Beginning Jan. 1, 2020, EmblemHealth is significantly reducing the number of procedure codes that need our approval before delivering care. This change is consistent with EmblemHealth’s commitment to partnering with our provider network to find ways to let them more fully devote their attention to delivering the care people deserve.
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Provider FAQ for Preauthorization Reduction Project
This change affects enrollees in all our plans, including Medicaid managed care, Medicare Advantage, coverage offered through employers, and Individual Market plans on the Exchange. Beginning Jan. 1, 2020, the list will apply to HIP members as well as GHI (non-City of New York) members with a “K” ID number. The remaining GHI PPO (non-City of New York) plans will change to the new list on their plan renewal date.
Preauthorization required physician offices to take several steps before EmblemHealth could approve the procedure. This included submitting clinical information, notes, lab tests, and more depending on the service. The administrative burden for this process can be significant for busy physician offices or facilities. Simplifying the process for gaining authorization for care also leads to patients freed of the anxiety of waiting for a decision.
Through careful analysis of our data, we identified services that almost always get approved. These services include some major surgical procedures and common surgical procedures where patients are going to the hospital (i.e. some cardiac and vascular procedures, gallbladder removal, and treatment of glaucoma).
We will continue to review our data to allow us to find additional ways to improve care for the people we serve.
EmblemHealth will continue to request it be notified when enrollees are admitted for inpatient hospitalizations but will not require a medical necessity determination for procedures that are no longer on the prior authorization list. For notifications, physicians should sign into our Provider Portal to contact our Medical Management Department. Provider Portal login screen can be reached at https://www.emblemhealth.com/providers/resources/provider-sign-in
The answer depends on the member’s benefit plan. If out of network (OON) service is available for that policy, then no preauthorization would be required. If the member does not have OON benefits, then it would require an authorization.
