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GuildNet Provider Manual

15 West 65th Street
New York, New York 10023
212-769-7855

Table of Contents
HOURS OF OPERATION ................................................................................................. 4
GUILDNET CONTACT NUMBERS ................................................................................ 5
EMPLOYMENT STANDARDS FOR GUILDNET PARTICIPATING PROVIDERS ... 6
GUILDNET OVERVIEW .................................................................................................. 7
ENROLLMENT ELIGIBILITY CRITERIA ..................................................................... 8
SERVICE AREA ................................................................................................................ 8
GUILDNET MLTCP COVERED SERVICES/BENEFITS .............................................. 9
GUILDNET MLTCP NON-COVERED SERVICES ...................................................... 10
GUILDNET GOLD COVERED SERVICES/BENEFITS ............................................... 11
GUILDNET GOLD NON-COVERED SERVICES ........................................................ 11
GUILDNET HEALTH ADVANTAGE COVERED SERVICES/BENEFITS ................ 12
GUILDNET HEALTH ADVANTAGE NON-COVERED SERVICES ......................... 12
THE ROLE OF GUILDNET CASE MANAGEMENT ................................................... 14
COORDINATION OF CARE/PROVIDER RESPONSIBILITIES ................................. 15
AUTHORIZATION REQUIREMENTS .......................................................................... 20
AUTHORIZATION PROCESS ....................................................................................... 25
SERVICE STANDARDS FOR PROVIDERS ................................................................. 28
CLAIMS SUBMISSION AND INQUIRY....................................................................... 29
FRAUD AND ABUSE ..................................................................................................... 30
GUILDNET MEDICARE CLAIM SUBMISSION AND INQUIRY ............................. 32
CLAIM INQUIRY: ........................................................................................................... 33
APPEALS OF DENIED CLAIMS ................................................................................... 35
ADVERSE REIMBURSEMENT CHANGE ................................................................... 36
FALSE CLAIMS ACT ..................................................................................................... 37
MEDICAID SPEND-DOWN AND THIRD PARTY INSURANCE .............................. 39
GUIDELINES FOR MARKETING GUILDNET SERVICES ........................................ 40
MEMBER CONFIDENTIALITY .................................................................................... 41
MEMBER RIGHTS .......................................................................................................... 42
MEMBER RESPONSIBILITIES ..................................................................................... 43
MEMBER GRIEVANCES ............................................................................................... 44
MEMBER APPEALS OF GRIEVANCES ...................................................................... 46
CHOOSING AMONG PROVIDERS............................................................................... 47
2

DISPUTE RESOLUTION ................................................................................................ 48
PROVIDER CREDENTIALING ..................................................................................... 49
MONITORING OF PROVIDERS ................................................................................... 50
PROVIDER AUDITS ....................................................................................................... 51
PROVIDER TERMINATION .......................................................................................... 52
UPDATING POLICIES AND PROCEDURES ............................................................... 54

HOURS OF OPERATION

Monday through Friday, 8:00AM to 5:00 PM:
Contact Numbers
Case Management and Member Services:
212-769-7855 - Telephone
646-619-6093 - Electronic Fax Number
Provider Relations:
917-386-9208 - telephone
212-712-2427 – fax
gnprovrel@jgb.org
Outside of Normal Business Hours, Weekends &
Holidays:

1-800-932-4703

GuildNet Contact Numbers
Wanda Figueroa-Kilroy, Executive Vice President

212-769-7851

Case Management Department
Eileen Hanley, Senior Vice President, GuildNet
Anne Becker, Assistant Vice President of Case Management
Sharese Brundage, Assistant Vice President of Case Management

212-769-7855
212-769-6301
212-769-7803
917-386-9701

Social Work:
Portia McCormack, Director, Clinical Support Services
Isabel Gill, Supervisor
Ellen Gordon, Supervisor

917-386-9844
212-712-9908
917-386-9356

Quality Assurance & Performance Improvement
Laura Brannigan, Senior Vice President
Michelle Sulfaro, Director of QA

212-769-7852
212-712-9940

Intake:
Ruth Fowler, Senior Vice President
Matilda Simpson, Senior Medicaid Eligibility Specialist

212-712-9939
212-769-7866

Marketing
Joselyn Salazar, Director

212-769-7854

Provider Relations:
Judith Shargel, Senior Vice President
Ada Bekker, Provider Relations Manager
Nancy Martinez, Senior Authorization Specialist
Lok Wong, Senior Authorization Specialist
Kelly Lewis, Provider Services Analyst
Monica Miller, Authorization Specialist
Margarita Morales, Authorization Specialist

917-386-9208
212-769-7857
212-769-7856
212-769-6238
212-712-9952
212-712-9906
212-712-9938
212-712-9998

Medicare Services
Sandra Birnbaum, Assistant Vice President

212-712-9918

Employment Standards for GuildNet Participating Providers

GuildNet is committed to providing the highest quality of health care to its members.
To provide the best possible care, it is essential that GuildNet Participating Providers
attract and retain the highest quality of staff to perform these services. While mindful that
providing services must be accomplished within available funding levels, we believe that
morally and ethically, we have an obligation to encourage our business partners to treat
their employees fairly.
The five items below enumerate the terms and conditions of employment that we
consider to be minimum standards for all GuildNet Participating Providers. Providers that
meet or exceed these minimum standards will be considered “preferred” in consideration
of future business:

1.
2.
3.
4.

Provide the highest level of care
Provide safe and healthy working conditions
Treat employees with dignity and respect
Maintain full compliance with the New York State Home Care Worker Wage
Parity Law Provide fair and reasonable wages;
5. Provide fringe benefits including, but not limited to, adequate health care,
retirement and paid leave.

GUILDNET OVERVIEW

GuildNet Inc., a subsidiary of The Jewish Guild for the Blind, offers a Managed Long
Term Care Program (MLTCP) established to coordinate healthcare services for
chronically ill adults wishing to remain in their own home and communities as long as
possible. Member’s healthcare needs, both covered and non-covered, are coordinated by
an assigned Case Manager in collaboration with Member’s primary care physician and
GuildNet Participating Providers. Collaboration by a physician means that the physician
is willing to write orders for covered services and non-covered services, to refer to
GuildNet’s Network Providers, and to work with the GuildNet Care Management Team
to coordinate all care. The benefits provided to individuals enrolled in GuildNet MLTCP
are considered to be Medicaid benefits.
GuildNet, Inc. also offers two Medicare Advantage Special Needs Plans (SNPs):
GuildNet Gold HMO-POS SNP, a Medicaid Advantage Plus plan, and GuildNet Health
Advantage HMO-POS SNP, a Medicaid Advantage plan. GuildNet Gold is available to
individuals who are eligible for both Medicare and Medicaid, and meet most of the
Managed Medicaid Long Term Care Program (MLTCP) enrollment criteria. GuildNet
Gold has an integrated benefit package that includes both Medicare and Medicaid
benefits. GuildNet Health Advantage is available to individuals who are also eligible for
both Medicare and Medicaid; however, its benefits package does not include long term
care services.

Enrollment Eligibility Criteria
To be enrolled in GuildNet members must meet the following eligibility criteria:
•
•
•
•
•
•

Age 18 or older;
Reside within GuildNet’s service area;
Have Medicaid;
Be eligible for nursing home level of care at the time of enrollment as determined
by the New York State patient assessment instrument;
Capable, at the time of enrollment, of returning to or remaining at home and
community without jeopardy to their health and safety;
Expected to need care management and long-term care services for at least 120
days.

In addition to criteria above, GuildNet Gold members must also:
•
•

Have Medicaid AND Medicare Part A & B;
Be enrolled in GuildNet’s Medicaid Advantage Plus.

GuildNet Health Advantage members must:
•
•
•
•
•

Be age 18 or older;
Reside within GuildNet’s service area;
Have Medicaid;
Be enrolled in GuildNet’s Medicaid Advantage.
No requirement to be eligible for nursing home level of care.

Service Area
GuildNet MLTCP is available in the Bronx, Brooklyn, Manhattan, Queens, Staten
Island, Westchester, Nassau and Suffolk Counties.
Gold and Health Advantage plans are available in the Bronx, Brooklyn, Manhattan,
Queens, Nassau and Suffolk Counties.

GUILDNET MLTCP Covered Services/Benefits
GuildNet Medicaid Benefits are community based services that would otherwise be
covered in whole or part by Medicaid. These services are listed below.
Adult Day Health Care
Adult Social Day Care
Audiology
Certified Home Health Care Services
Dentistry
Durable Medical Equipment
Medical and Surgical Supplies
Licensed Home Care
Meals (Home/Congregate)
Non-Emergency Transportation
Skilled Nursing Facility
Nutritional Counseling
Optometry
Outpatient and in-home physical, occupational, speech therapy
Podiatry
Personal Emergency Response System (PERS)
Private Duty Nursing
Prosthetics/Orthotics
Respiratory Therapy
Social and Environmental Supports
Social Work Services
There are no cost-sharing expenses for GuildNet members, including deductibles or copayments. For more information, please call GuildNet Provider Relations at 1-917-3869208 Monday through Friday, between 8:30 a.m. to 5:00 p.m.
GuildNet is always secondary payer to Medicare and other third party payers.

GUILDNET MLTCP Non-Covered Services
Services that a GuildNet MLTCP Member may require that are not covered by GuildNet
but are billed directly by the Provider to Medicaid, Medicare, or other third party payer
may be included in the Member’s GuildNet Service Plan of Care and coordinated by the
Case Manager in collaboration with the PCP and Providers involved in the Member’s
care. These non covered services include:
Physician Services
Inpatient Hospital Stay
Laboratory Services
Radiology and Radioisotope Services
EMERGENCY Transportation
Chronic Renal Dialysis
Hospice Services
Alcohol and Substance Abuse Services
Family Planning Services
Prescription & Non Prescription Medications
Mental heath services listed below
 Methadone maintenance treatment
 Intensive psychiatric rehabilitation treatment programs
 Day treatment
 Continuing day treatment
 Case management for seriously and persistently mentally ill
 Partial hospitalizations
 Assertive Community Treatment (ACT)
 Personalized recovery oriented services (PROS)
Rehabilitation services provided to residents of OMH Licensed Community Residences
and Family Based Treatment Programs
Office of Mental Retardation and Developmental Disabilities (OMRDD) Services
AIDS Adult Day Health Care

GUILDNET GOLD Covered Services/Benefits
GuildNet Gold covered benefits include all services otherwise covered by fee for
Service Medicaid, Original Medicare under Part A and Part B, and prescription
medications covered under Part D, excluding those listed under “GuildNet Gold NonCovered Services”. There are no cost-sharing expenses for GuildNet Gold members,
including deductibles or co-payments, except small co-payments for some Part D
Prescription medications.
For more information, please call GuildNet at 1-917-386-9208 Monday through Friday,
from 8:30 a.m. to 5:00 p.m.

GUILDNET GOLD Non-Covered Services

Services that a Member may require that are not covered by GuildNet Gold may be
included in the Member’s Plan of Care and coordinated by the Case Manager in
collaboration with the PCP and Providers involved in the Member’s care. These noncovered services include:
Services Covered by Direct Reimbursement from Original Medicare:
• Hospice services
Services Covered by Medicaid Fee-for-Service:
• Family planning, (covered by Medicaid fee for service)
• Mental heath services listed below
 Methadone maintenance treatment
 Intensive psychiatric rehabilitation treatment programs
 Day treatment
 Continuing day treatment
 Case management for seriously and persistently mentally ill
 Partial hospitalizations
 Assertive Community Treatment (ACT)
 Personalized recovery oriented services (PROS)
• Rehabilitation services provided to residents of OMH Licensed Community
Residences and Family Based Treatment Programs
• Office of Mental Retardation and Developmental Disabilities (OMRDD) Services
• AIDS Adult Day Health Care

GUILDNET Health Advantage Covered Services/Benefits
GuildNet Health Advantage covered benefits include all services otherwise covered by
Original Medicare Part A and Part B, prescription drugs covered under Part D, and some
services covered by Medicaid only, excluding those listed under “GuildNet Health
Advantage Non-Covered Services”. There are no cost-sharing expenses for GuildNet
Health Advantage members, including deductibles or co-payments for covered medical
services, except small co-payments for Part D Prescription drugs.
For more information, please call GuildNet at 1-917-386-9208 Monday through Friday,
from 8:30 a.m. to 5:00 p.m.

GUILDNET Health Advantage Non-Covered Services

Services that a Member may require that are not covered by GuildNet Health Advantage
may be included in the Member’s Plan of Care and coordinated by the Case Manager in
collaboration with the PCP and Providers involved in the Member’s care. These noncovered services include:
Services Covered by Direct Reimbursement from Original Medicare:
• Hospice services
Services Covered by Medicaid Fee-for-Service:
•
•
•
•
•
•
•
•
•
•
•
•

Non-Medicare covered skilled nursing facility care
Adult Day Health Care
Adult Social Day Care
Dentistry (Nassau and Suffolk only)
Medicaid-only Medical and Surgical Supplies
Licensed Home Care
Non-Emergency Transportation (Nassau and Suffolk only)
Nutritional Counseling
Personal Emergency Response System (PERS)
Social Work Services
Family planning
Mental heath services listed below
 Methadone maintenance treatment
 Intensive psychiatric rehabilitation treatment programs
 Day treatment
 Continuing day treatment
 Case management for seriously and persistently mentally ill
12

•
•
•

 Partial hospitalizations
 Assertive Community Treatment (ACT)
 Personalized recovery oriented services (PROS)
Rehabilitation services provided to residents of OMH Licensed Community
Residences and Family Based Treatment Programs
Office of Mental Retardation and Developmental Disabilities (OMRDD) Services
AIDS Adult Day Health Care

The Role of GuildNet Case Management

Case Manager/Interdisciplinary Team
Each Member is assigned to a Case Manager/care coordinator/Interdisciplinary Care
Team that will include health care professionals (nurses, social workers, psychologists or
therapists, as appropriate) who have ongoing responsibility for coordinating, managing
and authorizing all aspects of the delivery of care and services to members.
As the primary coordinator of care, the Case Manager’s responsibilities include:
•
•
•
•

Authorization and implementation of covered services outlined in the Member’s
service plan,
Monitoring of all services for quality and effectiveness,
Integration of feedback, observations, and recommendations of other
professionals involved in managing the care to the Member, including network
Providers, PCP’s, Specialists, and Providers of uncovered services,
Coordination of discharge planning from hospital or nursing home stays.

Member Service Representative/Member Service Assistant
Member service staff serves as liaison between the Member and Case Manager and assist
the care management team by providing information about GuildNet policies, available
services, and network Providers to Members; making and confirming service
arrangements; issuing authorizations as directed by the Case Manager; and answering
questions and resolving problems presented by Members and Providers, as appropriate.

Coordination of Care/Provider Responsibilities

GuildNet’s New York State Managed Long Term Care program is responsible for
providing long-term care and health services to its members. Because intensive care
coordination and management is critical to the health and well-being of its membership,
GuildNet participating providers agree, through the GuildNet Participating Provider
Agreement, to fully cooperate with GuildNet case management, even if the episode of
care does not result in any payment by GuildNet to the participating provider because the
provider's fee is covered entirely by a primary payer, such as Medicare. Specifically, it is
not unusual for a GuildNet member to also be Medicare-eligible. In these cases, because
Medicaid is always the payer of last resort and Medicare is the primary payer, under the
GuildNet coordination of benefits procedure GuildNet may owe no secondary payments
to the participating provider. This payment circumstance does not alter the responsibility
of participating providers to cooperate with GuildNet care management.
Providers are responsible for effectively communicating with the Case Manager/
Interdisciplinary Team, along with the Member Services staff regardless of primary
payer, in order to promote optimal scheduling of services, prevent duplication of
services, remove barriers to care, access appropriate reimbursement sources for services,
increase continuity of care, and progress toward goal achievement.
As part of its role in managing a Member’s care, GuildNet authorizes services and
provides the following information:
• Member Demographics
• Physician Information
• Description of Requested Service
• Clinical Status as appropriate
Podiatry, Optometry, and Audiology screening services provided by network Providers
do not require authorization; however, the above information is available upon request.
A Member may refuse care that has been specified in the Member’s service plan.
GuildNet will not place, or will terminate, services that the Member refuses after the
Member, their family, or representative has been fully informed of the health risks and
consequences involved in such refusal, and the Member, upon being fully informed,
continues to refuse care. Providers must notify GuildNet immediately if an authorized
or requested service is refused.

All Providers are required to
• Comply with all regulatory and professional standards of practice and are
responsible to acquire physician orders whenever required by regulation or
local, state or federal law as well as for determination of medical necessity and/or
3rd party reimbursement. The Case Manager/Interdisciplinary Team may assist
in obtaining orders if the Provider has been unsuccessful.
• Notify GuildNet immediately whenever there is identification of a clinical issue
of serious concern, change in Member status, refusal of service, inability to access
Member’s home, or inability to provide service for any reason.
• Communicate verbally and in writing on a timely basis regarding the nature and
extent of services provided to the Member and the Member’s progress and status.
• Cooperate with GuildNet on any grievance, appeal, or incident investigations as
required. Incident reports must be submitted to GuildNet within 10 working days
of request.
• Communicate to GuildNet any complaint made by or on behalf of the Member.
• Cooperate with GuildNet’s quality assurance and improvement programs (QAPI)
as needed.
• Assure that all Provider’s employees and agents involved in direct contact with
Members carry proper Agency identification.
• Notify GuildNet of the provision of any unauthorized urgent services within 48
hours.
• Prior to the addition of any new Provider owner, director, employee, agent,
contractor or referral source, and on a monthly basis thereafter, Provider shall
confirm that such individuals and entities are not Excluded by checking the
excluded parties lists maintained by the New York State Office of the Medicaid
Inspector General, the United States Department of Health and Human Services
Office of Inspector General, and the United States General Services
Administration;
In addition:
Home Care Providers are responsible for
• Obtaining physician orders;
• Developing the aide care plan for requested services;
• Ensuring that Family members of GuildNet enrollees who are HHA/PCA are
NOT assigned to handle the care of their family member;
• Notifying Member in advance of name of assigned staff;
• Notifying GuildNet and Members in advance of need for replacements and
name of replacement staff;
• Submitting evaluation and progress notes following first assessment visit by
any/all disciplines and every two weeks thereafter unless specified otherwise;
• Cooperating fully with GuildNet case management; communicate verbally or in
writing regarding the member’s progress even if the episode of care does not
result in any payment by GuildNet to the participating provider;
• Confirming aide daily attendance: Effective January 1, 2012 all Licensed
Home Care Providers (LHCSAs) must implement an electronic call in/call out
attendance program in addition to other manual random verification. Agency
protocols on Aide attendance verification must be available to GuildNet Provider
16

•

Relations upon request. If a member does not allow the aide to call in or call out
from their telephone, the Case Manager must be informed and the information
documented;
Submitting Attendance Activity reports as requested. Reports should be indicate:
1. date and time of electronic call in/out;
2. date and time of manual modifications/entries; and
3. name of user modifying/entering time in/out.
Maintain full compliance with the New York State Home Care Worker
Wage Parity Law (New York State Public Health Law Section 3614-c, as
amended, and all New York State Health Department regulations and
guidance with respect thereto) (the "Wage Parity Law"); and shall
provide GuildNet with all information to verify such compliance

Residential Health Care Providers are responsible for:
For Short Term Stay (up to 6 months):
• Determining the type of health insurance coverage the prospective resident has
and whether or not the RHCF is authorized to serve the member (MAP Procedure
03-01 );
• Submitting progress notes to GuildNet Case Manager Bi-Weekly;
• Obtaining authorization for any covered service outside of daily rate; and
• Assisting in the Medicaid recertification process.
For Long Term Care:
• Determining eligibility for Institutional Medicaid and other Third Party Health
Insurance and whether or not the RHCF is authorized to serve the member;
• Submitting Conversion applications for members placed for long term care;
identifying the admission as a Managed Long Term Care admission;
• Collecting the NAMI (NAMI will be deducted from payments);
• Submitting Resident Monthly Summaries to the GuildNet Case Manager;
• Including GuildNet Case Manager in case conferences;
• Obtaining authorization for any covered service outside of daily rate; and
• Assisting in the Medicaid recertification process.
Note: GuildNet members must be eligible for Institutional Medicaid to remain in a
RHFC for long term care.
DME and Medical Supply Providers are responsible for:
• Verifying primary payor coverage and eligibility prior to delivery;
• Acquiring physician orders whenever required by regulation or local, state or
federal law as well as for determination of medical necessity and/or 3rd party
reimbursement;
• Exhausting all other payment sources prior to billing GuildNet; and
• Timely Delivery of requested products.

Note: It is the responsibility of the provider to determine whether Medicare covers the
item or service being billed. If the service or item is covered or if the provider
does not know if the service or item is covered, the provider must first submit a
claim to Medicare, as GuildNet is always the payer of last resort.
If the item is normally covered by Medicare but the Provider has prior
information that Medicare will not reimburse due to duplicate or excessive
deliveries, the information should be communicated to the GuildNet Case
Manager prior to delivery.

Transportation Providers are responsible for:
• Arriving within 30 minutes of scheduled pick up time and within 1 hour of
will call time;
• Providing all requested in and out of borough transportation requests, including
special needs transports;
• Assuring that all transportation is to Medical Appointments unless specifically
noted in the authorization;
• Notifying GuildNet when a requested trip is to a non-medical destination not
noted in the authorization;
• Notifying GuildNet when a member cancels or does not show for a pick up;
• Notifying GuildNet when it is determined, upon arrival, that the driver is unable
to transport a member safely; and
• Obtaining documentation for each trip provided, including the following:
 Member’s name and ID number
 Date of Transport
 Pick up address and time of pick up
 Drop off address and time of drop off
 Vehicle License Plate number
 The full printed name of Driver
GuildNet requires that all Ambulette and Car Service participating providers follow the
safety criteria in accordance with the TLC & Safety Emissions of New York when
transporting members, including the following securement systems:
• Tie Down Straps: 4 Tie Down Straps for each Wheelchair Position.
• Seat Belts: A passenger seat belt and shoulder harness shall also be provided for
use by mobility aid users for each mobility aid securement device. These belts
shall not be used in lieu of a device, which secures the mobility aid itself.
ADDITIONAL TRANSPORTATION REQUIREMENTS:
Each vehicle must be equipped (installed) as follows:
• Body Fluid/Spill Kit
• Reflector Triangle Kit (3 Triangles)
• First Aid Kit
• Fire Extinguisher

AUTHORIZATION REQUIREMENTS

MLTCP Authorization Requirements
GuildNet MLTCP requires prior written authorization, except for in network Optometry,
Podiatry, Dentistry, Nutritional Counseling and Audiology Screening. Those services
may be self-selected and self-scheduled by the Member from the Provider Network for
routine visits. Limitations of services are in accordance with MMIS guidelines.

GuildNet Gold and Health Advantage Authorization Requirements
GuildNet Gold and Health Advantage members do not require a referral, but some
GuildNet Gold and Health Advantage services require prior authorization. Please see the
table on the following pages for authorization requirements.
GuildNet Gold and Health Advantage are point of service plans for most Medicare
services. Out of network providers must accept Medicare assignment and can submit
claims for services not requiring authorization to:
GuildNet c/o EmblemHealth, PO Box 2830, New York, NY 10116-2830
Out of Network provider forms can be obtained on line at:
http://www.emblemhealth.com/pdf/hcfa1500-emb.pdf
The table on the following pages outlines the authorization requirements for GuildNet
MLTCP, GuildNet Gold and GuildNet Health Advantage. Services not requiring prior
approval are allowed according to Medicare/Medicaid quantities and limitations,
including appropriate diagnosis. It is best to check prior approval requirements with
EmblemHealth/GHI by calling:
1-866-557-7300 or fax to: 1-866-725-6603.

For GuildNet MLTCP, authorizations and prior approvals are obtained from the
GuildNet Case Manager (1-212-769-7855)
For GuildNet Gold and Health Advantage, authorizations and prior approvals for
covered services are obtained from the GuildNet Case Manager (1-212-769-7855) or
EmblemHealth Utilization Management (1-866-557-7300 Fax: 1 866-725-6603) as
follows:
Authorization/Prior Approval Requirement
Covered Service

GuildNet
MLTCP

GuildNet
Gold

GuildNet
Health Advantage

Yes

GuildNet Case
Manager

Not Covered

None

Yes

GuildNet Case
Manager

GuildNet Case
Manager. Not covered
in Nassau and Suffolk

Sometimes
Claim submitted to
EmblemHealth.
Authorization from
EmblemHealth needed
for non-Abbott items.

Sometimes

Yes

Yes*

GuildNet Case
Manager

> $500 * EmblemHealth> $500 * EmblemHealth
< $500 none
< $500 none

Medical and
Surgical Supplies Medicaid-covered

Yes

GuildNet Case
Manager

Medical and
Surgical Supplies Part B

Yes

GuildNet Case
Manager

> $500 * EmblemHealth> $500 * EmblemHealth
UM; < $500 none
UM; < $500 none

Yes

GuildNet Case
Manager

EmblemHealth UM

EmblemHealth UM if
Medicare-covered

Adult Day Care
Ambulance Emergency
Ambulance Non-emergent

Diabetes
Yes
Monitoring GuildNet Case
Diabetes selfManager
monitoring,
management training
and supplies,
including glucose
monitors, test strips
and lancets.
Durable Medical
Equipment (DME)

Parenteral/
enteral feeds

Not Covered

Claim submitted to
EmblemHealth.
Authorization from
EmblemHealth needed
for non-Abbott items.

Not Covered

Yes

Authorization/Prior Approval Requirement
Covered Service
Hearing Exams/
Hearing Aids

Home Health Care
(CHHA)

GuildNet
MLTCP

GuildNet
Gold

GuildNet
Health Advantage

None

Yes

GuildNet Case
Manager

EmblemHealth UM for EmblemHealth UM for
skilled services;
skilled services.
GuildNet Case
Manager for long term
chronic care.

Home Health Care
(Licensed)
Hospice Care:
Fee for service
Medicare/Medicaid
Meals on Wheels

Nutrition Therapy

Occupational
Therapy Services

Yes

GuildNet Case
Manager

Not Covered

Yes

Not Covered

GuildNet Case
Manager

No for in-network
providers

Not Covered

Yes

GuildNet Case
Manager

EmblemHealth UM
EmblemHealth UM for
for Medicare-covered. Medicare-covered.
GuildNet Case
Manager for chronic
care.

No
Optometry - Eye
Exams, Eye Glasses,
Contact Lenses; Low
Vision Services

Orthotics/Prosthetics Yes
Orthopedic
GuildNet Case
Footwear
Manager

Not Covered

GuildNet Case
Manager for chronic
care.

No
Davis Vision Network
for vision services, exams, glasses, contacts
Phone: 800-999-5431
Eligibility: 800-783-6872*
PO Box 1525, Latham, NY 12110
www.davisvision.com
Yes

Yes

>$500
EmblemHealth UM

Authorization/Prior Approval Requirement
Covered Service

GuildNet
MLTCP
Yes

Ostomy Supplies

Oxygen Therapy

PERS

GuildNet
Gold

GuildNet
Health Advantage

None

Yes

GuildNet Case
Manager

EmblemHealth UM

Yes

Not Covered

GuildNet Case
Manager

Yes
Physical Therapy/
Occupational
GuildNet Case
Therapy/ SpeechManager
Language Pathology
(PT/OT/ST)

Yes

GuildNet Case
Manager for chronic
care.

Podiatry/Foot Care

None

No*

Yes

EmblemHealth UM
EmblemHealth UM for
for Medicare-covered. Medicare-covered.

Routine foot care 4
times per year and
for medicallynecessary treatment
of injuries or
diseases of the foot.
*GuildNet Case
Manager for routine
foot care beyond 4
visits per year.

Private Duty
Nursing

Yes

GuildNet Case
Manager

Prosthetics and
Orthotics

Yes

GuildNet Case
Manager

> $500 * EmblemHealth> $500 * EmblemHealth
UM; < $500 none
UM; < $500 none
23

Authorization/Prior Approval Requirement
Covered Service

GuildNet
MLTCP
Yes
GuildNet Case
Manager

Respite Care

GuildNet
Gold

GuildNet
Health Advantage

Yes*
Not Covered
EmblemHealth UM
for first 8 Respite days
in calendar year (in
home or SNF)
GuildNet Case
Manager for
remaining days after
the 8th day.

Skilled Nursing
Facility (SNF) Care

Social and
Environmental
Modifications
Social Day Care

Social Work
Services

Speech-Language
Pathology

Transportation –
Non Emergent

Yes

GuildNet Case
Manager

EmblemHealth UM for EmblemHealth UM for
skilled services
Medicare-covered care.
GuildNet Case
Non-Medicare services
Manager for long term are not covered.
chronic care

Yes

Not Covered

GuildNet Case
Manager

Yes

GuildNet Case
Manager

Yes

Not Covered

Yes

GuildNet Case
Manager

EmblemHealth UM
EmblemHealth UM for
for Medicare-covered. Medicare-covered.

Not Covered

GuildNet Case
Manager

GuildNet Case
Manager for chronic
care.

Yes

GuildNet Case
Manager

GuildNet Case
Manager for NYC. Not
covered in Nassau and
Suffolk.

Authorization Process

For Services Authorized by the GuildNet Case Manager:
Authorization for services, revised authorizations, and authorization terminations are
faxed to the Provider. Each authorization has the following information:
•
•
•
•
•
•
•
•
•
•
•
•

Heading indicating the Plan name (GuildNet MLTCP, GuildNet Gold or GuildNet
Health Advantage)
Authorization or Request Number
Authorization effective and expiration date;
Name, Address, and GuildNet Identification Number of Member;
Diagnosis;
Physician Name, Address, and Telephone Number;
Service code and description of service;
Amount, frequency and duration of service;
Name and Address of the Provider;
The name of the Member service staff person entering authorization;
The name of the member’s Case Manager;
Additional information is documented in the “Notes” section of the authorization.
This information would include relevant clinical information and reason for
referral.

In addition, if the request is unusual, time-sensitive, especially complicated or requires a
particular customization, additional written or verbal communication with the Provider
will take place. This information will be provided consistent with the Confidentiality
Policy referenced in the Quality Assurance Plan.
The Provider should review the authorization to confirm the vendor name, dates of
service, service code, and number of units authorized. If any of these fields do not match
the service/item requested, call the GuildNet representative issuing the authorization
immediately and request a corrected authorization.
Authorization is not required for payment of Medicare or other Primary Payor CoInsurance, with the exception of Skilled Nursing Facilities.
See sample authorization on next page.

Services fully or partially covered by Medicare or other primary insurance:
Verifying primary payor coverage and eligibility, acquiring any needed physician
orders and exhausting all other payment sources prior to billing GuildNet remains the
responsibility of the Provider.
In the event that a provider has knowledge that a Medicare covered item has already been
obtained through Medicare, or other payor, and the allowable time period for replacement
has not expired, the provider must contact the GuildNet Case Manager prior to delivery.
Where required by individual regulatory requirements, or third party reimbursement,
Providers are responsible for obtaining their own physician orders and medical necessity.
The Case Manager/Interdisciplinary Care Team can assist the Provider in obtaining the
orders if the Provider’s attempts have been unsuccessful.
Providers must advise GuildNet immediately if services cannot be provided.
For GuildNet Gold or Health Advantage Services requiring Prior Approval from
EmblemHealth Utilization Management (UM) please call:
EmblemHealth: 1-866-557-7300 Fax: 1-866-725-6603

Service Standards for Providers

Providers participating in the GuildNet Provider Network shall provide service to
Members in accordance with the standards set by GuildNet except when a longer timeframe is required by the Member. These standards are outlined below:
Service:

Standard (relative to requested start date):

Adult Day Health Care
Audiology

Placement must occur within 14 days
Standard: within 7 days
Emergency: within 48 business hours
Standard: within 28 days
Emergency: within 24 business hours
Delivery must occur within 72 hours, unless custom
order or otherwise noted.
Initial visit must occur within 24 hours
Date and time specified by GuildNet
Placement must occur within 7 days or as otherwise
noted
Service must be provided within 14 days
Standard: within 7 days
Emergency: within 24 business hours
Initial visit must occur on the date and time
specified by GuildNet

Dentistry
DME/Supplies
Home Health Care
Meals (Home/Congregate)
Skilled Nursing Facility
Nutritional Counseling
Optometry
Personal Care

Physical, Occupational
& Speech Therapy (not in home) Initial visit within 7 days
Physical, Occupational
&Speech Therapy (in home)
Initial visit must occur within 72 hours
Podiatry
Standard: within 7 days
Emergency: within 24 business hours
Private Duty Nursing
Date and time specified by GuildNet
Prosthetics/Orthotics
Measurement within 14 days
Respiratory Therapy
Initial visit must occur within 24 hours
Social Day Care
Placement must occur within 14 days
Social and Environmental Supports Delivery within 14 days unless custom ordered
Social Work Services
Service must be provided within 14 days
Transportation
Pick up within 30 minutes of scheduled time
Clinical notes should be submitted within 48 hours of assessment visit. Progress
notes/summaries should be submitted every two weeks thereafter unless otherwise
requested or there is a decrease in member health status.

Claims Submission and Inquiry

Providers must inform GuildNet Provider Relations of any changes in Tax ID, Corporate
Name and/or addresses as soon as they are known. Allow 30 days for record updates.
CLAIM SUBMISSION
Claims for authorized services must be submitted to GuildNet within 120 days of the date
of service. GuildNet may pay claims denied for untimely filing where the provider can
demonstrate that a claim submitted after 120 days of the date of service resulted from an
unusual occurrence and the provider has a pattern of timely claims submissions.
Claims submitted beyond 120 days will be paid at a discount up to 25%. Claims for
dates of service beyond 365 days will not be considered for payment. All claims should
be submitted to:
GuildNet c/o Relay Health
1564 Northeast Expressway
Mail Stop HQ-2361
Atlanta, GA 30329
1-866-775-8860
Fax 1-770-237-1535
Claims for services partially covered by Medicare or another primary payor must be
accompanied by a Medicare or other primary payor EOB.
Electronic Submission:
Participating Providers submitting claims for 10 or more GuildNet members per month
must submit electronic claims in HIPAA 5010 format. Information regarding
submission of electronic claims can be obtained by sending an email to:
guildnetit@jgb.org.
All Claims must include:
1. Member name and GuildNet Member ID number
2. Provider Name, Tax ID Number and NPI number
3. Valid ICD-9/Diagnosis Code
4. A Date of Service that falls within the effective and expiration date printed on the
authorization
5. The Service Code
6. The number of Units (cannot exceed the total units or units per day on the
authorization)
7. Copy of the primary insurer EOB for co insurance claims

Prompt Payment:
Electronic Claims will be paid within 30 days of receipt.
Paper claims will be paid within 45 days of receipt.
29

PAPER CLAIMS MUST BE SUBMITTED IN THE FOLLOWING FORMAT:
•

CMS HCFA 1500 :
Individual Practitioners
DME & Medical Supplies
Transportation Providers
Rehab Therapy - Pvt. Practice (home or office setting)

All fields must be completed including Place of Service and Valid Diagnosis Code
•

UB-04
Home Care
Nursing Home
Day Care
PERS
Rehab Therapy Clinic Setting

All fields must be completed including Bill Type and Valid Diagnosis Code

Company invoices and spread sheets will not be accepted.
Electronic Claims are submitted in 837I or 837P format.

FRAUD AND ABUSE
Do not submit claims based on authorizations without proper
documentation. Billing for services not rendered or different
than the service actually provided is considered to be Fraud
and Abuse.
All Providers are expected to be familiar with and compliant
with GuildNet’s Fraud, Waste and Abuse Policies and
Procedures. Fraud, Waste and Abuse Training for Providers is
located on GuildNet’s website at
http://www.jgb.org/pdf/shared/FraudWasteandAbuse.pdf.

How to Obtain a GuildNet 835
•

Provider must obtain access to an FTP product or program

•

Provider must supply IP address of machine(s) that will send and receive files

•

Provider must supply Public Key and obtain GuildNet’s Public Key

Once all requirements above are met, a testing phase must take place in order to ensure
accuracy.
To begin, please email GuildNet IT at guildnetit@jgb.org.

GUILDNET MEDICARE CLAIM SUBMISSION AND
INQUIRY

GuildNet Gold and Health Advantage Claims for services accessed through
EmblemHealth (see GuildNet Gold and GuildNet Health Advantage Covered Services)
should be submitted to EmblemHealth. Please see contact numbers and addresses below.
GuildNet Gold and Health Advantage are Point of Service plans for most services. If you
are not an EmblemHealth/ GHI Medicare Choice Participating Provider, you may obtain
a non-participating claim form at: http://www.emblemhealth.com/pdf/hcfa1500-emb.pdf.
Claims for all other GuildNet services (those authorized by the GuildNet Case Manager)
should be submitted to GuildNet in the same manner as claims for the MLTCP.
EmblemHealth Contact Numbers for GuildNet Providers of Medicare Services
Member Eligibility and Benefits

1-866-557-7300 (toll free)

Claims Status Inquiries

1-866-557-7300 (toll free)
EmblemHealth/ GuildNet
P.O. Box 2830
New York, NY 10116-2830
EmblemHealth/ GuildNet
P.O. Box 4296
Kingston, NY 12402-4296

Claims Submission Address
Provider Correspondence
All facilities and practitioners
Pre-Certification Inquiries

1-866-557-7300 (toll free)

Electronic Claims Inquiries
Payer ID Number 13551

1-212-615-4362

CLAIM INQUIRY:
All Claim inquiries/appeals must be submitted within 45 days of receipt of claim
determination.
To inquire about the status of a claim for which no payment or denial has been received
within 45 days
Or
If a line/claim that was submitted in a batch with other claims that were paid on an EOP
is missing from that EOP, contact:
GuildNet CLAIMS PROCESSING at 1-866-775-8860.
For all other inquiries:
Compare the claim to the authorization. Only authorized services are paid. If the service
is provided on an emergency basis or requested outside of business hours, an
authorization should be requested on the next business day.
• If you are denied for a claim and subsequently find that there is an error on the
authorization, call Provider Relations at 917-386-9208.
• If you provided a service different from the service requested (changed hours or
days, completed visit after expiration date, etc) contact the Member’s case
manager or staff person who issued the authorization to discuss the situation.
(Note: Case Management is not required to change an authorization if a different
service was provided).
• If your claim is incorrect, resubmit the claim with the corrections clearly noting
“CORRECTED CLAIM”.
Changes or Retroactive authorizations will only be considered if there is documentation
that GuildNet intended to authorize the service provided.
Paper Claims: If your claim matches the authorization, compare all fields of the claim
line printed on the EOP with your claim. If any of the fields (date of service, code,
amount charged, etc) are not the same as what you submitted on your claim, call Claims
Processing at 866-775-8860. Provide the claim number and the information that was
entered incorrectly
Denials or partial payments due to authorization issues, member status or fee schedule,
contact Provider Relations at: 917-386-9208.

COMMON REASONS FOR DENIAL:
Denied for “NO AUTH” or “SERVICE NOT AUTHORIZED”:
This means that there is no authorization found for date of service or that there is an
authorization but not for the service (code) billed. Check your authorization dates and
codes.
Denied for Duplicate or Paid Authorized Units:
This means that a payment for that code and that day of service was previously paid in
full.
Denied for Diagnosis Code (DX Code):
This means that the Diagnosis code on your claim is either missing or inactive.
Denied for Incorrect Bill Type:
This means that you may have used the wrong Claim Form or your Bill Type is
inconsistence with service.
UNA - “Units Not Authorized” means that the number of units charged is in excess to
the amount authorized or the date of service falls within the authorization effective date
range but no units are authorized for that particular day (i.e. authorized MWF; billed
Tues).
FNF - “Service Not in Fee Schedule”:
The Code billed is not among the list of codes attached to your contract with GuildNet.
For paper claims, check to see if the service code on the EOP is the same as the service
code on your Claim.
ALL - “Reimbursement limited to Prevailing Medicaid or Contractual Amount:”
Contact Provider Relations for Unit Rate inquiry.
PAU - Claim units are in excess of units billed for date of service:
The claim paid the authorized number of units for that day or authorization.
NOTE: A corrected authorization does not automatically reprocess denied claims. You
must submit a corrected claim.
GUILDNET GOLD/ GUILDNET HEALTH ADVANTAGE CLAIM INQUIRIES
GuildNet Medicare claim inquiries regarding claims submitted to EmblemHealth/GHI
must be addressed with EmblemHealth at: 1-866-557-7300.

Appeals of Denied Claims

All Claim inquiries and Appeals must be submitted within 45 days of receipt of
claim determination and include the following information:
After comparing your claim to the EOP and the authorization, appeals must include:
• Claim Number
• Authorization Number
• Member Name
• GuildNet ID Number
• Date of Service (do not include range)
• Service Code Billed
• Units Billed
• Amount Billed
• Reason for Inquiry or Appeal
Claim Inquiry Contacts:
Claims Processing: 866-775-8860
Provider Relations: 917-386-9208
Member Services:
212-769-7855
Written Appeals should be sent to:
Senior Vice President, GuildNet Provider Relations
15 West 65th Street
New York, NY 10023
gnprovrel@jgb.org

Adverse Reimbursement Change

Notice of adverse reimbursement change will be provided at least 90 days prior to an
adverse reimbursement change to the Health Care Professional’s (HCP) contract. If the
health care professional objects to the change that is the subject of the notice by the
MCO, the health care professional may, within thirty days of the date of the notice, give
written notice to the GuildNet to terminate the contract effective upon the implementation
of the adverse reimbursement change. An adverse reimbursement change is one that
“could reasonably be expected to have an adverse impact on the aggregate level of
payment to a health care professional.” A health care professional under this section is
one who is licensed, registered or certified under Title 8 of the New York State
Education Law.
Exceptions:
1) The change is otherwise required by law, regulation or applicable regulatory
authority, or is required due to changes in fee schedules, reimbursement methodology
or payment policies by the State or Federal government or by the American Medical
Association’s Current Procedural Terminology (CPT) Codes, Reporting Guidelines
and Conventions; and
2) The change is provided for in the contract between the MCO and the provider or the
IPA and the provider through inclusion of or reference to a specific fee or fee
schedule, reimbursement methodology or payment policy indexing mechanism.
There is no private right of action for a health care professional relative to this provision.

False Claims Act

Scope of the False Claims Act
The False Claims Act (the “FCA”) is a federal law (31 U.S.C. § 3279) that is intended to
prevent fraud in federally funded programs such as Medicare and Medicaid. The FCA
makes it illegal to knowingly present, or cause to be presented, a false or fraudulent claim
for payment to the federal government. Under the FCA, the term “knowingly” means
acting not only with actual knowledge but also with deliberate ignorance or reckless
disregard of the truth.
FCA Penalties
The federal government may impose harsh penalties under the FCA. These penalties
include “treble damages” (damages equal to three times the amount of the false claims)
and civil penalties of up to $11,000 per claim. Individuals or organizations violating the
FCA may also be excluded from participating in federal programs.
Potential FCA Violations
Knowingly submitting claims to (GuildNet) for services not actually provided. Examples
of the type of conduct that may violate the FCA include the following:
•

Submitting a claim for DME or Supplies when delivery was refused by the
member;

•

Submitting a claim for 2-man transportation, as authorized, but providing 1 man;
and

•

Submitting a claim for a service not provided.

The FCA’s Qui Tam Provisions
The FCA contains a qui tam, or whistleblower, provision that permits individuals with
knowledge of false claims activity to file a lawsuit on behalf of the federal government.
The FCA’s Prohibition on Retaliation
The FCA prohibits retaliation against employees for filing a qui tam lawsuit or otherwise
assisting in the prosecution of an FCA claim. Under the FCA, employees who are the
subject of such retaliation may be awarded reinstatement, back pay and other
compensation. GuildNet’s False Claims Act Policy strictly prohibits any form of
retaliation against employees for filing or assisting in the prosecution of an FCA case.
State Laws Punishing False Claims and Statements
There are a number of New York State laws punishing the submission of false claims and
37

the making of false statements:
•

Article 175 of the Penal Law makes it a misdemeanor to make or cause to make a
false entry in a business record, improperly alter a business record, omit making a
true entry in a business record when obligated to do so, prevent another person
from making a true entry in a business record or cause another person to omit
making a true entry in a business record. If the activity involves the commission
of another crime it is punishable as a felony.

•

Article 175 of the Penal Law also makes it a misdemeanor to knowingly file a
false instrument with a government agency. If the instrument is filed with the
intent to defraud the government, the activity is punishable as a felony.

•

Article 176 of the Penal Law makes it a misdemeanor to commit a “fraudulent
insurance act,” which is defined, among other things, as knowingly and with the
intent to defraud, presenting or causing to be presented a false or misleading claim
for payment to a public or private health plan. If the amount improperly received
exceeds $1,000, the crime is punishable as a felony.

•

Article 177 of the Penal Law makes it a misdemeanor to engage in “health care
fraud,” which is defined as knowingly and willfully providing false information to
a public or private health plan for the purpose of requesting payment to which the
person is not entitled. If the amount improperly received from a single health plan
in any one year period exceeds $3,000, the crime is punishable as a felony.

Medicaid Spend-down And Third Party Insurance

GuildNet assumes responsibility for billing Medicaid Spend-down amounts for
community-based GuildNet Members who have been determined by Medicaid to have
monthly surplus amounts and/or excess resources. Providers shall not bill or collect such
amounts from the Member.
For long term/permanent nursing home placement, the Residential Health Care Facility is
responsible to collect the NAMI for Members designated long term. A stay is considered
short term for a maximum of six (6) months.
Providers are required to bill Medicare or any other third party insurance that is Primary
to Medicaid.
Medicare and Other Primary Payor Services
MLTCP members continue to access their services fully or partially covered by
Medicare through Original Medicare or another Medicare plan that the MLTCP member
may be enrolled in. Participating Providers may bill GuildNet for any required secondary
payments not covered by other insurance as stipulated in the Provider Agreement.
GuildNet members are not responsible for any deductibles or co-payments for
covered services.
GuildNet Gold and GuildNet Health Advantage members access their services fully or
partially covered by Medicare through the Emblem Health/ GHI Medicare Choice PPO
Network under an arrangement between GuildNet and EmblemHealth. Under this plan,
providers do not have to bill separately for Medicare covered services that are
traditionally paid for in part by fee for service Medicaid. Providers are paid in full by
GuildNet Gold through EmblemHealth. No secondary billing is needed. GuildNet Gold
and GuildNet Health Advantage members are not responsible for any deductibles or
co-payments for covered medical services.
Referrals for services fully or partially covered by Medicare:
GuildNet is payor of last resort. It is the provider’s responsibility to determine primary
coverage and eligibility. Co-insurance claims do not require authorization, except Skilled
Nursing Facilities. A copy of the primary and secondary insurer’s EOP must accompany
all co-insurance claims.

Guidelines for Marketing GuildNet Services

Providers may market GuildNet services under the following parameters:
•
•
•
•
•

Providers may distribute brochures provided by GuildNet.
GuildNet may conduct marketing activities at the Provider’s site with the
permission of the Provider.
“Cold Call” telephoning and door-to-door distribution of material and solicitation
is not permitted.
There is no offer of monetary incentives to Medicaid Recipients to join the plan.
There is no offer of monetary incentives to Providers to market GuildNet services
or refer prospective Members to GuildNet.

Member Confidentiality

Providers shall ensure the confidentiality of all Member related information by
maintaining all Member specific information and Member records in accordance with
New York State Public Health Law and the New York State Social Services Law and
HIPAA (Health Insurance Portability Accountability Act). Member information shall be
used or disclosed by a Provider only with the Member’s consent unless otherwise
required by law and only for purposes directly connected with Provider’s performance
and obligations under GuildNet’s Provider Agreement.
Provider will inform and train its employees and personnel to comply with the
confidentiality and disclosure requirements of New York State statutes and HIPAA
(Health Insurance Portability Accountability Act).
Member authorization is not required for access by:
• Medicare or CMS
• The New York State Department of Health
• Accreditation surveyors
• Federal, State and Local government agencies authorized to conduct
investigations of Medicaid Managed Long Term Care Programs

Member Rights

Providers will uphold the Member’s rights and responsibilities as outlined below.
As a Member of GuildNet, the Member has the right to:
• Receive medically necessary care;
• Privacy about the Member’s medical record and treatment;
• Timely access to care and services;
• Receive information on available treatment options and alternatives presented in a
manner and language understood by Member;
• Receive information necessary to give informed consent before the start of treatment;
• Be treated with respect and dignity;
• Receive a copy of their medical records and ask that the records be amended or
corrected;
• Take part in decisions about their health care, including the right to refuse treatment;
• Be free from any form of restraint or seclusion used as a means of coercion,
discipline, convenience or retaliation;
• Receive care without regard to sex, race, health status, color, age, national origin,
sexual orientation, marital status or religion;
• Be told where, when and how to receive the services they need from GuildNet,
including how they can receive covered benefits from out-of-network Providers if
they are not available in the plan network;
• Complain to GuildNet, the New York State Department of Health or the New York
City Human Resources Administration, the Nassau County Department of Social
Services, the Suffolk County Department of Social Services, including the right to use
the New York State Fair Hearing System or in some instances request a NYS
External Appeal;
• Appoint someone to speak for them about their care and treatment; and
• Make advance directives and plans about their care.

Member Responsibilities

As a GuildNet Member, the Member is responsible to:
•

Use Network Providers who work with GuildNet for Covered Services*

•

Receive approval from their physician, Case Manager or care management team
before receiving a covered service requiring such approval;

•

Tell GuildNet about their care needs and concerns and work with their Case Manager
in addressing them;

•

Notify GuildNet when they go away or are out of town;

•

Make all required payments to GuildNet; and

•

Cooperate with any requests for documentation related to maintaining Medicaid
eligibility.
*GuildNet Gold and GuildNet Health Advantage are point of service plans; members
of these plans may go out of network for services normally covered through Original
Medicare.

Member Grievances

A grievance is any communication by a Member to GuildNet about dissatisfaction with
the care and treatment received from GuildNet staff or Providers of covered services,
which does not amount to a change in scope, amount, and duration of service or other
actionable reason.
A Member or a Provider on the Member’s behalf may make a grievance verbally or in
writing. Members are advised of their right to file a grievance at the time of enrollment
(and are advised of their rights and responsibilities annually). Members are advised as to
how to file a grievance, and of their ability to receive assistance from GuildNet staff, if
necessary. All grievances will be resolved without disruption to the Member’s plan of
care. Members will be free from coercion, discrimination or reprisal in response to a
grievance.
All grievances (both same day and non-same day resolution) are logged, tracked and
reported. GuildNet will designate appropriate personnel who were not involved in the
previous level of decision-making to review grievances in supervisory capacity and on
grievance appeal. If the grievance relates to clinical matters, the personnel assigned will
include duly registered health professionals to process both grievances and grievance
appeals.
Grievances (Non –same day resolution) are of two types: standard and expedited.
Standard grievances, including both those reported verbally or written, are
acknowledged in writing within 15 business days of receipt of grievance or less by the
Quality Assurance Performance Improvement Department (QAPI) or Care Management
Department. Grievances are addressed as quickly as required by the Member’s condition.
A standard determination is to be made within 45 calendar days of the receipt of all
necessary information and no more than 60 calendar days from receipt of grievance. The
standard grievance decision will be communicated by telephone and in writing within 3
business days of the decision. The review period for GuildNet’s grievance determination
can be increased by an additional 14 calendar days if it is in the Member’s best interest.
The Member, the Provider on the Member’s behalf, or GuildNet may request the
extension. The reason for the extension must be documented. When the extension is
initiated by GuildNet, a notice will be sent to the Member or the Provider advising of the
extension, the reason for the extension and specify how it is in the best interest of the
Member. If a decision on the grievance is reached before the written acknowledgement
was sent, GuildNet will send the written acknowledgement with the grievance
determination. A GuildNet decision to initiate an extension is made by senior staff, i.e.,
supervisors or directors, when it is established that inadequate information is available to
make an informed decision.
If the standard response time to the grievance would seriously jeopardize the Member’s
life or health or ability to attain, maintain or regain maximum function, GuildNet will
expedite the grievance. The Member or the Provider may request that a grievance be
44

expedited. If GuildNet agrees to expedite the grievance, the expedited grievance
determination will be made within 48 hours of receipt of all necessary information and no
more than 7 calendar days from receipt of the grievance. The expedited grievance
decision will be communicated by telephone and in writing within 3 business days of the
decision.
If the expedited grievance decision is made before the written acknowledgement is sent,
both the acknowledgement and expedited grievance decision will be combined. If the
Member or the Provider on the Member’s behalf, requests that the grievance be expedited
and GuildNet does not agree, GuildNet will notify the Member or the Provider verbally
within 2 days and in writing within 15 days that the grievance decision was not expedited
and the grievance will be handled within the standard grievance decision timeframes.
Grievance data and its analysis are to be used to identify opportunities for program
improvement. GuildNet senior staff will review the grievance data from several
perspectives, including Provider type, specific Providers, and GuildNet staff identified as
responsible parties in the grievance.
The QAPI Director is responsible for all internal management and external reports such
as those to: the Case Management Supervisors and Directors, the Administrative Senior
Staff, the QA Advisory Committee, the GuildNet Board of Directors and the New York
State Department of Health.

Member Appeals of Grievances

A grievance appeal is a written communication from the Member that the Member
disagrees with the decision of GuildNet in response to the grievance filed. Once a
Member files a grievance appeal, GuildNet must look again at the determination to
decide if the decision was the correct one.
Members are instructed during enrollment of their right to appeal a grievance
determination if the Member is dissatisfied with the determination of a grievance.
Members are advised how to file a grievance appeal and if needed, told how to obtain
assistance from GuildNet staff. GuildNet staff will review the grievance appeal with no
disruption in the Member’s care, and Members will be free from coercion, discrimination
or reprisal by the program.
The Member has the right to present their reasons for the grievance appeal both in person
and in writing during the grievance appeal process. The Member has the right to examine
all records that are part of the grievance appeal process. The Member has the right to
have a designated representative.
There are two (2) types of grievance appeal processes. They are:
a. Standard grievance appeal decisions, which are made within 30 business days of
the date of receipt of necessary information.
b. Expedited grievance appeal decisions (if the Member, Provider on behalf of
Member or GuildNet feel that the time interval for a standard grievance appeals
process could result in serious jeopardy to the Member’s health, life or ability to
attain, maintain or regain maximum function), which are made within 2 business
days of receipt of all necessary information.
For both the standard and expedited process, the Member must submit a written
grievance appeal form request within 60 business days from the receipt of the initial
grievance decision. The appeal request form is sent with all notices of action, denial of
service requests or grievance determinations not made in the Members favor. Members
may request an appeal verbally and GuildNet staff will complete the appeal request form
on the Member’s behalf and file with QAPI.

Choosing Among Providers

Providers are selected based on the following criteria:
•
•
•
•
•

Member request for a specific Network Provider
Member has a special need (such as language),
Geographic Area
Provider Performance, including but not limited to:
Level of Complaints & Incidents
Level of past assistance in providing services
Providers that meet or exceed minimum employment standards described in this
manual.

Dispute Resolution

Service Issues:
If there are service issues that are not resolved between the Provider and Case
Management Team, the Provider can contact:
• Case Manager Supervisor, then
• Director of Case Management, then
• Assistant Vice President of Case Management
•
An internal appeal of a Plan Action may be initiated when a member or provider, on the
member’s behalf disagrees with GuildNet’s decision to deny a request for additional
services or payment or to terminate, reduce or suspend a service. The member or
provider may make the request for an appeal verbally or in writing within 45 days of
receipt of the notice of GuildNet’s action to the Director of Quality Assurance (QAPI). If
the request is made after the 45-day requirement the appeal will not be processed. If the
member is requesting aid continuing as a result of a GuildNet decision to terminate,
reduce or suspend services, the appeal must be filed within 10 days of notice or by the
intended date of the action.
Provider complaints regarding GuildNet staff should be forwarded to Provider Relations.

Claim Issues:
Discrepancies between the claim and GuildNet’s approval of services will be processed
as follows:
•

If the Claim Processing Provider denies a claim due to a discrepancy between
GuildNet’s approval record and the claim, or any other problem with the claim or
authorization, the Provider may submit a corrected claim within 45 days of the
denial or follow the claim inquiry procedures outlined in the Provider Manual.

•

If the designated claim inquiry staff decides against the Provider, the Provider can
appeal to the Senior Vice President of Provider Relations.

•

The Provider will be notified in writing of the decision.

•

If the Provider wishes to pursue the discrepancy further, the discrepancy becomes
a dispute, and is adjudicated through the dispute resolution process.

If a dispute arises out of, or relates to, the Provider’s (Provider’s) contract with GuildNet,
and the dispute can not be resolved by the parties within a reasonable time of either
parties notice to the other party of the dispute, the dispute shall be resolved by arbitration,
unless otherwise stipulated. Arbitration shall be conducted pursuant to the contract
between GuildNet and the Provider. Arbitration decisions shall be final and binding.
48

Provider Credentialing

GuildNet Provider Relations maintains credentialing files for each Provider and ensures
timely re-credentialing. Providers must submit information and documentation required
by GuildNet to validate Provider’s qualifications to provide contracted services to
GuildNet Members.
Required documents include:
Completed and signed participating Provider application
All regulatory licenses and certifications
Evidence of Insurances:
(GuildNet, Jewish Guild for the Blind and its subsidiaries must be included as certificate
holder and additional insured for General Liability)
• General Liability
• Professional Liability
• Worker’s Compensation
• Automobile Insurance (as applicable)
NPI (National Provider Identification Number)
Medicaid and Medicare Provider numbers for all Medicaid/Medicare Providers
Provider information is forwarded to a credentialing organization for credential
verification and to check for any existing Medicaid or Medicare sanctions.
Renewed licenses and insurances must be submitted to GuildNet Provider Relations
within 7 business days of receipt.
GuildNet will inform Provider of any deficiencies or missing documents. If the Provider
cannot correct deficiencies or provide timely submission of documents, termination
procedures will be initiated.
GuildNet may conduct a site survey of the Provider’s premises when services are to be
rendered on-site at the Provider’s facility at the discretion of the Senior Vice President of
Provider Relations. GuildNet will consider the results of the site survey in determining
whether to contract with a Provider, and in determining whether to renew a contract with
a Provider. Re-credentialing will be conducted every two years.

Monitoring of Providers
GuildNet monitors provider performance on an ongoing basis as follows:
•

Quality Assurance (QAPI) reviews Member satisfaction surveys and Member
complaint logs.

•

QAPI and Provider Relations meet monthly to review Member complaints.

•

Repeated complaints regarding a particular Provider are followed up by Provider
Relations.

•

Provider Relations contacts the Provider to discuss complaints and request a plan
of action.

•

If repeated issues cannot be remedied, Provider Relations will commence contract
termination procedures.

Provider Audits

GuildNet will annually review a sampling of Provider records documenting evidence of
service delivery to determine accuracy and any patterns of error.
Documents collected and reviewed will include but not be limited to:
• Medical Record Notes
• Attendance records
• Activity Records and/or clinical notes
• Time Slips
• Sign in logs/attendance sheets
• DME delivery tickets
• Trip Verification
• Monitoring Reports from Network Providers
Audits will be based upon a sampling of paid claims for a specific time frame. Provider
selection will be rotated based on utilization. No less than 150 claims will be reviewed.
Method:
1) Upon 30 days notice to Provider, GuildNet will give the Provider a list of invoice
numbers, Member Names and service dates.
2) Provider will make available service rendered documents for GuildNet to review against
the paid claims.
3) GuildNet will compile data into a report indicating number of Providers audited, number
of claims, and number of errors, if any, found.
4) Providers showing a pattern of errors (excess of 5%) will be notified, and corrective
action requested. Re-audits of these Providers will be conducted quarterly.
5) If no corrective action is taken, Provider Relations will be notified and contract
termination procedures will be initiated.

Provider Termination

GuildNet may terminate its contract with a Provider/Provider pursuant to the provisions
of the GuildNet Provider Agreement.
GuildNet shall not terminate a contract with an individual health care Provider except in
compliance with the requirements of Section 4406-d of the New York Public Health Law.
Under this policy, the term “health care professional” shall be defined in accordance with
Section 4406-d of Public Health Law, as a health care professional licensed, registered or
certified pursuant to Title Eight of the New York Education Law.
In accordance with the requirements of Section 4406-d, termination by GuildNet of a
contract with a health care professional shall comply with the following:
a. GuildNet shall not terminate a contract with a health care professional unless
GuildNet provides to the health care professional a written explanation of the
reasons for the proposed contract termination and an opportunity for a review
or hearing as hereinafter provided. This provision shall not apply in cases
involving imminent harm to patient care, a determination of fraud, or a final
disciplinary action by a state licensing board or other governmental agency
that impairs the health care professional’s ability to practice.
b. The notice of the proposed contract termination provided by GuildNet to the
health care professional shall include: (i) the reasons for the proposed action;
(ii) notice that the health care professional has the right to request a hearing or
review, at the professional’s discretion, before a panel appointed by GuildNet;
(iii) a time limit of not less than thirty (30) days within which a health care
professional may request a hearing; and (iv) a time limit for a hearing date
which must be held within thirty (30) days after the receipt of a request for a
hearing.
c. The hearing panel shall be comprised of three persons appointed by GuildNet.
At least one person on such panel shall be a clinical peer in the same
discipline and the same or similar specialty as the health care professional
under review. The hearing panel may consist of more than three person,
provided however that the number of clinical peers on the panel shall
constitute one-third or more of the total Membership of the panel.
d. The hearing panel shall render a decision on the proposed action in a timely
manner. Such decision shall include reinstatement of the health care
professional by GuildNet, provisional reinstatement subject to conditions set
forth by GuildNet, or termination of the health care professional. Such
decision shall be provided in writing to the health care professional.

e. A decision by the hearing panel to terminate a health care professional shall
be effective not less than thirty (30) days after the receipt by the health care
professional of the hearing panel’s decision; provided, however, that Section
4403(6)(e) of the New York Public Health Law, concerning Members’ rights
to continue an ongoing course of care, shall apply to such termination.
f. In no event shall termination be effective earlier than sixty (60) days from the
receipt of the notice of termination.

UPDATING POLICIES AND PROCEDURES

Updates and changes in policies and procedures related to Provider services will be
reviewed and distributed to Providers at least thirty (30) days in advance of
implementation.
Providers will be required to attend in-service and orientation programs as requested.

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