Policy Updates That Impact Where Members Get Care

Updated Aug. 14, 2026:

At EmblemHealth, our members’ health is our highest priority. This means we stay on top of best practices and adopt the ones we believe can help them get and stay healthy in an affordable way. As part of this ongoing effort, we review how our members get their care. When we find a better way of doing something, we update our policies. You may already know about some of these changes, but we were notified by the New York State Department of Financial Services (DFS) that we did not properly let you know. 

Site of Service Medical Policy – Infusions and Injectables Policy

This policy was changed on July 14, 2024, to help our members take advantage of some of the region’s best infusion centers and care offered in their doctor’s office or even in their own homes for injectable and/or intravenous medications that can safely be administered outside of a hospital setting. 

EmblemHealth works with multiple organizations that will recommend the most medically appropriate, convenient, and cost-effective options for your EmblemHealth patients.

Prior authorization requests should be submitted to Prime Therapeutics by one of the following methods:

Fax: 888-656-6671
Telephone: 833-519-4548, 8 a.m. to 6 p.m., Monday through Friday
Online: gatewaypa.com

Prime Therapeutics may direct a member to a setting other than the one you and/or they prefer for these services. You have the right to request a real-time clinical peer-to-peer discussion as part of the Prior Authorization process by calling 833-519-4548. If you disagree with Prime Therapeutics' decision, you have the right to file an appeal. Prime Therapeutics’ decision will include information about how to file an appeal.   

Services the policy covers: Specialty pharmacy infusions and specialty pharmacy injections administered by a health care professional. To see all services the policy covers, view the full Site of Service Medical Policy – Infusions and Injectables Policy.

Potential service or network provider limits: The site of service clinical review may limit the settings in which services covered under the policy may be provided and may render a network provider unable to perform a service.

For full details, see the Site of Service Medical Policy – Infusions and Injectables Policy.

Site of Service Medical Policy – Ambulatory Surgery Policy

This policy was implemented on Aug. 1, 2025. It requires preauthorization for the procedures and surgeries listed in the “Services the policy covers” section below only when they are performed in a hospital setting for patients under the age of 75.

Note that procedures and surgeries no longer require preauthorization if they are one of the following:

• Scheduled in an ambulatory surgery center (ASC).
• Scheduled in a doctor’s office.
• For members 75 years of age or older.

Preauthorization requests should be submitted through the provider portal.

Services the policy covers include minor surgeries (such as the laparoscopic repair of an initial hernia or the excision of an ingrown or deformed nail) and routine procedures such as a colonoscopy or a bronchoscopy. To see all services the policy covers, view the full Site of Service Medical Policy – Ambulatory Surgery Policy.

Potential service or network provider limits: The site of service clinical review may require you to perform a surgery or a procedure in a setting other than in a hospital, if it is clinically appropriate. It may also mean you may not be able to perform a surgery or procedure.

For full details, see the Site of Service Medical Policy – Ambulatory Surgery Policy.

You have the right to request a real time clinical peer to peer discussion as part of the preauthorization process by calling 646-447-7479. If you disagree with our decision on your preauthorization request, you have the right to appeal. The decision will include information about how to file an appeal. 

Appeal Rights for Site of Service Denials

EmblemHealth respects the care you provide. If your preauthorization request is denied (called an adverse determination) based on our site of service policy(s), you, a member, their representative, or an attorney can appeal our determination. The appeal must be submitted within 180 days of the date of the adverse determination.  

You can mail or fax the appeal to the address(es) or number(s) listed below as applicable: