All non-Par services (unless the member is accessing a non-Par benefit) require prior approval.
This is a complete list of all 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./p>
*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 complete pre-authorization list for further information on these codes.