Revised Prior Approval List for Networks Effective January 22, 2014

Date Issued: 1/23/2014

On January 22, 2014, a revised Prior Approval List went into effect for benefit plans in the following networks:

  • HIP Premium
  • HIP Prime
  • Medicaid Prime
  • NY Metro
  • Select Care
  • VIP Prime*
  • Vytra
WHAT requires prior approval? Services that require prior approval are now consistent for the networks noted above unless the service is not covered by the member’s benefit plan.
WHEN should a prior approval be requested? When submitting a prior approval request, there may be minor exceptions in timing (for example, the number of referral visits allowed before a prior approval request must be made).
WHO will conduct the pre-service review? Pre-service reviews are administered by the managing entity listed on the member ID card or by the vendor managing a utilization program on our behalf.

A Prior Approval Look-up Tool to simplify determining what procedures need pre-service review and approval became operational on our secure website on January 22, 2014. To facilitate claims payment, this tool will advise you whether a referral, prior approval or notification must be entered into our systems when HIP or EmblemHealth is the managing entity for the member. Sign in to our secure website to access the Look-up Tool.

*Correction: The cover letter mailed with the Prior Approval List incorrectly identified Medicare HMO as an exception. Only Medicare plans using the Medicare Choice PPO network are excluded from this list.