EmblemHealth Utilization Management Preauthorization Lists

07/17/2020

  • Preauthorization Check

    EmblemHealth has introduced a new and improved Preauthorization Check tool. This tool provides an easy way to see if a CPT/HCPCS code requires preauthorization for a HIP/HIPIC member. You will need a member line of business, the CPT/HCPCS code for review and place of service where the services are being performed.

EmblemHealth Preauthorization List

Please click on the link above for a complete list of all services that require preauthorization.  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 and it includes Pharmacy codes.

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 the preauthorization list above:

  • The creation of the list is inclusive of EH’s Medical Policies, MedTech Data base, 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, in addition to DME and Homecare 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, PT, OT, ST, home infusion therapy)

 

GHI PPO City of New York Preauthorization List

This is an EXCLUSIVE list for GHI PPO City of New York membership for services rendered at EmblemHealth, and this list applies to the following lines of business:

  • GHI Commercial City of New York
  • GHI Medicare City of New York