Chapter 12: EmblemHealth Spine Surgery and Pain Management Therapies Program

OrthoNet, LLC reviews preauthorization requests for EmblemHealth’s Spine Surgery and Pain Management Therapies Program for select spine surgery and interventional pain management therapy procedures.

 

This chapter covers:

  • Service locations 
  • Program inclusions and exclusions 
  • ICD-10 Procedure/Diagnosis codes 
  • Preauthorization requirements and process 
  • Appeal process

A preauthorization does not guarantee payment for services. Payment of claims is dependent on eligibility, covered benefits, provider contracts, and correct coding and billing practices.

  • All GHI members
  • HealthCare Partners Cohort 1 and Cohort 2 members
  • Montefiore CMO members 

While many plans require referrals to access network specialists, the EmblemHealth Spine Surgery and Pain Management Therapies Program does not require referrals. 

 

Refer to Clinical Corner for services requiring  preauthorization. Procedure codes are subject to change; always refer to Clinical Corner for the current list.

Preauthorization is required when services are performed in the following settings:

  • Practitioner’s office (POS 11)
  • Outpatient hospital setting (POS 22)
  • Inpatient hospital (POS 21)
  • Ambulatory surgery center (POS 24)

Complete the applicable form and fax it with supporting clinical documentation to: 844-296-4440

OrthoNet needs sufficiently detailed, patient-specific clinical information. At minimum, this should include: 

  • Relevant patient history including priortreatments for this condition(s), surgeries, pain management, etc. 
  • Copie sof significant imaging reports such as MRI and CT scans, plain films and, if performed, copies of relevant electrodiagnostic studies. 
  • A proposed treatment plan/descriptionof the proposed surgery, including the use of any implants. While awritten statement of the proposed clinical procedure(s) is preferred, alist ofpossible CPT-4 codes can be submitted.

In addition, a contact telephone number and fax number will help expedite requests for additionalinformation.

All utilization management decisions meet accreditation (National Committee for Quality Assurance (NCQA)) and regulatory time frames.

  • Pre-service requests: within one (1) to two (2) business days following the receipt of all necessary information. 
  • Urgent pre-service Medicaid requests: within 72 hours of receiving the request.

OrthoNet notifies physicians (and applicable facilities) on the day the decision is made, and gives the following information both verbally and via fax:

  • Authorization number
  • Number of approved visits and/or units 
  • Next review date

Preauthorizations are valid for 90 days from the date they are issued.

Contact OrthoNet’s Customer Service department at 844-730-8503, Monday through Friday, 8:30 a.m. to 5:30 p.m. 

For Commercial and Medicaid members, providers may ask for a reconsideration or peer-to-peer discussion upon receipt of the denial of service notice by calling OrthoNet’s Customer Service department at 844-730-8503.

 

For Medicare members, providers may request a peer-to-peer discussion, but the decision cannot be changed. However, providers may submit a written request to OrthoNet to “Re-Open” the case. Providers should include additional clinical information supporting the request for OrthoNet to review. Written requests must be faxed to OrthoNet at 844-296-4440.

Practitioners may submit an appeal of a denied preauthorization request to:

OrthoNet
EmblemHealth Appeals
P.O. Box 5046
White Plains, NY 10602-5046 

Fax: 844-296-4440

OrthoNet reviews all Commercial and Medicaid member appeals. If a provider still disagrees with the decision, the provider may exercise their rights as outlined in the adverse determination notice.

 

For Medicare, the member, or practitioner on behalf of the member, may file a clinical appeal with EmblemHealth in accordance with the instructions included with the denial.

OrthoNet only oversees utilization management. Refer to the Claims Contacts section of the Directory Chapter in the Provider Manual for instructions on submitting claims.

 

Note: Claims submitted without the required authorization will be denied.

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