CurrentEmblemHealthPolicy N/A

EmblemHealth Child Health Plus Plan — Covered Services (Clinical/Medical Policy)

Lists services covered for members of the EmblemHealth Child Health Plus Plan and notes prior approval requirements and in-network expectations; applies to plan members and their in-network providers.

Policy Summary

PayerEmblemHealth

PolicyChild Health Plus Plan — Covered Services

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionContact Customer Service at 855-283-2146 (TTY: 711) to determine and obtain prior approval when required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18document chunks extracted

Well-Child visits + Immunizationspreventive services highlighted

Behavioral Healthbehavioral health service categories listed

Prior approval requiredadministrative requirement noted

Covered Services and Limitations

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Preventive care: Well-child care visits per the American Academy of Pediatrics schedule and Advisory Committee on Immunization Practices (ACIP) recommended immunizations are covered.

Behavioral health: Inpatient mental health and alcohol/substance use services; Residential Rehabilitation Services for Youth (RRSY); Assertive Community Treatment services (Young Adult ACT and Youth ACT); outpatient visits for mental health and treatment of alcoholism and substance use; children and family treatment and support services. Services must be provided by certified and/or licensed professionals.

Inpatient care: Hospital care as a registered bed patient for treatment of an illness, injury, or condition that cannot be treated on an outpatient basis; hospital must be a short-term, acute care, New York State–licensed facility.

Outpatient surgery: Procedures performed in a physician's office and ambulatory surgery procedures in hospital-based or freestanding ambulatory surgery centers are covered.

Diagnostic and laboratory tests: Prescribed ambulatory clinical laboratory tests and diagnostic X‑rays are covered.

Durable medical equipment, prosthetics, and orthotics: Durable medical equipment (DME) intended for use by one person, which may be custom-made or customized, is covered.

Therapeutic services: Ambulatory radiation therapy, chemotherapy (including medicines provided at time of therapy), injections, hemodialysis, and blood‑clotting deficiency treatment are covered.

Speech and hearing: Hearing examinations, speech therapy, and hearing aids provided by audiologists, language pathologists, speech therapists, and/or otolaryngologists are covered.

Pre-surgical testing: All tests (laboratory, X‑ray, etc.) necessary prior to inpatient or outpatient surgery are covered.

Second opinions: Second surgical and medical opinions are provided by a qualified doctor or appropriate specialist (including those affiliated with specialty care centers).

Drugs: Prescription and non‑prescription medicines are covered when authorized by a professional licensed to write prescriptions.

Ambulance services: Pre‑hospital emergency medical services, including prompt evaluation and treatment of an emergency condition and non‑airborne and air ambulance transportation to a hospital, are covered.

Medical supplies: Ostomy equipment and supplies, and diabetic supplies and equipment are covered.

Diabetes education: Diabetes self‑management education (including diet), reeducation or refresher, and home visits for diabetic monitoring and/or education are covered.

Vision care: Emergency, preventive, and routine vision examinations by a doctor or optometrist, including prescribed lenses, frames, and contact lenses, are covered.

Autism services: Screening, diagnosis, and treatment of autism spectrum disorders are covered.

Dental care: Emergency, preventive, and routine dental care, including orthodontics, is covered.

This coverage criteria document applies to members of the EmblemHealth Child Health Plus Plan and describes the scope of benefits and expectations for service delivery. Coverage applies when services are medically necessary and, in most cases, must be provided by in-network health care professionals. The document summarizes covered categories but does not list every covered service or every limitation or exclusion; providers should verify benefits for specific cases.

Except in emergency situations, non-emergency out-of-network services may not be paid. When prior approval is required or eligibility is unclear, providers should contact EmblemHealth Customer Service at 855-283-2146 (TTY: 711) for guidance and to determine whether prior authorization is needed.

Provider Responsibilities and Authorization

Prior Authorization

Prior Authorization Required

Some services require prior approval from EmblemHealth before they are provided. Prior authorization helps determine coverage and medical necessity — contact Customer Service to confirm whether a specific service needs approval.

Call Customer Service at 855-283-2146 for prior authorization requirements.
TTY: 711.

Denial Risk

Out-of-Network Denial Risk

Except in emergencies, services provided by out-of-network providers may be denied or not covered. Verify network status and authorization requirements before scheduling non-emergency care to avoid claim denials or unexpected member liability.

Out-of-network non-emergency services may not be paid by EmblemHealth.
Confirm in-network providers and obtain prior approval when required.

Prior Authorization

Authorization for Medications

Providers must obtain prior authorization for prescription and non-prescription medicines that require an authorized prescriber’s order. Contact Customer Service if unsure whether a drug requires prior approval.

Prescription and non-prescription medicines must be authorized by a licensed prescriber.
For prior approval or questions, call 855-283-2146 (TTY 711).

Documentation Required

Provider Action — Verify and Document Authorizations

Action required: before delivering services that may require approval, verify prior authorization requirements and document authorization on the claim. If you have questions, contact EmblemHealth Customer Service for guidance.

Document prior authorization number on claims when applicable.
Contact Customer Service at 855-283-2146 (TTY 711) for determinations and assistance.

Policy Background and Scope

This document summarizes the services covered for Child Health Plus members when medically necessary across multiple care settings. Covered service areas include preventive care—such as well-child visits per the American Academy of Pediatrics schedule and recommended immunizations; behavioral health services including inpatient mental health, substance use services, residential rehabilitation for youth, assertive community treatment, and outpatient mental health and substance use treatment; inpatient hospital care for conditions that cannot be treated on an outpatient basis; and outpatient surgery performed in physician offices or ambulatory surgery centers.

The policy also covers diagnostic and laboratory tests, durable medical equipment (DME), prosthetics, and orthotics, therapeutic services (for example ambulatory radiation therapy, chemotherapy, injections, hemodialysis), speech and hearing services including hearing aids, pre-surgical testing, second surgical and medical opinions, prescription and non-prescription drugs authorized by a licensed prescriber, ambulance services, medical supplies (such as ostomy and diabetic supplies), diabetes education and home visits, vision care (emergency, preventive, and routine), autism screening/diagnosis/treatment, and dental care including orthodontics.

OpenPayer

EmblemHealth Child Health Plus Plan — Covered Services (Clinical/Medical Policy)

Covered Services and Limitations

Provider Responsibilities and Authorization

Key Definitions

Policy Background and Scope