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  • Care Management > Ambulatory Surgery Procedures for Facilities

    Prior to Procedure

    It is the responsibility of the physician or surgeon who will be performing the procedure in the ambulatory surgical facility to obtain prior approval (if required). The practitioner must provide all the required clinical information to the managing entity to obtain the prior approval for the procedure or surgery. The facility must confirm that a prior approval has been issued to HIP, CompreHealth EPO and Medicare HMO members by signing in to www.emblemhealth.com. For all other members, please call Customer Service as indicated in the Directory chapter.

    At the Time of Procedure

    Ambulatory surgery facilities must verify member eligibility by signing in to www.emblemhealth.com.

    EmblemHealth will not issue a prior approval and/or case number until the admission or procedure has been reviewed and either approved or denied. Facilities may check the status of a prior approval request by signing in to www.emblemhealth.com or by calling Customer Service for EmblemHealth-managed members as indicated in the Directory chapter or, for all other members, the managing entity listed on the back of the member's card. The ambulatory surgery representative must have the following information available when contacting Customer Service or the managing entity:

    • Member ID number
    • Member name
    • Procedure date
    • Diagnosis
    • Clinical information supporting the medical necessity of the procedure
    • CPT codes for the requested procedure

    Failure to get prior approval may result in claim denial. Please see the Dispute Resolution chapters - Commercial/CHPMedicaid and Medicare.

    Ambulatory surgery claims will be processed as outpatient care pursuant to the prior approval. (See the "Facility Appeals" sections of the Dispute Resolution chapters - Commercial/CHPMedicaid and Medicare - for guidelines surrounding claims submitted without prior approval.)

    Hospital Transfers

    If an emergency occurs and the member must be transported by ambulance to a hospital, the facility must notify the member's managing entity (for EmblemHealth-managed members, call Customer Service as indicated in the Directory chapter) immediately, or as soon as possible thereafter. In the event circumstances prevent immediate contact with the managing entity, the facility should take all medically appropriate actions to safely transport the member to the nearest hospital.

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    Glossary terms found on this page:

    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 itemized statement of health care services and their costs provided by a hospital, physician's 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.

    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 person’s bodily functions; (c) serious dysfunction of any bodily organ or part of such person; or (d) serious disfigurement of such person.

    A health care benefit arrangement that is similar to a preferred provider organization in administration, structure and operation but does not cover out-of-network care. Also called an Exclusive Provider Organization.

    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 and/or approved by the Office of Alcoholism and Substance Abuse Services is a facility.

    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.

    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 24-hour 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 patient's requirements

    A unique number which identifies the member's enrollment with EmblemHealth. EmblemHealth's claims are processed by this number. Also known as Member ID Number.

    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.

    A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.

    A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 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 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 practitioner's agreement.

    A unique number that identifies the member's enrollment with EmblemHealth. EmblemHealth's claims are processed by this number. Also known as ID Number.

    Treatment that is provided to a patient who is able to return home after care without an overnight stay in a hospital or other inpatient facility

    A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.

    A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.

    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 non-emergency outpatient services before the services are provided. Also called pre-authorization or pre-certification or pre-determination.

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