Which procedures require prior approval by OrthoNet?
Refer to the Spine Surgery and Pain Management Procedure Therapy Codes section for the list of codes that apply require prior approval. These codes are subject to change.
Does this program require referrals?
The EmblemHealth Spine Surgery and Pain Management Therapies Program does not require referrals. Prior approval is required for any service or procedure included in the code list. However, most plans do require a referral to access network specialists. Providers are reminded to verify member eligibility and benefits, and ensure there is a valid referral on file prior to the patient’s appointment.
How do providers request prior approval from OrthoNet?
To request prior approval, providers must complete and fax the correct OrthoNet EmblemHealth Prior Authorization Request form for the services being requested along with any supporting clinical notes, including relevant clinical history, imaging reports and other pertinent clinical information to: 1-844-296-4440.
What information do providers need to submit?
1. Complete the fax request form and make sure to include the following information when submitting requests:
- Provider Information section: of the fax request form, include either the facility name or the treating provider name along with the corresponding NPI or Tax ID number.
- To identify offices with multiple locations, please provide the full address of the location where the member will be treated.
- Member Information section: provide the member’s name, date of birth and the EmblemHealth member identification number.
- Request Information section: please complete all fields including:
- Diagnosis code(s)
- Requested procedure
- Spinal level
- Service setting*
- Anticipated date of service
*Please note - OrthoNet will also review for appropriateness of location.
2. Fax the completed request form along with any supporting clinical information to OrthoNet at 1-844-296-4440.
Only prior approval request forms and any associated documents should be faxed to this number.
What documentation will OrthoNet need to render a decision?
OrthoNet will need sufficiently detailed, patient-specific clinical information to make a decision. This will include, at minimum, a relevant patient history that includes any prior treatments for this condition(s) including surgery, pain management, etc. Also required are copies of reports of significant imaging, such as MRI, CT, plain films and copies of relevant electro-diagnostic studies, if they have been performed. A proposed treatment plan/description of the proposed surgery, including the use of any implants is also essential. While a list of possible CPT-4 codes can be submitted, it is far more preferable to provide a written statement of the proposed clinical procedure(s). It is important to include a contact telephone number and fax number with the submission. This will help expedite any requests for additional information.
How long will it take to obtain prior approval?
For pre-service requests, it is OrthoNet’s goal to review the supporting clinical data, verify eligibility/ benefits, render a determination and assign an authorization number, if approved, within one (1) to two (2) business days following the receipt of all necessary information. All utilization management decisions will meet accreditation (NCQA) and regulatory time frames. Providers will be notified and given the following information, both verbally and via fax:
- Authorization number
- Number of approved visits and/or units
- Next review date
For procedures performed at locations other than the clinician’s office, OrthoNet will also notify the facility.
Who reviews the prior approval requests?
All prior approval requests will be reviewed for medical necessity by a licensed health care professional who has received additional training in his/her specialty and who is supported by board certified MDs and DOs.
How do providers file requests for continued pain management therapy services?
Complete an OrthoNet EmblemHealth Pain Management Fax Request form and fax it to OrthoNet at 1-844-296-4440. For questions, contact OrthoNet’s Customer Service Department at 1-844-730-8503, Monday through Friday, 8:30 a.m. to 5:30 p.m.
Is it possible to check the status of a prior approval request?
To check on the status of a prior approval request, providers may contact OrthoNet’s Customer Service Department at 1-844-730-8503, Monday through Friday, 8:30 am to 5:30 pm. Once a determination has been made providers will be notified, both verbally and via fax, on the day the decision is made.
Please note: An authorization is not a guarantee of payment and it is contingent upon the member’s benefits, contract limitations and eligibility at the time of service.
Can providers still request prior approval from EmblemHealth?
No. Providers may not submit requests through emblemhealth.com. Requestors will be directed to contact OrthoNet.
How long will the prior approval be valid?
Prior approvals are valid for 90 days from the date they are issued.
Where can I find the OrthoNet Prior Authorization Fax Request form?
The OrthoNet Prior Authorization Fax Request form can be downloaded from orthonet-online.com or the Provider Toolkit at emblemhealth.com. Providers may also call OrthoNet Provider Services at 1-844-730-8503 to request forms.
Where do I send my claims?
OrthoNet has only been engaged to oversee utilization management. Providers should continue to submit claims to EmblemHealth. Instructions for submitting claims are available in the Claims chapter.
Note: Claims submitted without the required prior approval will be denied.
How do providers request a peer-to-peer review?
For Commercial and Medicaid members, providers may ask for a reconsideration or peer-to-peer discussion upon receipt of the notice of a denial of service from OrthoNet. Providers may also contact OrthoNet’s Customer Service department at 1-844-730-8503.
For Medicare members, providers may request a peer -to-peer discussion, but the decision cannot be changed. However, providers may request a “Re-Open,” which must be submitted in writing to OrthoNet with the additional clinical information the provider would like OrthoNet to review. Written requests must be faxed to OrthoNet at 1-844-296-4440.
How do providers file an appeal?
All commercial and Medicaid member appeals will be reviewed by OrthoNet. If a provider still disagrees with the decision, the provider may exercise his/her rights as outlined in the adverse determination notice. For Medicare, the member, or practitioner on behalf of the member, may file a clinical appeal with EmblemHealth in accordance with the instructions that accompany the denial.
Where do providers send appeals?
A prior approval request that is denied by OrthoNet for spine surgery and pain management therapies may be appealed through OrthoNet. Provider appeals should be mailed to OrthoNet at the following address:
P.O. Box 5046
White Plains, NY 10602-5046
Where can providers find more information?
For additional information, contact OrthoNet directly using one of the options provided below. To ask additional questions, you may sign in to use the Message Center at emblemhealth.com. Select “General Information” from the drop down menu on the “Ask a Question” page.
Glossary terms found on this page:
An evaluative process in which a health care organization undergoes an examination of its policies and procedures to determine whether the procedures meet designated criteria as defined by the accrediting body, and to ensure that the organization meets a specified level of quality.
A determination by EmblemHealth or its agents that an admission, extension of stay or other health care service has been reviewed and, based on the information provided, is not medically necessary.
Oral or written request from a member or their designee for EmblemHealth to review or reconsider a decision made by the plan.
Services that have been approved for payment based on a review of EmblemHealth's policies.
Services available to a member as defined in his or her contract. Benefit design includes the types of benefits offered, limits (e.g., number of visits, percentage paid or dollar maximums applied) and subscriber responsibility (cost sharing components).
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 legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.
The date on which a service was rendered.
A determination of whether or not a person meets the requirements to participate in the plan and receive coverage under the plan.
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.
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.
A unique number that identifies the member's enrollment with EmblemHealth. EmblemHealth's claims are processed by this number. Also known as Member ID Number.
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 permit (or equivalent) to practice medicine or a health profession that is: 1) issued by any state or jurisdiction in the United States and 2) required for the performance of job functions.
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.
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 nonprofit organization that performs quality-oriented accreditation reviews of HMOs and similar types of managed care plans. Also called National Committee for Quality Assurance.
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 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.
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
- Doctor of podiatric medicine
- Physical therapist
- Nurse midwife
- Certified and registered psychologist
- Certified and qualified social worker
- Nurse anesthetist
- Speech-language pathologist
- Clinical laboratory
- Screening center
- General hospital
- Any other type of practitioner or facility specifically listed in the member's 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 Provider's license or certification.
A request for inpatient review, made while the member is still in the facility, of a case that was denied on the basis of medical necessity.
A recommendation by a physician that an enrollee receive care from a specialty physician or facility.
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.