

repair

renal

biopsy

perq

fragmenting

of

kidney

stone

injection

for

bladder

xray

insert

bladder

catheter

cystometrogram

wvp

cystometrogram

wvpup

electrouroflowmetry

first

us

urine

capacity

measure

cystoscopy

cystoscopy

ureter

catheter

cystoscopy

wbiopsys

cystoscopy

and

treatment

cystoscopy

and

treatment

cystoscopy

and

treatment

cystouretero

or

pyeloscope

cystouretero

wlithotripsy

circum

days

or

older

excise

lesion

testis

suspension

of

testis

removal

of

hydrocele

removal

of

sperm

ducts

revise

spermatic

cord

veins

biopsy

of

prostate

exam

of

vulva

wscope

repair

bladder

defect

bxcurett

of

cervix

wscope

endocervical

curettage

conization

of

cervix

biopsy

of

uterus

lining

dilation

and

curettage

catheter

for

hysterography

reopen

fallopian

tube

endometr

ablate

thermal

hysteroscopy

biopsy

hysteroscopy

remove

myoma

hysteroscopy

ablation

hysteroscopy

sterilization

laparoscopy

remove

adnexa

laparoscopy

excise

lesions

laparoscopy

tubal

cautery

laparoscopy

tubal

block

removal

of

ovarian

cysts

chorion

biopsy

obstetrical

care

abortion

abortion

biopsy

of

thyroid

removal

of

thyroid

scan

proc

cranial

extra

spinal

fluid

tap

diagnostic

low

back

disk

surgery

destroy

nerve

neck

muscle

revise

armleg

nerve

carpal

tunnel

surgery

internal

nerve

revision

corneal

trnspl

endothelial

prep

corneal

endo

allograft

incise

inner

eye

adhesions

implant

eye

shunt

after

cataract

laser

surgery

removal

of

lens

lesion

cataract

surgery

complex

reinforcegraft

eye

wall

revise

two

eye

muscles

revise

eye

muscle

revise

eye

muscles

revise

eye

muscles

addon

repair

tear

ducts

probe

nasolacrimal

duct

create

eardrum

opening

microsurgery

addon

new

eye

exam

treatment

cmptr

ophth

img

optic

nerve

cptr

ophth

dx

img

post

segmt

oral

function

therapy

tympanometry

reflex

thresh

acoustic

immitance

testing

eval

aud

rehab

status

cardioversion

electric

ext

insert

intracoronary

stent

electrocardiogram

complete

cardiovascular

stress

test

ecg

monitreprt

up

to

hrs

right

heart

cath

left

hrt

cath

wventrclgrphy

l

hrt

artgrft

angio

rl

hrt

artventricle

angio

ablate

heart

dysrhythm

focus

ablate

heart

dysrhythm

focus

ablate

heart

dysrhythm

focus

tilt

table

evaluation

intracardiac

ecg

ice

intracranial

complete

study

lower

extremity

study

vascular

study

vascular

study

penile

vascular

study

respiratory

flow

volume

loop

exhaled

air

analysis

pulm

function

test

by

gas

therprophdiag

iv

inf

init

chemo

iv

infusion

addl

hr

hot

or

cold

packs

therapy

Diab

manage

trn

per

indiv

Removal

of

impacted

wax

md

Arthro

loose

body

chondro

POS

Office

POS

Home

POS

Inpatient

hospital

POS

Outpatient

hospital

POS

Ambulatory

surgical

center

Other

Services

That

Do

Not

Require

Prior

Approval

Mastectomy

supplies

The

following

services

performed

in

a

provider

office

or

outpatient

facility

Place

of

Service

Office

outpatient

and

ambulatory

surgery

center

Referral

rules

for

initial

specialty

care

office

visits

still

apply

for

those

members

whose

plan

requires

a

referral

Endoscopy

CPT

codes

Capsule

endoscopy

CPT

code

does

require

prior

approval

Colonoscopy

CPT

codes

Virtual

colonoscopy

HCPCS

codes

and

do

require

prior

approval

Dilated

eye

exam

for

EmblemHealth

Medicaid

members

Note

Effective

January

Medicaid

members

diagnosed

with

diabetes

may

selfrefer

ie

no

prior

approval

or

referral

is

required

to

any

network

provider

of

vision

services

an

optometrist

or

ophthalmologist

for

a

dilated

eye

retinal

exam

once

in

any

period

Emergency

hospital

admissions

Emergency

services

Services

provided

when

EmblemHealth

is

the

secondary

insurer

Pulmonary

perfusion

imaging

Services

that

do

not

require

prior

approval

but

may

require

a

referral

from

the

members

PCP

eg

basic

Xrays

mammograms

and

bone

density

tests

Officeoutpatient

physical

and

occupational

therapy

initial

visits

For

GHI

HMO

members

an

initial

physical

therapy

referral

for

the

first

six

visits

from

the

PCP

is

required

For

HIP

feeforservice

members

a

referral

is

needed

for

the

initial

evaluation

visit

All

additional

visit

requests

for

these

services

should

be

faxed

to

Palladian

at

How

To

Obtain

a

Prior

Approval

All

providers

must

verify

member

eligibility

and

benefits

prior

to

rendering

nonemergency

services

How

to

Obtain

Prior

Approval

PlanManaging

Entity

Instructions

HIP

Requests

may

be

submitted

via

the

EmblemHealth

website

wwwemblemhealthcom

or

faxed

to

for

DME

requests

or

for

all

other

requests

Call

for

more

information

or

to

use

the

IVR

system

Hospitals

and

skilled

nursing

facilities

can

verify

prior

approval

status

by

reviewing

their

concurrent

review

status

reports

EmblemHealth

EPOPPO

GHI

Requests

may

be

submitted

via

the

EmblemHealth

website

wwwemblemhealthcom

faxed

to

or

by

calling

the

Coordinated

Care

Intake

department

at

See

Additional

Prior

Approval

Procedures

for

GHI

Practitioners

for

more

information

Medicare

PPO

GHI

Requests

may

be

submitted

via

the

EmblemHealth

website

wwwemblemhealthcom

or

faxed

to

Call

for

more

information

or

to

use

the

IVR

system

For

questions

regarding

the

status

of

a

request

submitted

or

the

prior

approval

process

call

Customer

Service

at

See

Additional

Prior

Approval

Procedures

for

GHI

Practitioners

for

more

information

HealthCare

Partners

Call

or

fax

your

request

to

Montefiore

CMO

Call

For

behavioral

health

services

call

Vytra

Health

Plan

Call

Prior

approval

requirements

and

procedures

may

be

different

for

Vytra

ASO

accounts

so

please

contact

the

administrator

listed

on

the

Vytra

members

ID

card

for

more

information

Behavioral

Health

Services

Emblem

Behavioral

Health

Services

Program

For

members

in

plans

underwritten

by

HIP

or

HIPIC

or

administered

by

VHMS

Requests

may

be

submitted

via

the

Beacon

Health

Options

website

httpswwwbeaconhealthoptionscomprovidersbeacon

or

by

calling

Beacon

Health

Options

at

EmblemHealth

Behavioral

Management

Program

For

members

in

plans

underwritten

by

GHI

Requests

may

be

submitted

via

the

Beacon

Health

Options

website

or

by

calling

Beacon

Health

Options

at

Montefiore

For

members

who

have

the

Montefiore

logo

on

the

lower

left

corner

of

their

ID

card

Requests

may

be

submitted

by

calling

University

Behavioral

Associates

UBA

at

Cardiology

and

Radiology

Services

eviCore

Radiology

Cardiology

Requests

may

be

submitted

via

the

eviCore

National

website

wwwevicorecom

or

by

calling

for

HIP

and

CompreHealth

EPO

members

or

for

GHI

HMO

and

EmblemHealth

EPOPPO

members

Chiropractic

Services

All

EmblemHealth

plans

Requests

may

be

submitted

via

the

Palladian

website

wwwpalladianhealthcom

by

calling

or

faxed

to

Outpatient

Physical

and

Occupational

Therapy

HIP

Requests

may

be

sumbitted

via

the

Palladian

website

wwwpalladianhealthcom

by

calling

or

faxed

to

Pharmacy

Services

EmblemHealth

Pharmacy

Benefit

Services

Call

Monday

through

Friday

am

to

pm

ICORE

Requests

may

be

submitted

by

calling

EmblemHealth

Injectable

Drug

Utilization

Management

Program

began

June

Requests

may

be

submitted

via

the

ICORE

website

wwwicorehealthcarecom

by

calling

Monday

through

Friday

am

to

pm

or

faxed

to

Submit

both

the

prior

approval

request

and

the

replacement

drug

order

from

ICORE

by

using

the

appropriate

fax

form

available

at

Specialty

Pharmacy

Program

Requests

may

be

submitted

by

calling

Monday

through

Friday

am

to

pm

or

faxed

to

Radiology

Services

See

the

Radiology

Program

and

Cardiology

Imaging

Program

chapters

Referrals

and

Elective

Hospital

Prior

Approvals

By

Plan

The

following

table

indicates

which

types

of

benefit

plans

require

referrals

and

hospital

prior

approvals

except

in

emergency

situations

Referrals

and

Elective

Hospital

Prior

Approvals

by

Plan

Type

of

Plan

Benefits

Available

Referral

Required

Elective

Hospital

Prior

Approval

Required

Access

I

Network

only

No

Yes

Access

II

Network

and

outofnetwork

No

No

Yes

Yes

Prime

POS

Network

and

outof

network

Yes

No

Yes

Yes

EPO

ie

Prime

EPO

Select

EPO

CompreHealth

EPO

retired

August

Network

only

No

Yes

Prime

HMO

GHI

HMO

Select

Care

HMO

Plans

Network

only

Yes

Yes

Medicaid

Including

Child

Health

Plus

Network

only

Yes

Yes

Medicare

HMO

Network

only

Yes

Yes

Medicare

PPO

Network

and

outofnetwork

No

No

Yes

Yes

GHI

PPO

Network

and

outofnetwork

No

No

Yes

Yes

Prime

PPO

Select

PPO

Network

and

outofnetwork

No

No

Yes

Yes

Vytra

ASO

clients

Network

and

outofnetwork

Check

with

ASO

administrator

Check

with

ASO

administrator

Outofnetwork

services

that

receive

prior

approval

may

be

subject

to

a

deductible

and

coinsurance

depending

on

the

members

contract

or

benefit

plan

If

a

prior

approval

is

not

obtained

there

may

also

be

a

penalty

reduction

of

benefits

up

to

percent

depending

on

the

members

contract

or

benefit

plan

Services

Requiring

PreCertification

for

GHI

PPO

City

of

New

York

Employee

and

NonMedicare

Eligible

Retirees

with

GHI

PPO

Benefits

Beginning

January

many

services

provided

on

an

inpatient

and

outpatient

basis

will

now

require

precertification

This

can

be

done

by

calling

the

NYC

Healthline

at

This

is

the

same

number

you

have

always

called

for

inpatient

precertification

and

is

on

your

ID

card

Services

Requiring

PreCertification

Services

Precertification

Required

Yes

No

Inpatient

Facility

Yes

Contact

Beacon

Health

at

Inpatient

Psychiatric

Substance

Abuse

Facility

Yes

MaternityPregnancy

Delivery

Stays

under

hours

normal

delivery

hours

CSection

requires

notification

only

Over

hours

requires

precertification

Yes

NICU

Admission

Yes

Acute

Inpatient

Rehabilitation

NOTE

This

benefit

is

part

of

the

Skilled

Nursing

Facility

SNF

benefit

day

in

an

acute

inpatient

rehabilitation

bed

days

in

a

SNF

days

in

an

acute

inpatient

rehab

is

equal

to

SNF

days

Therefore

the

SNF

benefit

remaining

would

only

be

Yes

Skilled

Nursing

Facility

SNF

NOTE

NYC

Healthline

can

choose

to

substitute

outpatient

benefits

for

SNF

days

The

formula

used

is

outpatient

visits

inpatient

SNF

day

Only

NYC

Healthline

can

authorize

substitution

of

benefits

No

outpatient

benefits

are

available

under

this

benefit

if

no

precertification

is

received

Yes

Outpatient

hospital

or

freestanding

ambulatory

surgery

facility

not

in

a

doctors

office

Includes

possiblecosmetic

procedures

reconstruction

outpatient

transplants

opticalvision

related

procedures

breast

reconstruction

cochlear

implants

functional

endoscopynasal

surgery

joint

replacements

experimentalinvestigational

procedures

hyperbaric

chamber

infertility

with

underlying

condition

pain

management

spinal

stimulatory

implants

wound

vac

bariatric

surgery

and

spinal

surgery

See

list

of

all

codes

requiring

precertification

for

Ambulatory

Surgery

Yes

Infertility

services

including

artificial

insemination

and

IVF

Precertification

required

when

in

the

MD

office

outpatient

facility

or

free

standing

facility

Yes

Physical

Therapy

Outpatient

NOTE

after

visits

needs

authorization

Yes

Outpatient

speech

therapy

NOTE

after

visits

needs

authorization

Yes

Occupational

Therapy

Outpatient

Not

covered

except

as

part

of

the

home

care

services

benefit

DME

Par

and

NonPar

ExamplesNot

limited

to

the

following

Electric

Beds

Wheelchairs

Yes

When

the

charge

for

DME

equals

or

exceeds

Prosthetics

Par

and

NonPar

Yes

Specialty

Drugs

nonself

injectables

in

office

or

outpatient

facility

See

list

of

all

codes

requiring

precertification

for

NonSelf

Injectables

Yes

Dialysis

Precert

for

network

status

and

place

of

service

only

as

dialysis

is

a

NYS

Mandate

Radiation

Therapy

Yes

Cardiac

Rehabilitation

Outpatient

Yes

Air

Ambulance

scheduled

only

Yes

Genetic

Testing

Yes

The

following

services

continue

to

require

precertification

by

EmblemHealth

Providers

should

call

for

precertification

Home

Health

Care

Yes

Home

Infusion

Therapy

billed

by

a

home

infusion

specialist

Yes

MRIMRAPETCAT

NUCLEAR

CARDIOLOGY

Yes

Nutritional

Supplements

and

Enteral

Formulas

Yes

Glossary

terms

found

on

this

page

Action

Admission

Ambulatory

Surgery

Appeal

Assignment

Authorization

Authorized

Behavioral

Health

Benefit

Plan

Benefits

Benefits

Exhausted

Certification

Chemotherapy

Claim

CMS

Coinsurance

Consultation

Consumer

Contract

Coordinated

Care

Date

of

Service

Deductible

Disabling

Condition

Disabling

Disease

DME

Durable

Medical

Equipment

Effective

Date

Eligibility

Emergency

Enrollee

EPO

Experimental

and

Investigational

External

Appeal

Facility

FeeForService

Fee

Schedule

Health

Care

Provider

Health

Professional

HMO

Home

Health

Care

Home

Infusion

Therapy

Hospice

Hospital

ID

Card

Infertility

Infusion

Therapy

InNetwork

Inpatient

IPA

Lifethreatening

Condition

or

Disease

Limitation

MA

Managed

Care

Medicaid

Medical

Care

Medical

Director

Medically

Necessary

Medicare

Medicare

Advantage

Member

Network

Network

Provider

NonParticipating

Provider

NYSDOH

Occupational

Therapy

OutofNetwork

OutofNetwork

Benefits

OutofNetwork

Provider

Outpatient

Surgery

Participating

Provider

PCP

Physical

Therapy

POS

PPO

PreExisting

Condition

Premium

Prescription

Prescription

Drugs

Prior

Approval

Provider

Provider

Network

Quality

Improvement

Radiation

Therapy

Referral

SDOH

Skilled

Nursing

Facility

SNF

Speech

Therapy

Substance

Abuse

Utilization

Management

An

activity

of

EmblemHealth

or

its

subcontractor

that

results

in

Denial

or

limited

authorization

of

a

service

authorization

request

including

the

type

or

level

of

service

Reduction

suspension

or

termination

of

a

previously

authorized

service

Denial

in

whole

or

in

part

of

payment

for

a

service

Failure

to

provide

services

in

a

timely

manner

Failure

of

EmblemHealth

to

act

within

the

time

frames

for

resolution

and

notification

of

determinations

regarding

complaints

action

appeals

and

complaint

appeals

Formal

acceptance

as

an

inpatient

by

an

institution

hospital

or

health

care

facility

Surgical

procedures

performed

that

do

not

require

an

overnight

hospital

stay

Procedures

can

be

performed

in

a

hospital

or

a

licensed

surgical

center

Also

called

Outpatient

Surgery

Oral

or

written

request

from

a

member

or

their

designee

for

EmblemHealth

to

review

or

reconsider

a

decision

made

by

the

plan

An

agreement

in

which

a

patient

assigns

to

another

party

usually

a

physician

or

hospital

the

right

to

receive

payment

from

a

public

or

private

insurance

program

for

the

service

the

patient

has

received

Services

that

have

been

approved

for

payment

based

on

a

review

of

EmblemHealths

policies

Services

that

have

been

approved

for

payment

based

on

a

review

of

EmblemHealths

policies

Conditions

that

affect

thinking

and

the

ability

to

figure

things

out

that

affect

perception

mood

and

behavior

A

health

insurance

product

offered

by

a

health

plan

company

that

is

defined

by

the

benefit

contract

and

represents

a

set

of

covered

services

Also

called

a

health

benefit

plan

Services

available

to

a

member

as

defined

in

his

or

her

contract

Benefit

design

includes

the

types

of

benefits

offered

limits

eg

number

of

visits

percentage

paid

or

dollar

maximums

applied

and

subscriber

responsibility

cost

sharing

components

When

the

maximum

number

of

visits

for

a

specific

service

is

reached

further

benefits

will

not

be

considered

A

process

in

which

an

individual

an

institution

or

educational

program

is

evaluated

and

recognized

as

meeting

certain

predetermined

standards

Certification

usually

applies

to

individuals

accreditation

usually

applies

to

institutions

Treatment

of

malignant

disease

by

chemical

or

biological

antineoplastic

agents

An

itemized

statement

of

health

care

services

and

their

costs

provided

by

a

hospital

physicians

office

or

other

health

care

facility

Claims

are

submitted

to

the

insurer

or

managed

care

plan

by

either

the

plan

member

or

the

provider

for

payment

of

the

costs

incurred

The

government

agency

responsible

for

administering

the

Medicare

and

Medicaid

programs

A

percentage

of

the

allowed

charge

that

is

payable

by

the

member

not

EmblemHealth

for

covered

services

rendered

by

an

outofnetwork

provider

After

the

member

has

met

his

or

her

deductible

EmblemHealth

will

pay

a

percentage

of

the

allowed

charge

for

those

covered

services

in

accordance

with

the

members

benefit

program

The

member

is

responsible

to

pay

the

remaining

percentage

of

the

allowed

charge

This

remaining

percentage

is

the

coinsurance

charge

Services

rendered

by

a

physician

whose

opinion

or

advice

is

requested

by

another

physician

for

further

evaluation

or

management

of

the

patient

An

individual

person

who

is

the

direct

or

indirect

recipient

of

the

services

of

the

organization

Depending

on

the

context

consumers

may

be

identified

by

different

names

such

as

member

enrollee

beneficiary

or

patient

A

consumer

relationship

may

exist

even

in

cases

where

there

is

not

a

direct

relationship

between

the

consumer

and

the

organization

For

example

if

an

individual

is

a

member

of

a

health

plan

that

relies

on

the

services

of

a

utilization

management

organization

then

the

individual

is

a

consumer

of

the

utilization

management

organization

A

legal

agreement

between

an

individual

member

or

an

employer

group

and

a

health

plan

that

describes

the

benefits

and

limitations

of

the

coverage

The

evaluation

of

the

medical

necessity

appropriateness

and

efficiency

of

the

use

of

health

care

services

procedures

and

facilities

under

the

provisions

of

the

applicable

health

benefit

plan

It

is

sometimes

called

utilization

review

or

utilization

management

The

date

on

which

a

service

was

rendered

A

portion

of

eligible

expenses

that

an

individual

or

family

must

pay

during

a

calendar

year

before

EmblemHealth

will

begin

to

pay

benefits

for

covered

services

Any

medically

determinable

physical

or

mental

impairment

that

can

be

expected

to

result

in

death

or

that

has

lasted

or

can

be

expected

to

last

for

a

continuous

period

of

not

less

than

months

and

renders

the

member

unable

to

engage

in

any

substantial

gainful

activities

Any

medically

determinable

physical

or

mental

impairment

that

can

be

expected

to

result

in

death

or

has

lasted

or

can

be

expected

to

last

for

a

continuous

period

of

not

less

than

months

and

renders

the

member

unable

to

engage

in

any

substantial

gainful

activities

Medical

equipment

goods

implements

and

prosthetics

that

are

prescribed

for

patient

care

usually

in

an

outpatient

setting

Examples

of

such

equipment

include

hospital

beds

wheelchairs

and

walkers

Medical

equipment

goods

implements

and

prosthetics

that

are

prescribed

for

patient

care

usually

in

an

outpatient

setting

Examples

of

such

equipment

include

hospital

beds

wheelchairs

and

walkers

The

date

on

which

the

coverage

of

an

insurance

policy

goes

into

effect

at

am

A

determination

of

whether

or

not

a

person

meets

the

requirements

to

participate

in

the

plan

and

receive

coverage

under

the

plan

Means

a

medical

or

behavioral

condition

the

onset

of

which

is

sudden

that

manifests

itself

by

symptoms

of

sufficient

severity

including

severe

pain

that

a

prudent

layperson

possessing

an

average

knowledge

of

medicine

and

health

could

reasonably

expect

the

absence

of

immediate

medical

attention

to

result

in

a

placing

the

health

of

the

person

afflicted

with

such

condition

in

serious

jeopardy

or

in

the

case

of

a

behavioral

condition

placing

the

health

of

such

person

or

others

in

serious

jeopardy

b

serious

impairment

to

such

persons

bodily

functions

c

serious

dysfunction

of

any

bodily

organ

or

part

of

such

person

An

individual

who

is

enrolled

and

eligible

for

coverage

under

a

health

plan

contract

Also

called

a

member

A

health

care

benefit

arrangement

that

is

similar

to

a

preferred

provider

organization

in

administration

structure

and

operation

but

does

not

cover

outofnetwork

care

Also

called

an

Exclusive

Provider

Organization

Treatment

procedure

drug

biological

product

or

medical

device

that

has

not

been

of

proven

benefit

for

the

particular

diagnosis

or

treatment

of

the

particular

condition

or

is

not

generally

recognized

by

the

medical

community

as

reflected

in

the

published

peerreviewed

medical

literature

as

effective

or

appropriate

for

the

particular

diagnosis

or

treatment

of

the

particular

condition

Written

request

for

an

independent

entity

that

has

been

certified

by

the

State

to

conduct

a

review

of

a

denial

of

coverage

based

on

lack

of

medical

necessity

or

that

the

service

requested

is

experimental

and

investigational

A

hospital

ambulatory

surgical

facility

birthing

center

dialysis

center

rehabilitation

facility

skilled

nursing

facility

or

other

provider

certified

under

New

York

Public

Health

Law

A

hospice

is

a

facility

An

institutional

provider

of

mental

health

substance

abuse

treatment

operating

under

New

York

Mental

Hygiene

Law

andor

approved

by

the

Office

of

Alcoholism

and

Substance

Abuse

Services

is

a

facility

A

payment

method

in

which

the

insurer

will

reimburse

the

member

or

provider

directly

for

each

covered

medical

expense

The

fee

determined

by

the

insurer

to

be

acceptable

for

a

procedure

or

service

that

the

physician

agrees

to

accept

as

payment

in

full

A

professionally

licensed

individual

facility

or

entity

giving

healthrelated

care

to

patients

Physicians

hospitals

skilled

nursing

facilities

pharmacies

chiropractors

nurses

nursemidwives

physical

therapists

speech

pathologist

and

laboratories

are

providers

All

network

providers

are

health

care

providers

but

not

all

providers

are

network

providers

An

individual

who

has

undergone

formal

training

in

a

health

care

field

holds

an

associate

or

higher

degree

in

a

health

care

field

or

holds

a

state

license

or

state

certificate

in

a

health

care

field

and

has

professional

experience

in

providing

direct

patient

care

An

organization

that

provides

comprehensive

health

care

coverage

to

its

members

through

a

network

of

doctors

hospitals

and

other

health

care

providers

Also

called

a

Health

Maintenance

Organization

Health

care

services

rendered

to

a

member

in

their

home

in

lieu

of

confinement

in

a

hospital

or

skilled

nursing

facility

Care

must

be

under

the

supervision

of

a

registered

professional

nurse

This

type

of

care

may

include

physical

occupational

or

speech

therapy

medical

supplies

and

medication

prescribed

by

a

doctor

The

administration

of

intravenous

drug

therapy

in

the

home

Home

infusion

therapy

includes

the

following

services

solutions

and

pharmaceutical

additives

pharmacy

compounding

and

dispensing

services

durable

medical

equipment

ancillary

medical

supplies

and

nursing

services

A

facility

or

service

that

provides

care

for

the

terminally

ill

patient

and

support

to

the

family

The

care

primarily

for

pain

control

and

symptom

relief

can

be

provided

in

the

home

or

in

an

inpatient

setting

An

institution

which

provides

inpatient

services

under

the

supervision

of

a

physician

and

meets

the

following

requirements

Provides

diagnostic

and

therapeutic

services

for

medical

diagnosis

treatment

and

care

of

injured

and

sick

persons

and

has

as

a

minimum

laboratory

and

radiology

services

and

organized

departments

of

medicine

and

surgery

Has

an

organized

medical

staff

which

may

include

in

addition

to

doctors

of

medicine

doctors

of

osteopathy

and

dentistry

Has

bylaws

rules

and

regulations

pertaining

to

standards

of

medical

care

and

service

rendered

by

its

medical

staff

Maintains

medical

records

for

all

patients

Has

a

requirement

that

every

patient

be

under

the

care

of

a

member

of

the

medical

staff

Provides

patient

services

Has

in

effect

agreements

with

a

home

health

agency

for

referral

and

transfer

of

patients

to

home

health

agency

care

when

such

service

is

appropriate

to

meet

the

patients

requirements

A

card

which

allows

the

subscriber

to

identify

himself

or

his

covered

dependents

to

a

provider

for

health

care

services

The

inability

to

conceive

or

an

inability

to

carry

a

pregnancy

to

a

live

birth

after

a

year

or

more

of

regular

sexual

relations

without

the

use

of

contraception

Treatment

accomplished

by

placing

therapeutic

agents

into

the

vein

including

intravenous

feeding

Such

therapy

also

includes

enteral

nutrition

that

is

the

delivery

of

nutrients

into

the

gastrointestinal

tract

by

tube

The

use

of

providers

who

participate

in

the

health

plans

provider

network

Many

benefit

plans

encourage

enrollees

to

use

network

providers

to

reduce

the

enrollees

outofpocket

expense

Service

provided

after

the

patient

is

admitted

to

the

hospital

Inpatient

stays

are

those

lasting

hours

or

more

An

organization

comprised

of

individual

physicians

or

physicians

in

group

practices

that

contracts

with

the

managed

care

organization

on

behalf

of

its

member

physicians

to

provide

health

care

services

Also

called

an

Independent

Practice

Association

A

condition

or

disease

that

has

a

high

probability

of

death

according

to

the

current

diagnosis

of

the

attending

physician

Specific

circumstances

or

services

listed

in

the

contract

for

which

benefits

will

be

limited

Acronym

for

Medicare

Advantage

An

alternative

to

the

traditional

Medicare

program

in

which

private

plans

run

by

health

insurance

companies

provide

health

care

benefits

that

eligible

beneficiaries

would

otherwise

receive

directly

from

the

Medicare

program

Any

form

of

health

plan

that

uses

selective

provider

contracting

to

have

patients

seen

by

a

network

of

contracted

providers

and

that

requires

prior

approval

of

certain

services

A

jointly

funded

federal

and

state

program

that

provides

hospital

and

medical

coverage

to

the

lowincome

population

and

certain

aged

and

disabled

individuals

Professional

services

rendered

by

a

physician

for

the

treatment

or

diagnosis

of

an

illness

or

injury

A

doctor

of

medicine

or

doctor

of

osteopathic

medicine

who

is

duly

licensed

to

practice

medicine

and

is

an

employee

of

or

party

to

a

contract

with

a

utilization

management

organization

and

has

responsibility

for

clinical

oversight

of

the

utilization

management

organizations

utilization

management

credentialing

quality

management

and

other

clinical

functions

Health

care

that

is

rendered

by

a

hospital

or

a

licensed

or

certified

provider

and

is

determined

by

EmblemHealth

to

meet

all

of

the

criteria

listed

below

It

is

provided

for

the

diagnosis

or

direct

care

or

treatment

of

the

condition

illness

disease

injury

or

ailment

It

is

consistent

with

the

symptoms

or

proper

diagnosis

and

treatment

of

the

medical

condition

disease

injury

or

ailment

It

is

in

accordance

with

accepted

standards

of

good

medical

practice

in

the

community

It

is

furnished

in

a

setting

commensurate

with

the

members

medical

needs

and

condition

It

can

not

be

omitted

under

the

standards

referenced

above

It

is

not

in

excess

of

the

care

indicated

by

generally

accepted

standards

of

good

medical

practice

in

the

community

It

is

not

furnished

primarily

for

the

convenience

of

the

member

the

members

family

or

the

provider

In

the

case

of

a

hospitalization

the

care

can

not

be

rendered

safely

or

adequately

on

an

outpatient

basis

or

in

a

less

intensive

treatment

setting

and

therefore

requires

the

member

receive

acute

care

as

a

bed

patient

The

fact

that

a

provider

has

prescribed

a

service

or

supplies

care

does

not

automatically

mean

the

service

or

supply

will

qualify

for

reimbursement

under

the

EmblemHealth

plan

To

be

eligible

for

reimbursement

by

EmblemHealth

all

covered

services

must

meet

EmblemHealths

medical

necessity

criteria

described

above

Medically

necessary

with

respect

to

Medicaid

and

Family

Health

Plus

members

means

health

care

and

services

that

are

necessary

to

prevent

diagnose

manage

or

treat

conditions

that

cause

acute

suffering

endanger

life

result

in

illness

or

infirmity

interfere

with

a

persons

capacity

for

normal

activity

or

threaten

some

significant

handicap

A

nationwide

insurance

program

for

the

disabled

and

people

age

and

over

created

by

the

amendments

to

the

Social

Security

Act

and

operated

under

the

provisions

of

the

Act

It

consists

of

two

separate

but

coordinated

programs

Part

A

and

Part

B

An

alternative

to

the

traditional

Medicare

program

in

which

private

plans

run

by

health

insurance

companies

provide

health

care

benefits

that

eligible

beneficiaries

would

otherwise

receive

directly

from

the

Medicare

program

Also

known

as

MA

An

individual

and

each

of

his

or

her

eligible

dependents

including

Medicare

beneficiaries

who

are

enrolled

or

participate

in

a

benefit

program

and

who

are

entitled

to

receive

covered

services

from

the

practitioner

pursuant

to

such

benefit

program

and

the

terms

of

the

practitioners

agreement

The

group

of

physicians

hospital

and

other

medical

care

providers

that

a

specific

plan

has

contracted

with

to

deliver

medical

services

to

its

members

A

physician

hospital

or

other

provider

who

has

signed

an

agreement

to

covered

services

to

EmblemHealth

plan

members

A

network

provider

is

a

member

of

the

EmblemHealth

network

of

network

providers

applicable

to

the

members

certificate

Therefore

they

are

sometimes

referred

to

as

participating

providers

Payment

is

made

directly

to

a

network

provider

Please

consult

the

EmblemHealth

Directory

or

go

online

to

search

for

network

providers

A

health

care

provider

such

as

a

physician

skilled

nursing

facility

home

health

agency

or

laboratory

that

does

not

have

an

agreement

with

EmblemHealth

plans

to

provide

covered

services

to

members

Also

called

an

OutofNetwork

Provider

The

state

regulatory

agency

that

certifies

reimbursement

methods

and

rates

to

hospitals

and

reviews

HMO

activities

in

the

state

of

New

York

Also

called

the

New

York

State

Department

of

Health

Treatment

to

restore

a

physically

disabled

persons

ability

to

perform

activities

such

as

walking

eating

drinking

dressing

toileting

and

bathing

activities

of

daily

living

The

use

of

health

care

providers

who

have

not

contracted

with

the

health

plan

to

provide

services

Depending

on

the

members

contract

outofnetwork

services

may

not

be

covered

Reimbursement

for

covered

services

provided

by

outofnetwork

providers

and

suppliers

Outofnetwork

benefits

are

generally

subject

to

a

deductible

and

coinsurance

and

therefore

have

higher

outofpocket

costs

Depending

on

the

members

contract

outofnetwork

services

may

not

be

covered

A

health

care

provider

such

as

a

physician

skilled

nursing

facility

home

health

agency

or

laboratory

that

does

not

have

an

agreement

with

EmblemHealth

plans

to

provide

covered

services

to

members

Also

called

a

NonParticipating

Provider

Surgical

procedures

performed

that

do

not

require

an

overnight

stay

in

the

hospital

or

ambulatory

surgery

facility

Such

surgery

can

be

performed

in

the

hospital

a

surgery

center

or

physician

office

A

physician

hospital

or

other

provider

who

has

signed

an

agreement

to

covered

services

to

EmblemHealth

plan

members

A

participating

provider

is

a

member

of

the

EmblemHealth

network

of

providers

applicable

to

the

members

certificate

Therefore

they

are

more

commonly

referred

to

as

network

providers

Payment

is

made

directly

to

a

participating

provider

Please

consult

the

EmblemHealth

Directory

or

go

online

to

search

for

participating

providers

A

family

physician

family

practitioner

general

practitioner

internist

or

pediatrician

who

is

responsible

for

delivering

or

coordinating

care

Also

called

a

primary

care

physician

Treatment

involving

physical

movement

to

relieve

pain

restore

function

and

prevent

disability

following

disease

injury

or

loss

of

limb

A

type

of

health

benefit

plan

that

allows

enrollees

to

go

outside

the

health

plans

provider

network

for

care

but

requires

enrollees

to

pay

higher

outofpocket

fees

when

they

do

Also

called

Point

of

Service

A

health

plan

that

offers

benefits

innetwork

and

outofnetwork

Innetwork

services

are

available

to

enrollees

at

lower

outofpocket

cost

than

the

services

of

nonnetwork

providers

In

addition

PPO

enrollees

may

selfrefer

to

any

network

provider

at

any

time

Also

called

a

Preferred

Provider

Organization

A

preexisting

condition

is

any

disease

symptom

or

condition

that

was

present

on

the

first

day

of

coverage

and

for

which

medical

advice

or

treatment

was

recommended

or

received

during

the

sixmonth

period

prior

to

the

enrollment

date

A

prepaid

payment

or

series

of

payments

made

to

a

health

plan

by

purchasers

and

often

plan

members

for

health

insurance

coverage

A

written

order

or

refill

notice

issued

by

a

licensed

medical

professional

for

drugs

available

only

through

a

pharmacy

Drugs

and

medications

that

are

required

by

law

to

be

dispensed

by

written

prescriptions

from

a

licensed

physician

The

process

of

obtaining

advanced

approval

of

coverage

for

a

health

care

service

or

medication

The

request

for

services

is

reviewed

to

assess

medical

necessity

and

appropriateness

of

elective

hospital

admissions

and

nonemergency

outpatient

services

before

the

services

are

provided

Also

called

preauthorization

or

precertification

or

predetermination

A

medical

practitioner

or

covered

facility

recognized

by

EmblemHealth

for

reimbursement

purposes

A

provider

may

be

any

of

the

following

subject

to

the

conditions

listed

in

this

paragraph

Doctor

of

medicine

Doctor

of

osteopathy

Dentist

Chiropractor

Doctor

of

podiatric

medicine

Physical

therapist

Nurse

midwife

Certified

and

registered

psychologist

Certified

and

qualified

social

worker

Optometrist

Nurse

anesthetist

Speechlanguage

pathologist

Audiologist

Clinical

laboratory

Screening

center

General

hospital

Any

other

type

of

practitioner

or

facility

specifically

listed

in

the

members

Certificate

of

Insurance

as

a

practitioner

or

facility

recognized

by

EmblemHealth

for

reimbursement

purposes

A

provider

must

be

licensed

or

certified

to

render

the

covered

service

The

covered

service

must

be

within

the

scope

of

the

Providers

license

or

certification

A

set

of

providers

contracted

with

a

health

plan

to

provide

services

to

the

enrollees

The

process

to

objectively

and

systematically

monitor

and

evaluate

the

quality

timeliness

and

appropriateness

of

covered

services

including

both

clinical

and

administrative

functions

to

pursue

opportunities

to

improve

health

care

and

resolve

identified

problems

in

any

of

these

services

Treatment

of

disease

by

Xray

radium

cobalt

or

high

energy

particle

sources

A

recommendation

by

a

physician

that

an

enrollee

receive

care

from

a

specialty

physician

or

facility

New

York

State

Department

of

Health

This

agency

provides

information

for

consumers

doctors

researchers

and

health

care

providers

A

licensed

institution

or

a

distinct

part

of

a

hospital

that

is

primarily

engaged

in

providing

continuous

skilled

nursing

care

and

related

services

for

patients

who

require

medical

care

nursing

care

or

rehabilitation

services

Also

called

a

SNF

A

licensed

institution

or

a

distinct

part

of

a

hospital

that

is

primarily

engaged

in

providing

continuous

skilled

nursing

care

and

related

services

for

patients

who

require

medical

care

nursing

care

or

rehabilitation

services

Also

called

a

skilled

nursing

facility

Treatment

of

the

correction

of

a

speech

impairment

which

resulted

from

birth

disease

injury

or

prior

medical

treatment

The

use

of

one

or

more

drugs

for

purposes

other

than

those

for

which

they

are

prescribed

or

recommended

A

review

to

determine

whether

covered

services

that

have

been

provided

or

are

proposed

to

be

provided

to

a

member

whether

undertaken

prior

to

concurrent

with

or

subsequent

to

the

delivery

of

such

services

are

medically

necessary

Also

called

Coordinated

Care

emblemhealth
care management
specialty care centers


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O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O

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Reservoir Management Software A Comprehensive Software Suite Placing uncertainty management at the heart of decisionmaking our comprehensive software suite from seismic interpretation to production management helps operators make better decisions leading to improved returns on investment We deliver the confidence and understanding that enables operators to enhance oil gas recovery and unlock the value of their assets Our flagship products and solutions include RMS Tempest METTE and Big Loop Reliably forecast your reservoir production LEARN MORE We are happy to welcome Paradigm to the Emerson family LEARN MORE Products Reservoir Geophysics Our Seismic solutions help you capture uncertainties generate multiple realizations and build accurate and robust reservoir models Reservoir Geology Accelerate the field development planning cycle by allowing multiple disciplines to work together simultaneously on a common reservoir model Reservoir Engineering and Simulation Support your economic decisionmaking process and have full confidence in your reservoir management with fast and accurate simulation results Well Planning and Monitoring Develop your production plans and drilling programs by generating accurate reservoir models regardless of reservoir type Production Monitoring and Modeling Obtain full control over flow conditions and turn data overflow into valuable expert guidance to optimize production and minimize downtime Services Consulting Consulting Lifecycle Services With the best expertise our regional service centers support all your projects service and technical queries Software Support We operate a system of regional helpdesks to provide a continuous support service during your local office hours Educational Services We offer a range of training services designed to integrate new members into the asset team quickly and efficiently Roxar Software Portal Submit new support cases review old cases access the technical knowledge base and register for training courses Media Case Studies Improve returns through integrated accurate reservoir modeling Learn about four key elements to an integrated production management system Watch our videos and learn more about our technology Explore the impact of reservoir modeling Explore the impact of reservoir modeling on a mature and geologically complex offshore Middle East field with the software suite used playing a key role in exploring the fields upside potential

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A DataCentered World Data is at the center of everything in our world From financial markets to healthcare to education it is the data that matters Decisions made every second rely on data Partner with a company that understands how to securely host and manage your data while reliably delivering your data to you when and where you need it most Encore offers an entire suite of IT services from the desktop to the data center Our solutions are aimed at maximizing our customers investment and improving their profitability Visit our Services to learn more What is Tomorrow At Encore our solutions are built from envisioning a future that reduces complexity and costs by automating and optimizing IT infrastructure With automation comes greater agility efficiency security and value In essence we use our past success and expertise in leadingedge technologies as a foundation to build tomorrows solutions today Why Encore At the rate your business moves its impossible to stay on top of trends and technologies Partnering with Encore Technologies brings valuable insight into what other companies are doing to solve the challenges in their environments Thats why we work with established partners such as Cisco DellEMC and HP as well as leadingedge upstarts like Pure Storage Red Hat and Cohesity Leveraging the best of breed of traditional players with opensource next generation newcomers allows us to deliver the best possible solutions for you the customer

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Public Transit in California California has more than 100 public transit and bus districts which serve individual cities entire counties or regions with bus rail trolley and ferry service About 53 percent of Californians commute to work by public transit which works out to millions of people each year ShortDistance Urban Transit ShortDistance Urban Transit Ridership in California Large Urban Areas 2013 Urban Area Passenger Trips 1000s Motor Bus Heavy Rail Light Rail Commuter Rail Other Los AngelesLong Beach Santa Ana 681565 779 73 93 20 18 San FranciscoOakland 449674 388 281 101 36 175 San Diego 154010 540 00 413 11 22 San Jose 44221 741 00 243 00 17 RiversideSan Bernardino 25790 942 00 00 00 44 Sacramento 31867 532 00 424 00 21 Total Statewide Urban Transit 1434266 652 123 121 23 70 Source State Transportation Statistics 2015 Table 43 US Department of Transportation Research and Innovation Technology Administration Bureau of Transportation Statistics Urban Transit Fuel Consumption An increasing percentage of urban transit buses in California are fuel by natural gas while the rail and trolleys in urban transit use electricity Fuel Consumption by Urban Transit Systems in California Year Electricity MWH Diesel Thousands of Gallons Gasoline Thousands of Gallons Natural Gas Thousands of Gallons Other Fuels Thousands of Gallons 2014 699307 45523 20636 90298 5619 2013 696549 49250 12993 85716 7396 2012 664826 51678 18908 80105 4313 2011 647473 53290 18010 84452 4542 2010 651038 52989 17368 82849 5238 2009 678673 58799 15300 95611 4824 Source Energy Commission Analysis of National Transit Database NTD Data Reports 20092014 LongDistance Intercity Transit About 53 million passengers use AMTRAK for long distance travel via rail annually in California Ridership on AMTRAK grew thirteen percent from 2009 to 2014 more than twice the growth rate of Californias population as a whole The California Department of Transportation Caltrans has been promoting intercity passenger rail service since 1976 by augmenting Amtraks basic system of interstate trains The Pacific Surfliner San Joaquin and Capitol Corridor are funded primarily by the State of California These trains collectively referred to as Amtrak California operate in addition to Amtraks own interstate trains the Coast Starlight the California Zephyr the Southwest More Information Caltrans Smart Traveler Amtrak California Website NTD Data State Transportation Statistics 2015 Almanac Information Electricity Natural Gas LNG Petroleum Power Plants Renewable Energy Transportation Energy

B I O B B O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I I O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O B O O O O O O O O O O O O B O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O

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INTELLIGENT WORK FORUMS FOR ENGINEERING PROFESSIONALS Come Join Us Are you an Engineering professional Join EngTips Forums Talk With Other Members Be Notified Of Responses To Your Posts Keyword Search OneClick Access To Your Favorite Forums Automated Signatures On Your Posts Best Of All Its Free Students Click Here Join Us EngTipss functionality depends on members receiving email By joining you are opting in to receive email Posting Guidelines Promoting selling recruiting coursework and thesis posting is forbidden Students Click Here EngTips Posting Policies Jobs Manufacturing Engineer 10976 Garland North Carolina Senior Project Engineer Burlington Massachusetts Electrical Engineer Louisburg Kansas Production Supervisor 3rd Shift Denison Texas Metric Data Analyst 461860 Fort Worth Texas Metric Data Analyst Sr 461862 Fort Worth Texas Forums Mechanical Engineers Activities Boiler and Pressure Vessel engineering Forum ReUsing Gaskets 3 thread794294193 FAQs MVPs Sharik Mechanical OP 11 Mar 11 0201 This is going to seem like a silly question but I know it is good and common practice to not reuse flange gaskets greylock spiral wound etccompression sealing etc Other people are not aware of this practice and want to reuse existing gaskets Im tired of trying to explain common sense to them while they are only interested in saving money and meeting minimum Code requirements Does anyone know of any standard national or international which states dont reuse gaskets you bonehead If I can show them something in writing we can move on from this Thanks unclesyd Materials 11 Mar 11 0740 Do not reuse gaskets peroid I wish I had just a pinch of the money spent by trying to reuse a gasket The only place Ive seen this referenced is in company catalogues Ive been told that there is one reference in one of the standards about this but Ive havent seen it or know which one With spiral wound gaskets you have already compressed them the required amount and in some cases used up the allowable design bolt stress If you dis by some chance reuse a gasket you would have to stress the bolt more and possibly cupping the flange One other point is that a lot of time you will lose part of the filler material from the spirals ash9144 Chemical 11 Mar 11 1221 Never reuse gaskets for a surface under pressure that requires a seal I got doused with several thousand gallons of acetone one night because some f idiot decided to save a few dollars reusing gaskets Compare a used gasket to a new gasket you will be able to see the wear deformation grooves etc This should be enough to convince any run of the mill moron If still not enough then get literature from your gasket supplier or training course I too think it is in one of the codes but I have no idea which one If that still isnt enough to change the practice then find a new place to work pennpiper Mechanical 11 Mar 11 1408 Make a big sign showing the cost of just one of your typical gaskets and The showing the amount of lost revenue resulting from a plant or Unit shutdown required to change out just one leaking Reused gasket Hang copies in all the Board Room the Control Rooms the Maintenance shop and the lunch rooms I would bet that will get peoples attention rustbuster Petroleum 11 Mar 11 1502 Rick The only place ive seen this documented are in vendor product manuals Garlock comes to mind 2 Canadieng Mechanical 11 Mar 11 1623 Formal recommendations against reusing gaskets can be found in ASME PCC1 chapter 6 Canadieng Mechanical 11 Mar 11 1652 I will elaborate as the particulars appear in the 2010 edition and were not in the 2000 ed Reuse of a gasket is generally not recommended One current exception is large grooved metal gaskets with facing layers see Appendix C that are reused in some instances after having been reconditioned and refaced in a manner consistent with the original product specifications Use of gaskets so refurbished is not considered as gasket reuse in the context of the first sentence For other gasket types experience has clearly shown that only a new gasket will reliably provide the necessary plastic deformation and elastic recovery characteristics essential to achieve an effective seal Visual or physical inspection of a used gasket for apparent damage is not sufficient to detect such sealing surface factors as workhardening brittleness or the affects of heat or interaction with the service fluid PAN Mechanical 11 Mar 11 1854 Please refer to API 6A 2004 Para 10424 Ring gaskets shall not be reused Reply To This Thread Posting in the EngTips forums is a memberonly feature Click Here to join EngTips and talk with other members

O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O


Grade 4 English Language Arts Prev Grade 4 English Language Arts Grade 4 ELA Module 1A Unit 1 Grade 4 ELA Module 1A Grade 4 ELA Module 1A Updates September 2014 Module 1A focuses on building community by making connections between visual imagery oral accounts poetry and written texts of various cultures with a focus on the Haudenosaunee Iroquois culture Students will determine a central idea and demonstrate how gathering information from a variety of sources can help us understand a central idea more fully Module 1 also reinforces reading fluency close text analysis explanatory paragraph writing and presenting to peers The module reinforces the fact that Native Americansspecifically the Iroquois Haudenosaunee People of the Longhouse were early inhabitants of the New York region and state and continue to contribute to In Unit 1 students will read and listen closely to interpret main ideas and thematic connections between visual imagery symbols and graphics oral tradition Haudenosaunee video and literary texts The Great Peacemaker Two Row Wampum and Frosts A Time to Talk Students will demonstrate their understanding by creating symbols and writing explanatory paragraphs about how they connect to the texts W411 RL411 Unit 3 expands on the conversation around symbolism and culture begun in Unit 1 to incorporate global perspectives Students listen to view and close read informational texts regarding the traditions other cultures use to tell stories and pass down information Students will review oral tradition and revisit it from a different angle as they explore the Griot tradition in Africa Students will look at how symbols can be captured in art through blanket making in Hawaii and quilt making through Patricia Polaccos story The Keeping Quilt Students will revisit specific texts and notes from Units 1 and 2 to examine how the central idea of community connects the texts within the module Students will use these texts videos and their understanding of symbols community and cultural traditions to create a quilt that defines the classroom community Each student will create a symbol on a quilt square that represents something they value about themselves and that they bring to the classroom community such as a positive personality trait or accomplishment Emulating the practice of oral tradition students will then explain the symbolism behind their quilt squares which Like 245 Curriculum Map Module 1A Unit 1 Unit 2 Unit 3 Module 1B Module 2A Module 2B Module 3A Module 3B Module 4

O O O O O O O O O O O B I I I O O O B I I I O B I I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O