All providers must verify member eligibility and benefits prior to rendering non-emergency services. See Clinical Corner for services that require Preauthorization.
| WHO TO CONTACT FOR PREAUTHORIZATION | |
|---|---|
| EmblemHealth | EmblemHealth has partnered with various companies to provide special utilization management programs. See additional contacts below.
Skilled Nursing Facility; Inpatient Rehabilitation Facility; Long-Term Care Facility; Home Health Care |
| Managing Entity Partners (Applicable to Health Insurance Plan of Greater New York (HIP) only) |
|
| HealthCare Partners | Call 800-877-7587 Fax 888-746-6433 |
| SOMOS IPA, LLC | Online smnyportal.valence.care Fax 877-590-8003 Call 844-990-0255 |
| Vendor Partners | |
| Anthem Blue Cross and Blue Shield (formerly known as Empire BCBS (NYC GHI PPO)) |
Utilization management for GHI PPO City of New York employees and non-Medicare eligible retirees with GHI PPO benefits is managed by Anthem Blue Cross and Blue Shield for inpatient and outpatient services. Call 800-521-9574 Fax 800-241-5308 For fertility prescriptions and infertility services, including artificial insemination and IVF: Call WINFertility 833-439-1515 To see what needs authorization, use their look-up tool. |
| Behavioral Health Services | |
| Emblem Behavioral Health Services Program | For members in plans underwritten by HIP or EmblemHealth Insurance Company (formerly HIPIC), submit requests: Online: carelonbehavioralhealth.com/providers Call Carelon Behavioral Health (formerly Beacon Health Options) at 888-447-2526 |
| EmblemHealth Behavioral Management Program | For members in plans underwritten by EmblemHealth Plan, Inc. (formerly GHI), submit requests: Online: carelonbehavioralhealth.com/providers Call Carelon Behavioral Health (formerly Beacon Health Options) at 800-692-2489 |
| Cardiology and Radiology Services; Durable Medical Equipment (DME) | |
| eviCore | Submit requests: Online: evicore.com Call: 866-417-2345 (for HIP members) 800-835-7064 (for EmblemHealth Plan, Inc. (formerly GHI) members) |
| Spine Surgery and Pain Management Therapy Program | |
| OrthoNet | For forms via orthonet-online.com by calling 844-730-8503. Requests and supporting clinical information must be faxed to 844-296-4440. |
| Pharmacy Services (also see the Pharmacy Medical Preauthorization List) | |
| EmblemHealth Pharmacy Benefit Services | Call 877-444-3657, Monday through Friday, 8 a.m. to 6 p.m. |
| Express Scripts | Commercial Pharmacy Drug Reviews:
Commercial Medical Drug Reviews:
Medicaid Medical Drug Reviews:
Medicare Pharmacy Drug Reviews:
Medicare Medical Drug Reviews:
Home Infusion Therapy |
| New Century Health | Submit requests: Online: my.newcenturyhealth.com Fax 877-624-8602 Call 888-999-7713, option 6, 8 a.m. to 8 p.m., Monday through Friday |
| Magellan (on behalf of NYRx, the Medicaid pharmacy program) | Medicaid Pharmacy Drug Reviews: Online newyork.fhsc.com Fax 800-268-2990 Call 877-309-9493, 24/7/365 |
| Dental Services | |
| Healthplex (effective 01/01/2022) |
Call Provider Hotline: 888-468-2183, Monday to Friday from 8 a.m. to 5 p.m. |
| Vision Services | |
| EyeMed | Medicaid: 877-324-2791 Medicare: 844-790-3878 Commercial (HMO, PPO, POS): 877-324-4063 On/Off Individual and Group Exchange and Essential Plans: 877-324-6211 |