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Neighborhood Care

Provider FAQ for Preauthorization Reduction Project

What changes are coming to Utilization Management Preauthorization?

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. 

Which EmblemHealth products are included?

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.

Why did EmblemHealth reduce the number of Utilization Management Preauthorization codes?

In the health care system today, there are too many instances of services being overprescribed, delivered in the most expensive settings, and codes submitted for services that do not meet patient needs. Science leads our decision-making, so we took a close look at national treatment standards developed by physicians and other medical professionals that establish best practices for ensuring people receive high-quality, affordable care. We also know from our experience as a health plan and a provider that our members and their providers often view preauthorization procedures as burdensome.

How will this benefit the doctor’s office?

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.

Why were specific codes chosen for removal?

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).

Will additional codes be considered for elimination?

We will continue to review our data to allow us to find additional ways to improve care for the people we serve. 

What if the procedure results in an inpatient stay?

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

How will the doctors know which codes no longer require preauthorization?

If the office initiates their requests through the Provider Portal and enters the code, a note indicating the need for authorization will be displayed.  If the office calls into the Medical Management Department, the staff will advise if preauthorization is required. 

Will this also impact authorizations for radiology or durable medical equipment?

No, this would not apply to any vendor preauthorization codes. 

What if the physician or provider is not participating?

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.