As you know, EmblemHealth requires providers and facilities to obtain preauthorization for elective services rendered in an inpatient hospital. Now, New York State has issued new guidance for health plans and providers that further defines how claims for inpatient services like these are handled.
Beginning on Jan. 1, 2021, if a facility fails to obtain preauthorization for an elective inpatient hospital admissions, claims will not be paid until medical necessity is established. Facilities will have 45 days to submit clinical information to the plan to support the elective inpatient services. A clinical determination will be made within 15 days of receipt of the clinical information, but no later than 60 days from the request. As usual, the facility may file a utilization review appeal for any denial.
Furthermore, state rules now allow health plans to impose administrative denials if there is a systemic and repeated failure of any facility to obtain preauthorization for an elective inpatient admission.
We would like to remind you, that in addition to elective inpatient admissions requiring preauthorization, admissions through the emergency room require notification.
We encourage providers to use the Provider Portal to submit requests for prior approval for elective procedures, to review instances of pended hospital claims, and to notify us of admissions from the emergency room. We also encourage them to review our list of codes requiring preauthorization.