New Utilization Management Pre-authorization List for Elective Services Starting July 1, 2019

EmblemHealth is simplifying our Utilization Management (UM) rules. We are reducing your need to seek pre-authorization based on the member’s type of plan (Commercial, Medicaid, and Medicare) and the selected site of service.

Please see our listing of new pre-authorization codes and details on site of service rules.

The same rules will be applied by all managing entities (HIP, Montefiore CMO, and HealthCare Partners) and delegates who conduct UM on our behalf. See our comprehensive contact list.

Non-Par Services

All non-Par services (unless the member is accessing a non-Par benefit) require prior approval.

This is a list of services requiring pre-authorization subject to their benefit plan's coverage for all places of service, including Office (POS 11). The list accounts for EmblemHealth’s medical policies, medical technology database, provider manual, MCG guidelines, and special utilization management programs. Pre-authorization is not a guarantee of payment. Payment is subject to a member’s eligibility for benefits on the date of service. Emergency services do not require a pre-authorization.

*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. To see what needs authorization, use their look-up tool.

Services that always require pre-authorization

All elective inpatient admissions and services require pre-authorization.

For a list of services, including elective inpatient, please refer to the provider manual.

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.

Services that do not require pre-authorization

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. Please refer to our pre-authorization list for further information on these codes.

Below is a list of products where updated pre-authorization codes will apply.

Company Provider Network Member Benefit Plan
HIP/HIPIC 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

Small Group:
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:
Prime HMO
HIP HMO Preferred (City of NY)
EmblemHealth HMO Plus
EmblemHealth HMO Preferred Plus
Prime POS
Access I
Access II
EmblemHealth EPO Value
Vytra HMO

Large Group-Prime Network:
Prime PPO
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)
Medicare: VIP Prime Network EmblemHealth VIP Dual (HMO SNP)
EmblemHealth VIP Gold (HMO)
EmblemHealth VIP Gold Plus (HMO)
EmblemHealth VIP Premier (HMO)
EmblemHealth VIP Rx Carve-Out (HMO)
EmblemHealth VIP Dual Group (HMO SNP)
EmblemHealth VIP Rx Saver (HMO)
EmblemHealth VIP Part B Saver (HMO)
EmblemHealth VIP Go (HMO-POS)
EmblemHealth VIP Essential (HMO)
EmblemHealth VIP Value (HMO)
EmblemHealth Affinity Medicare Passport Essentials (HMO)
EmblemHealth Affinity Medicare Passport Essentials NYC (HMO)
EmblemHealth Affinity Medicare Ultimate (HMO SNP)
EmblemHealth Affinity Medicare Solutions (HMO SNP)