Spine Surgery and Pain Management Therapies Program Starts November 16, 2015

Date Issued: 11/6/2015

EmblemHealth will implement a new utilization management program for spine surgery and pain management therapy. This program which begins November 16, 2015, requires providers to contact OrthoNet directly to obtain prior approval for select spine surgery and interventional pain management therapy procedures. This applies to services provided by practitioners in their offices (POS 11), in an outpatient hospital (POS 22), ambulatory surgery center (POS 24) or inpatient hospital (POS 21) setting.

OrthoNet’s dedicated phone and fax lines will open November 9, 2015 to allow you to set up services that will be needed when the program officially begins on November 16, 2015.

Our partnership with OrthoNet gives you access to experts in the field of Orthopedics and Pain Management who can assist you in planning the best and most effective course of treatment for your patients.

Beginning November 16, 2015 you will be required to contact OrthoNet directly to obtain prior approval for select spine surgery and pain management therapy procedures. (See Program Guide below for codes). This will apply to procedures that are done in any of the following settings: provider office (POS 11), inpatient hospital (POS 21), ambulatory surgery center (POS 24), and Outpatient hospital (POS 22) for members in the following networks:

NETWORK INCLUSIONS
Included Networks:
Enhanced Care Prime Network Medicare Essential Network
Premium Network
(aka Vytra Premium Network)
Associated Dual Assurance Network
Prime Network* EmblemHealth Dual Assurance Network
Select Care Network VIP Prime Network
NY Metro Network
Exceptions:
• Members assigned to a Montefiore, St. Barnabas or a Health Care Partners PCP

*Includes GHI HMO branded benefit plans

The EmblemHealth Spine Surgery and Pain Management Therapies Program requires that you obtain prior approval for any in-scope service or procedure. (See Program Guide below for codes).

The EmblemHealth Spine Surgery and Pain Management Therapies Program Guide provides you with information on requesting prior approval, the codes that require prior approval and what to do if a request for prior approval is denied and more.

Please note: Most plans require members to have a referral to access network specialists. Remember to check member eligibility, benefits and if there is a valid referral on file prior to the patient’s appointment.

Requesting Prior Approval

To request prior approval you must complete and Fax the correct OrthoNet EmblemHealth Prior Authorization Request Form along with any supporting clinical notes including relevant clinical history, imaging reports and other pertinent clinical information to: 1-844-296-4440.

Pain Management Prior Authorization Request Form

Spinal Surgery Prior Authorization Request Form

Phone Lines Open November 9, 2016

OrthoNet’s dedicated phone and fax lines for this program will open November 9, 2015 to allow you to set up services that will be needed when the program officially begins on November 16, 2015.

Members Currently Undergoing Treatment

Prior Approvals will not be available through emblemhealth.com. If the member is undergoing a course of treatment on the start date of the program, and has a valid prior approval from EmblemHealth, then that prior approval will be honored until the treatment is complete or the prior approval expires, whichever occurs first.

Claims Submission

This program does not change our claims submission procedures. Please submit your claims as usual to EmblemHealth.

Sign Up for Email Updates

We suggest you sign up for email updates from the new EmblemHealth Spine Surgery and Pain Management Therapies Program chapter of the Provider Manual to ensure you always have the most up-to-date information.