New Utilization Management Pre-authorization Rules Starting Jan. 1, 2020

10/01/2019

 

EmblemHealth is aligning its Utilization Management (UM) preauthorization (PA) requirements across all lines of business.  We are reducing the number of codes that require PA by half and are adopting a strategy which limits your need to seek preauthorization based on the type of plan the member has (Commercial, Medicaid and Medicare).  Lists may further limit what needs a PA based on diagnosis, site of service and member age, as described in the table below.  

The changes will apply to most members January 1.  Those with large group plans underwritten by Group Health Incorporated (GHI) who are not affiliated with the City of New York (non-CNY) will adopt these new rules as their plans renew and they are migrated to our new claims system and are given a new member ID number that will begin with the letter “K”.  For a sample of the new ID card, GHI PPO non-CNY members will receive upon renewal, click here.  Until renewal, members will continue to follow the existing GHI PA List.

The new rules will be applied by all Managing Entities (EmblemHealth, Montefiore CMO, and HealthCare Partners) and delegates who conduct UM on our behalf.

The table below outlines the PA changes and rules that will apply to all members.

 

 

Lines of Business

Date of Change

Preauthorization (PA)

Changes Beginning on 1/1/20

Existing preauthorization rules*

that will continue

*The code lists are updated based on CMS rules.

HMO

All Products:

· Commercial

· PPO

· POS

· EPO

· ASO

· Medicaid / HARP

 

 

1/1/20

 

·       Separate PA requirements for each line of business:

o   Commercial

o   Medicaid

 

·       Site of Service rules implemented on 9/1/19 will continue to apply for HMO Commercial and HMO Medicaid members only.    

·       The following changes will apply to Site of Service rules on 1/1/20:

o   For HMO Commercial and HMO Medicaid individuals 18 years or younger, no preauthorizations will be needed for any of the services that have a Site of Service rule.

o     These rules will apply to all HMO Commercial POS members who choose to use their out of network benefit.  Members will be responsible for obtaining PA for out-of-network care.

 

·       Diagnosis Codes

o    A PA may be required at the diagnosis code level.  Check the diagnosis code columns in the lists above carefully to ensure that the code requires a PA.

 

 

 

 

 

·    All inpatient types of care require PA, including:

o   Medical

o   Surgical

o   Hospice

o   Skilled Nursing Care

o   Rehabilitation Care

o   Behavioral Health

o   DME

o   Home Health Care Services (nursing, PT, OT, ST and home infusion therapy)

 

 

HMO Medicare

 

 

1/1/20

·       Separate PA requirements for each line of business:

o   Medicare

 

·       Diagnosis Codes

o    A PA may be required at the diagnosis code level.  Check the diagnosis code columns in the lists above carefully to ensure that the code requires a PA.

 

·    All inpatient types of care require PA, including:

o   Medical

o   Surgical

o   Hospice

o   Skilled Nursing Care

o   Rehabilitation Care

o   Behavioral Health

o   DME

o   Home Health Care Services (nursing, PT, OT, ST and home infusion therapy)

 

 

GHI PPO (non-City of New York)

 

All Products:

Commercial

Beginning on 1/1/20 – will adopt new rules as the plans renew and members are migrated to our new claims system and are given a new member ID card that begins with the letter “K”. See sample ID card by clicking here. Until renewal, members will continue to follow the existing GHI PA List.

·       Separate PA requirements for each line of business:

o   Commercial

 

·       Site of Service rules implemented on 9/1/19 will continue to apply for GHI PPO Commercial members only.   

·       The following changes will apply to Site of Service rules on 1/1/20:

o   For individuals 18 years or younger, no preauthorizations will be needed for any of the services that have a Site of Service rule.

o     These rules will apply to all GHI PPO Commercial members who choose to use their out of network benefit.  Members will be responsible for obtaining PA for out-of-network care.

 

 

 

·       Diagnosis Codes

o    A PA may be required at the diagnosis code level.  Check the diagnosis code columns in the lists above carefully to ensure that the code requires a PA.

 

·    All inpatient types of care require PA, including:

o   Medical

o   Surgical

o   Hospice

o   Skilled Nursing Care

o   Rehabilitation Care

o   Behavioral Health

o   DME

o   Home Health Care Services (nursing, PT, OT, ST and home infusion therapy)

 

 

GHI PPO (non-City of New York) Medicare

1/1/20

·       Separate PA requirements for each line of business:

o   Medicare

 

·       Diagnosis Codes

o    A PA may be required at the diagnosis code level.  Check the diagnosis code columns in the lists above carefully to ensure that the code requires a PA.

 

·       All inpatient types of care require PA, including:

o Medical

o Surgical

o Hospice

o Skilled Nursing Care

o Rehabilitation Care

o Behavioral Health

o DME

o Home Health Care Services (nursing, PT, OT, ST and home infusion therapy)

 

GHI PPO (City of New York

No Change

·       Does not apply to GHI PPO City of New York members.  PA for GHI PPO City of New York is managed by Empire BCBS for all services, with the exception of the four services listed in the next column.

 

·       To see what needs authorization, use the Empire BCBS look-up tool.  

 

·       The current exception will continue – EmblemHealth manages PA for any items on the list related to:

o Home Health Care

o Home Infusion

o Nutritional Supplements and Enteral Therapy

o High Tech Radiology (eviCore)