Switch to:

Provider

Switch to:
Switch to:

Search

Popular Tasks

Contact Us

Neighborhood Care

Preauthorization Lists

The following chart shows our preauthorization lists for your reference.

Preauthorization Lists
List Description
EmblemHealth Preauthorization List The list indicates which CPT codes require preauthorization based on site of service and diagnosis codes. It indicates which codes are handled by a vendor.
The list applies to the following EmblemHealth lines of business:
  • GHI Commercial non-City of New York
  • GHI Medicare non-City of New York
  • HIP Commercial
  • HIP Medicaid
  • HIP Medicare
Please be aware of the following information concerning this preauthorization list:
  • Pharmacy services covered by members’ medical benefits that require preauthorization are now addressed in a separate list.
  • The creation of the list is inclusive of EmblemHealth’s Medical Policies, Medical Technical Database, Provider Manual, Vendor Management, and Place of Service policies.
  • Preauthorization is required for all Inpatient types of care including Medical, Surgical, Hospice, Skilled Nursing Care, Rehabilitation Care, as well as DME and Home Care services.
  • In addition to the defined services, we have identified specific CPT/HCPCS codes that require preauthorization.
    • Including:
      • All non-emergency inpatient hospital admissions (acute, rehabilitation, behavioral health, and skilled nursing facility care)
      • Home health care (nursing, physical therapy, occupational therapy, speech therapy, and home infusion therapy)
    Select Notable Changes To The Preauthorization List above to see key changes made to this list.
    EmblemHealth Pharmacy Medical Preauthorization List Notable changes are captured in the Revision History on the list.
    GHI PPO City of New York Preauthorization List This is an EXCLUSIVE list for GHI PPO City of New York members for services rendered by EmblemHealth’s providers, and this list applies to the following lines of business:
    • GHI Commercial City of New York
    • GHI Medicare City of New York
    ConnectiCare’s Coverage Guidelines and Preauthorization Lists These Commercial and Medicare preauthorization rules apply to ConnectiCare members who are seen by EmblemHealth providers. See the Summaries of Companies, Lines of Business, Networks & Benefit Plans in our Provider Toolkit to see which ConnectiCare plans give their members access to EmblemHealth providers.

     

    To see full information on our Utilization Management programs, preauthorization requirements, and who conducts preauthorization reviews, see the EmblemHealth Provider Manual’s Care Management chapter and the Coverage Guidelines section of the ConnectiCare website.

    For services that are managed by EmblemHealth and ConnectiCare directly,* please submit preauthorization requests using our Provider Portals (EmblemHealth Provider Portal and ConnectiCare Provider Portal). These transactions may be done on either site for all members. To see full information on our Utilization Management programs, preauthorization requirements, and who conducts preauthorization reviews, see the EmblemHealth Provider Manual’s Care Management chapter and the Coverage Guidelines section of the ConnectiCare website.

    No need to fax in supporting materials. Preauthorization transactions allow for attachment of medical records and other supporting documentation when creating the request. You can also return to the preauthorization request to upload information after the request is submitted. To learn about the preauthorization transaction, see our videos and user guides and frequently asked questions.

     

    The Preauthorization Check Tool provides an easy way to see if a CPT/HCPCS code requires preauthorization. This tool is available to help expedite preauthorization requirement research. If there is a discrepancy between this tool and the preauthorization lists on EmblemHealth’s and ConnectiCare’s websites, the lists posted below will prevail.

    To use the tool, you will need the:

    • CPT/HCPCS code
    • Type of plan the member has (line of business)
    • Diagnosis code
    • Planned place of service

    Note: To ensure accurate responses, you must clear the screen between searches. 

    Lookup Tool
    Date Issued (YYYY/MM/DD) Title
    2022/04/05 Codes That No Longer Require Preauthorization
    2021/10/27 Preauthorization List Reductions and Updates for 2022
    2021/06/10 Oncology Drug Program - Additional Codes Require Preauthorization Effective August 15, 2021
    2022/04/15 Durable Medical Equipment (DME) Additional Codes Require Preauthorization Effective Aug. 1, 2022
    2022/07/01 Annual Review of Preauthorization Requirements – Scheduled Updates for July, September, and November 2022

     

    Find a doctor or medical office

    provider

    Language Assistance:

    © 2020 EmblemHealth. All Rights Reserved.

    Any information provided on this Website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider's office.

    Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your plan. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage.