Provider Manual

Chapter 12: EmblemHealth Spine Surgery and Pain Management Therapies Program

This chapter contains policies and procedures for the EmblemHealth Spine Surgery and Pain Management Therapies Program, and includes the following information:

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

The EmblemHealth Spine Surgery and Pain Management Therapies Program applies to members participating in benefit plans associated with the following networks:

  • Prime Network
  • Enhanced Care Prime Network
  • Select Care Network
  • VIP Prime Network

While many plans require referrals to access network specialists, the EmblemHealth Spine Surgery and Pain Management Therapies Program does not require referrals. Providers are reminded to verify member eligibility and benefits and ensure valid referrals to network specialists are on file prior to the patient’s appointment.

 

The EmblemHealth Spine Surgery and Pain Management Therapies Program is managed by OrthoNet, LLC and requires providers to contact OrthoNet directly to obtain prior approval for select spine surgery and interventional pain management therapy procedures.

 

Refer to the Spine Surgery and Pain Management Procedure Therapy Code List for inpatient and outpatient procedures and therapies requiring prior approval. Procedure codes are subject to change; always refer to the above link for the most up-to-date list.

Prio rapproval is required for all codes in the Spine Surgery and Pain Management Procedure Therapy Code List when performed in the following settings:

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

To request prior approval for initial or continued services, providers must complete and fax the form matching the requested service: 

 

Fax the form and any supporting clinical notes (including relevant clinical history, imaging reports, and other pertinent clinical information) to: 844-296-4440. 1

 

Be sure to include the following information on the form:

  • Provider Information: either the facility name or the treating provider name along with the corresponding NPI or tax ID number, as well as the full address of the location where the member will be treated.
  • Member Information: member’s name, date of birth, and EmblemHealth member ID number.
  • Request Information: all fields including:
    • Diagnosis code(s)
    • Requested procedure
    • Spinal level
    • Service setting 2
    • Anticipated date of service

 

Only prior approval request forms and any associated documents should be faxed to this number.

OrthoNet will also review for appropriateness of location.

OrthoNet needs sufficiently detailed, patient-specific clinical information to make a decision. This includes, at minimum, relevant patient history including prior treatments for this condition(s), surgeries, pain management, etc. Also required are copies of significant imaging reports such asMRI and CT scans, plain films and, if performed, copies of relevant electro-diagnostic studies. A proposed treatment plan/description of the proposed surgery, including the use of any implants, is also essential. While a written statement of the proposed clinical procedure(s) is preferred, a list of possible CPT-4 codes can be submitted. It is important to include a contact telephone number and fax number with the submission. This will help expedite requests for additional information.

For pre-service requests, it is OrthoNet’s goal to review the supporting clinical data, verify eligibility/benefits, render a determination, and assign an authorization number, if approved, within one (1) to two (2) business days following the receipt of all necessary information. (For urgent pre-service Medicaid requests, this will occur within 72 hours of receiving the request.) All utilization management decisions meet accreditation (National Committee for Quality Assurance (NCQA)) and regulatory time frames. Providers are notified on the day the decision is made, and given the following information, both verbally and via fax:

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

For procedures performed at locations other than the clinician’s office, OrthoNet also notifies the facility.

 

Prior approvals are valid for 90 days from the date they are issued.

 

To check on the status of a prior approval request, providers may contact OrthoNet’s Customer Service department at 844-730-8503, Monday through Friday, 8:30 a.m. to 5:30 p.m. 

Note: Anauthorization is not a guarantee of payment and it is contingent upon the member’s benefits, contract limitations, and eligibility at the time of service.

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.

Prior approval requests denied by OrthoNet for spine surgery and pain managementtherapies may be appealed by mail to the following address:

 

OrthoNet 
EmblemHealth Appeals
P.O. Box 5046
White Plains, NY 10602-5046 
Fax: 844-296-4440

 

All Commercial and Medicaid member appeals are reviewed by OrthoNet. If a provider still disagrees with the decision, the provider may exercise his/her 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 oversees only 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 prior approval will be denied.

For members whose care is managed by Montefiore Medical Group (CMO) or HealthCare Partners (HCP), providers must contact the applicable organization for prior approval. Check the member’s ID card or eligibility information on emblemhealth.com to determine whether HIP, CMO, or HCP is the managing entity responsible for managing a member’s care.