Office Visit

Starting Aug. 1, 2025, EmblemHealth will require preauthorization for certain hospital outpatient surgeries (places of service 19 and 22) for all members under age 75. Only surgeries that are clinically appropriate in a hospital setting will be approved. See Notable Changes for the specific services and codes that will require preauthorization along with other changes to the list including the removal of 303 services.

The same surgeries scheduled in an ambulatory surgery center (ASC) or physician office will not require preauthorization. Surgeons are encouraged to obtain privileges at an ASC so their patient’s insurance can cover procedures that will not be approved in a hospital outpatient setting.

We are providing advance notice of this change to allow surgeons a three-month grace period to partner with an ASC. To find a participating ASC that is accepting new doctors for the surgeries you perform, see this list. For questions, send a message to our Provider Customer Service team using the provider portal’s Message Center or Live Agent Chat.

The Message Center has a new feature: “All Messages.” You can now see and follow up on the messages submitted by others who have the same security settings as you.* Similarly, they will be able to see your messages, join the conversation, and attach supporting documentation. Communications with Provider Customer Service for the last two years will be available, including those originating outside the portal. 

The messages change is being made to support better collaboration and to reduce rework. Shared access to these messages makes it easier for staff to cover for one another. For example, to see if someone submitted a grievance or appeal, you can self-serve and look up the submitted messages to determine if one is already recorded before you duplicate the effort. To get to Messages:

• Click the user profile icon in your browser’s top right corner. (It looks like a person in a circle.)
• A drop-down menu will open.
• Select “Inquiries.”

This will take you to the Message Details page. In the top section you will be able to see the opened messages you have sent or received. Click on “All Messages” to search by tax ID (required) and NPI (optional) for inquires others submitted. These will display in the second section of the screen.

*Anyone who can conduct business for the same provider, i.e., has the same tax ID, NPI, and same portal role (e.g., Clinical Staff, Billing Staff, etc.).

New: Update diagnosis codes before submitting requests and notices

If you are entering a preauthorization request or elective inpatient admission notification (requests and notices) and the member’s diagnosis changes before you submit the request or notice you will be able to update it on the Review Details page. For a better portal experience when submitting requests and notices, see this new Tip Sheet.

Managing osteoporosis is a key quality measure under the Healthcare Effectiveness Data and Information Set (HEDIS^®) and an important part of delivering needed care to our older members. 

Be sure to assess women 67 – 85 years of age who suffered a fracture and prescribe a medication to treat osteoporosis in the six months after the fracture. Also, recommend a bone mineral density (BMD) test.  

There are several exclusions:

• Patients who had a BMD test during the 730 days (24 months) prior to the episode.
• Patients who had a claim/encounter for osteoporosis therapy during the 365 days (12 months) prior to the episode.
• Patients who received a dispensed prescription or had an active prescription to treat osteoporosis during the 12 months prior to the episode.

 Helpful tips to close gaps in care:

• Ask all female patients 67 – 85 years of age if they have had a fracture since their last visit.
• Consider writing a prescription for a BMD test at time of fracture.
• If patients are unable or unwilling to have a BMD test, prescribe osteoporosis medications if appropriate.
• Place a reminder in the patient’s chart for a BMD test.
• Partner with your EmblemHealth team to offer in home BMD screening assessments. If you do not already have a contact, please email us.
• Use telehealth visits to review, document, and prescribe medication, when appropriate.
• Educate patients on safety and fall prevention.

By following these recommendations, you can help improve patient health outcomes.  

As part of our annual review process, EmblemHealth is removing 303 services and codes from the EmblemHealth Preauthorization List. 

In addition, we are adding five new codes, expanding some existing preauthorization requirements to additional members. Also, as shared in EmblemHealth Site of Service Rules for Certain Surgeries Start Aug. 1 and in our Notable Changes, starting Aug. 1, 2025, some codes will require preauthorization when performed in an outpatient hospital setting, places of service (POS) 19 and 22 for members under 75 years of age.

EmblemHealth Preauthorization List: See list for code changes and applicable effective dates. 

See revision histories for the updates to the following lists:

• GHI PPO City of New York Preauthorization List.
• ConnectiCare Commercial Preauthorization List.
• ConnectiCare Medicare Preauthorization List.
• EmblemHealth/ConnectiCare: Home Infusion Therapy Drug Preauthorization List.
• The Pharmacy Medical Preauthorization Lists for EmblemHealth and ConnectiCare.

Quarterly Code Updates

EmblemHealth and ConnectiCare update their claims processing systems based on code updates received from American Medical Association (AMA), CPT, and Centers for Medicare & Medicaid Services (CMS). Both the AMA and CMS release quarterly updates to their respective code sets. Below are links to the latest preauthorization lists.

We strive to load and configure each code update within 60 days of the update’s effective date. The current process will hold the entire claim if it contains a new code while it is being configured. To avoid delaying critical payments to our providers, we adjudicate the claim for all services except for the new code(s) that need configuration. Once the new CPT and/or HCPCS codes have been loaded into our claims processing system, we will reprocess the claims to ensure proper adjudication of the claim.

• EmblemHealth/ConnectiCare: Home Infusion Therapy Drug Preauthorization List.
• The Pharmacy Medical Preauthorization Lists for EmblemHealth and ConnectiCare.