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  • Directory > How to Obtain Prior Approval

    All providers must verify member eligibility and benefits prior to rendering non-emergency services. Requests and supporting clinical information must be sumbitted via fax to 1-844-296-4440.


    How to Obtain Prior Approval
    Plan/Managing Entity Instructions


    Requests may be submitted via the secure provider website:, or faxed to either (866) 426-1509 (for DME requests) or (866) 215-2928 (for all other requests).

    Call (866) 447-9717 for more information or to use the IVR system.

    Hospitals and skilled nursing facilities can verify prior approval status by reviewing their concurrent review status reports.

    EmblemHealth EPO/PPO (GHI)

    Requests may be submitted via the secure provider website:, faxed to (212) 563-8391, or by calling the Coordinated Care Intake department at (800) 223-9870.

    See Additional Prior Approval Procedures for GHI Practitioners for more information.

    Medicare PPO (GHI)

    Requests may be submitted via the secure provider website: or faxed to (877) 508-2643.

    Call (866) 557-7300 for more information or to use the IVR system.

    For questions regarding the prior approval process or the status of a specific request, call Customer Service at (877) 244-4466.

    See Additional Prior Approval Procedures for GHI Practitioners for more information.

    HealthCare Partners

    Call (800) 877-7587 or fax your request to (888) 746-6433.

    Montefiore CMO

    Call (888) 666-8326.

    For behavioral health services, call (800) 401-4822.

    Vytra Health Plan

    Call (888) 288-9872.

    Prior approval requirements and procedures may be different for Vytra ASO accounts, so please contact the administrator listed on the Vytra member's ID card for more information.

    Empire BCBS

    Effective January 1, 2016, utilization management for GHI PPO City of New York employees and non-Medicare eligible retirees with GHI PPO benefits will be managed by Empire BCBS for inpatient and outpatient services.

    Call (800) 521-9574.

    See a list of all services requiring pre-certification from Empire BCBS.

    Behavioral Health Services

    Emblem Behavioral Health Services Program

    Requests may be submitted via the Beacon Health Options website: or by calling Beacon Health Options at (888) 447-2526. (For members in plans underwritten by HIP or HIPIC or administered by VHMS)

    EmblemHealth Behavioral Management Program

    Requests may be submitted via the Beacon Health Options website: or by calling Beacon Health Options at (800) 692-2489. (For members in plans underwritten by GHI)


    Requests may be submitted by calling (800) 401-4822. (For members who have the Montefiore logo on the lower left corner of their ID card)

    Cardiology and Radiology Services


    Requests may be submitted via the EviCore website:, or by calling (866) 417-2345 (for HIP members) or (800) 835-7064 (for GHI HMO, GHI PPO and EmblemHealth EPO/PPO members)
    Chiropractic Services

    All EmblemHealth plans

    Requests may be submitted via the Palladian website:, by calling (877) 774-7693 or faxed to (716) 809-8324.

    Outpatient Physical and Occupational Therapy


    Requests may be sumbitted via the Palladian website:, by calling (877) 774-7693, or faxed to (716) 809-8324.

    Spine Surgery and Pain Management Therapy Program
    HIP Requests and supporting clinical information must be faxed to (844) 296-4440.
    Pharmacy Services
    EmblemHealth Pharmacy Benefit Services

    Call (877) 362-5670, Monday through Friday, 8 a.m. to 6 p.m.

    EmblemHealth Injectable Drug Utilization Management Program

    Requests may be submitted via the Magellan Rx website:, by calling (800) 424-4084, Monday through Friday, 8 a.m. to 6 p.m., or faxed to (716) 809-8324.

    Submit both the prior approval request and the replacement drug order from Magellan Rx by using the appropriate fax form available at:

    Specialty Pharmacy Program

    Requests may be submitted by calling (888) 447-0295, Monday through Friday, 8:30 a.m. to 5 p.m. or faxed to (877) 243-4812.

    Radiology Services

    See the Radiology Program and Cardiology Imaging Program chapters.

    My Subscriptions

    Enter your e-mail address to receive a link to your subscriptions.


    Glossary terms found on this page:

    Conditions that affect thinking and the ability to figure things out that affect perception, mood and behavior.

    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).

    A process in which an individual, an institution or educational program is evaluated and recognized as meeting certain predetermined standards. Certification usually applies to individuals; accreditation usually applies to institutions.

    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.

    The evaluation of the medical necessity, appropriateness and efficiency of the use of health care services, procedures and facilities under the provisions of the applicable health benefit plan. It is sometimes called utilization review or utilization management.

    Medical equipment, goods, implements and prosthetics that are prescribed for patient care, usually in an outpatient setting. Examples of such equipment include hospital beds, wheelchairs and walkers.

    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.

    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 card which allows the subscriber to identify himself or his covered dependents to a provider for health care services.

    Service provided after the patient is admitted to the hospital. Inpatient stays are those lasting 24 hours or more.

    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 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.

    Treatment to restore a physically disabled person's ability to perform activities such as walking, eating, drinking, dressing, toileting and bathing (activities of daily living).

    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
    • Dentist
    • Chiropractor
    • Doctor of podiatric medicine
    • Physical therapist
    • Nurse midwife
    • Certified and registered psychologist
    • Certified and qualified social worker
    • Optometrist
    • Nurse anesthetist
    • Speech-language pathologist
    • Audiologist
    • 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 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.


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