UM & Medical Management
EmblemHealth is simplifying our utilization management (UM) rules. We are reducing your need to seek pre-authorization (PA) based on the member’s type of plan (Commercial, Medicaid and Medicare) and the selected site of service.
Please be aware that some of our policies and procedures may be affected by COVID-19 regulations published by state and federal regulators. Please review our Provider COVID-19 page to stay up-to-date on all changes.
News
| Date | Title |
|---|---|
| 02/26/2021 | Site of Service Rules for Medicare Effective April 1, 2021 |
| 10/22/2020 | Claims Submission and Utilization Management for SOMOS Community Care |
| 01/02/2020 | No referrals needed for initial evaluation of PT, OT, and radiology |
| 01/02/2020 | Infertility Coverage Expansion for HIP Medicaid and Commercial Members |
| 01/02/2020 | 2020 Infertility Mandate PA Coding |
| 10/01/2019 | New Utilization Management Preauthorization Rules Starting Jan. 1, 2020 |
| 09/01/2019 | Utilization Management Preauthorization Codes Removed Jan. 1, 2020 |
| 09/01/2019 | New Empire Precertification Requirement (NYC Healthline) |
| Notification: Pharmacy Utilization Management Services Starting January 1, 2021 | |
| Notification: Pharmacy Utilization Management Services Starting Aug 3, 2020 | |
| New Authorization Process for Fertility Prescriptions for City of NY |
Preauth Rules
| Date | Title |
|---|---|
| 07/17/2020 | EmblemHealth Utilization Management Preauthorization Lists |
UM Programs
| Date | Title |
|---|---|
| Radiology Related Programs | |
| Frequently Asked Questions: EmblemHealth Oncology Drug Management |