New Utilization Management Pre-authorization List for Elective Services Starting July 1, 2019
EmblemHealth is focused on ensuring members receive services in clinically appropriate settings. A few weeks ago, we announced upcoming changes to the pre-authorization list and we are providing you with an update to our previous announcement. Our goal is to provide you with additional information on this change.
Beginning July 1, 2019, we will supplement our current utilization management pre-authorization list with 99 codes that have site of service rules. These codes apply to Commercial and Medicaid lines of business only. See our supplemental list.
Here are details surrounding the 99 codes with site of service rules:
- 27 of these codes are present on the current utilization management pre-authorization list, and EmblemHealth will now process these codes with site of service rules. Click here for a list of these codes.
The site of service rules identify procedures that do not require a pre-authorization if performed in certain medical settings. For the Commercial and Medicaid lines of business, there are certain procedures performed in an office setting (POS 11) or in an ambulatory surgery center (POS 24) that do not require pre-authorization.
Emergency services will not require a pre-authorization.
The same rules will be applied by all managing entities (HIP, Montefiore CMO, and HealthCare Partners) and delegates who conduct utilization management on our behalf. See our comprehensive contact list.
EmblemHealth will continue to require pre-authorization for the services listed below.
For a list of services, including elective inpatient, please refer to the Provider Manual.
A few services that require pre-authorization are:
- All elective inpatient admissions and services require pre-authorization.
- The inpatient hospital place of service (POS 21) always requires pre-authorization.
- Cosmetic, and Experimental & Investigational services require pre-authorization regardless of site of service.
- All non-Par services (unless the member is accessing a non-Par benefit) require prior approval.
*GHI PPO City of New York employees and non-Medicare eligible retirees with GHI PPO benefits will be managed by Empire BlueCross BlueShield for inpatient and outpatient services. To see what needs authorization, use their look-up tool.
List of products
Below is a list of products where updated pre-authorization codes will apply.
||Member Benefit Plan
||Commercial: Select Care Network
||Individual On/Off Exchange:
EmblemHealth Platinum/EmblemHealth Platinum D
EmblemHealth Gold/EmblemHealth Gold D
EmblemHealth Silver/EmblemHealth Silver D
EmblemHealth Bronze/EmblemHealth Bronze D
EmblemHealth Basic/EmblemHealth Basic D
EmblemHealth Gold Value/EmblemHealth Gold Value D
EmblemHealth Silver Value/EmblemHealth Silver Value D
EmblemHealth Platinum Choice
EmblemHealth Gold Choice
EmblemHealth Gold Value S
EmblemHealth Silver Choice
EmblemHealth Silver Value S
EmblemHealth Bronze Value S
||Commercial: Prime Network
||Prime Network-NYC, LI & Westchester:
Child Health Plus
Large Group-Prime Network with Tristate Access:
HIP HMO Preferred (City of NY)
EmblemHealth HMO Plus
EmblemHealth HMO Preferred Plus
EmblemHealth EPO Value
Large Group-Prime Network:
HIP Select PPO
Small Group-Prime Network with Tristate Access:
EmblemHealth Platinum Premier
EmblemHealth Gold Premier
EmblemHealth Gold Premier 1
EmblemHealth Gold Plus
EmblemHealth Gold Plus 1
EmblemHealth Healthy NY Gold
EmblemHealth Silver Premier
EmblemHealth Silver Premier 1
EmblemHealth Silver Plus
EmblemHealth Silver Plus 1
EmblemHealth Bronze Plus H.S.A.
||Medicaid/Commercial: Enhanced Care Prime Network
||EmblemHealth Enhanced Care (Medicaid)
EmblemHealth Enhanced Care Plus (HARP)
Essential Plan (BHP)