Provider Portal –
Create Preauthorization Requests

Note: Required data elements will have an asterisk “*” next to the field name.

A preauthorization request consists of two parts.

Part One

• Identify Member.
• Requesting Provider.
• Servicing Provider.
• Diagnosis Code(s).
• Service Details.
• Created By.
• Review Details.

After the first set of information is entered and reviewed, the user may continue directly to Part Two or they can save a draft for 120 hours.

Once a draft is saved, any authorized user can find the draft and submit the clinical information and supporting documentation needed for the medical necessity review.

Part Two

Clinical Information

The portal will not allow a request to be submitted until expected clinical information is addressed and supporting documentation attached. If the person entering the clinical information is completing a saved draft, they will first see a summary of what was previously entered but will not be able to make changes to that information. If the diagnosis has significantly changed, we recommend restarting with a new request so the portal can prompt you to address the applicable clinical criteria.

When an ambulance company submits a preauthorization request for their own services, they should:

• Select Outpatient as the Preauthorization Type. Enter the Service Date From and Service Date To. 
• In general, if you are unsure when service will be scheduled, enter a 90-day time frame to allow for maximum flexibility.
• If you are requesting post-acute care services, enter the earliest anticipated discharge date in the Service Date From field.

• Select Outpatient as the Preauthorization Type. Enter the Service Date From and Service Date To.
• If you are unsure when discharge will be scheduled, enter a 7-day time frame to allow for maximum flexibility.
• Select Yes as the answer to the discharge planning question.

For initial home care request:

• Select Outpatient as the Preauthorization Type.
• Enter the Service Date From and Service Date To. If you are unsure when service will be scheduled, enter a 90-day time frame to allow for maximum flexibility.

For subsequent home care requests to ask for more visits:

To request more visits than the amount approved in the prior request(s), you must enter a new preauthorization request.

TIP: Make sure the Service From Date on the new request is after the Service Date To on the previous request.

To extend the date range in which approved visits may be used:

To ask for more days to use approved visits, do not enter a new request. Instead use the Modify Request feature to ask to change the date range for the approval so it aligns with the date(s) of service on your claim(s).

Select Inpatient as the Preauthorization Type.

Enter the Service Date From and Service Date To. If you are requesting post-acute care services, enter the earliest anticipated discharge date in the Service Date From field.

Answer Yes or No to identify if this request is to assist with discharging a patient to:

• Inpatient rehabilitation facility (IRF). 
• Long-term acute care facility (LTAC). 
• Skilled nursing facility (SNF).

If Inpatient and Yes are selected above, you will be asked to identify the acute care hospital where the member is currently admitted.

This screen will only display if you indicated that the requested services are needed for discharge planning. On this screen you will search for and select the acute care hospital where the member is being discharged from.

See detailed instructions for finding the facility.

TIP: We recommend searching by NPI.

STOP: If the member’s Managing Entity is not EmblemHealth or ConnectiCare, or the service to be requested is managed by one of our partners, you must submit your request directly to the organization responsible for conducting the member’s medical necessity reviews. See: Who Conducts Utilization Management.

See detailed instructions for finding the member.

Tip: When picking the member from the search results table, select the row with an Active Status and Medical Coverage Type.

For dental predeterminations, select the row with an Active Status and Dental Coverage Type.

If you select a row where the member’s coverage is inactive, a warning message will display.

In general, the Requesting Provider is the doctor or practitioner who is responsible for the member’s care.

See detailed instructions for finding the requesting provider.

An ambulance company submitting a preauthorization request should select their company as both the Requesting Provider and the Servicing Provider.

See detailed instructions for finding the requesting provider.

Note: Ambulance companies should select No when prompted for a Servicing Facility.

For hospitals and other inpatient facilities that need to request an ambulance’s services as part of the discharge plan, the Requesting Provider is the discharging facility.

See detailed instructions for finding the requesting provider.

In general, the Servicing Provider is the doctor or practitioner, or ancillary provider who will provide the requested services.

If the services will be provided by a doctor in a hospital, ambulatory surgery center, or other facility setting, you will first enter the doctor’s information, then you will be given the option to enter the facility where the services will be performed. This information is required for inpatient services. It is optional for outpatient services.

Note: The address selected must match the specialist’s Tax ID and NPI. The combination of these three elements (address, Tax ID, and NPI) are critical for processing claims, preauthorization requests, and referral transactions.

See detailed instructions for finding the requesting provider.

Note: Ambulance companies should select No when prompted for a Servicing Facility.

Facilities asking for ambulance services as part of discharge planning should select Yes and select the discharging facility as the Servicing Facility.

On this screen you will enter the primary and secondary diagnosis codes. The diagnosis codes entered here will determine which clinical criteria the portal will expect to be addressed in Part Two. If the notice is saved as a draft and the diagnosis changes before the clinical information is entered, we recommend restarting with a new notice so the portal can prompt you for the applicable clinical criteria.

See detailed instructions for finding diagnosis codes.

The primary diagnosis code is mandatory while secondary diagnosis codes are optional. Use the Secondary Diagnosis Codes section to search for and add up to 11 secondary diagnoses. Between diagnoses, click Add to enter the next code.

TIP: Do not use periods when entering in the diagnosis code. For example, “A41.9” should be entered as “A419”.

Select the Service Type from the drop-down menu.

Note: Options will change based on the Place of Service selected.

Private Duty Nursing

Select Private Duty Nursing as the Service Type rather than Home Care even if the Place of Service is Home.

Home Care

If the Service Type selected is Home Care, when you click Add Service Line, a Warning will pop up to ask you to confirm your choice. This is meant to reduce unintended impacts to the benefit limit calculations.

On the pop-up, click OK to confirm the intended Service Type is home health care and continue with the next steps in the transaction. If the Service Type is not home health care, click OK and then choose the correct Service Type before proceeding.

Select the Type of Care from the drop-down menu.

TIPs:

• For sleep studies, select Medical Care. 
• For surgery, select Surgical Care. 
• For infertility, e.g., IVF/IUI, select Infertility. 
• For lab services, select Diagnostic Lab.

Select the Bed Type from the drop-down menu.

TIP: For post-acute care in an inpatient facility, pick the most accurate bed type. For example, if the member is going to a skilled nursing facility, choose skilled nursing facility instead of medical.

Enter the Admission Date.

TIP: If you do not know the actual date, enter the expected date.

You must enter at least one service line and may enter up to 20 service lines per preauthorization request.

For some services (e.g., elective inpatient admissions, home care, and skilled nursing care) this means entering the CPT Procedure Codes for each requested service. If you do not know the CPT code, you will be able to search for it using the service description. Use the Add Service Line button to search for and select the applicable CPT Procedure Code.

When requesting skilled nursing facility services, we recommend selecting the following options from the drop-down menu:

• Place of Service: Skilled Nursing Facility.
• Service Type: Skilled Nursing Care.
• Type of Care: Elective Standard.
• Bed Type: Skilled Nursing Facility.

When requesting acute rehabilitation services in a stand-alone facility, we recommend selecting the following options from the drop-down menu:

• Place of Service: Comprehensive Inpatient Rehabilitation Facility.
• Service Type: Rehabilitation – Inpatient.
• Type of Care: Elective Standard.
• Bed Type: Acute Rehab.

When requesting acute rehabilitation services in a hospital, we recommend selecting the following options from the drop-down menu:

• Place of Service: Inpatient Hospital.
• Service Type: Rehabilitation – Inpatient.
• Type of Care: Elective Standard.
• Bed Type: Acute Rehab.

When requesting long term acute care (LTAC) services, we recommend selecting the following options from the drop-down menu:

• Place of Service: Inpatient Hospital.
• Service Type: Medical Care. 
• Type of Care: Elective Standard. 
• Bed Type: LTAC.

You can review the details of all the sections you have completed.

Click Edit if you need to change any information in the respective section.

Once you complete this screen and click Next, you will not be able to make additional edits to the information entered before the request is submitted. You will be given the option to continue or save a draft for 120 hours.

Reminder emails: If you save a draft, the identified Contact will be sent an email reminder before the draft expires. If no action is taken after the reminder, another email will be sent notifying the Contact that the draft expired.

You will be given the option of continuing or saving a draft for 120 hours.

Reminder emails: If you save a draft, the identified Contact will be sent an email reminder before the draft expires. If no action is taken, another email will be sent letting them know the draft has expired.

At the end of Part One, on the Review Details screen, you can choose to continue or exit and save a draft of the notice for 120 hours.

Anyone associated with the notice can find a copy of the draft, address the MCG/Clinical Guidelines, attach supporting documentation, and submit the notice.

TIP: If you save a draft and expect someone else to enter the clinical information, make sure they know you have started the notice, share the Draft Number and how much time they have to finish and submit it. If you enter their information as the identified Contact, we will send them an email reminder before the draft expires. If no action is taken after the reminder, we will send another email letting them know the draft expired.

Navigating to Drafts

There are three ways to get to the screen that lists the incomplete and expired draft requests created in the last 30 days:

On the Incomplete Preauthorization Requests and Emergent Inpatient Admission Notifications page, you will be able to locate both the active and expired drafts submitted in the last 30 days.

To find a draft for a specific member, enter the Member ID or Member Name in the Filter By box, or sort on the Member ID or Member Name column and scroll through the table.

If the draft is expired, the Draft Number will no longer be a functioning link and the Draft Retained Until column will show a date/time that is more than 120 hours past the Draft Initiated date/time.

Anyone who is associated with the request will be able to find a copy of the draft to complete the clinical information, attach supporting documentation, and submit the notice.

To be associated with the notice, you must have the Administrator/Office Manager or Clinical Staff role and be linked to the tax ID for the:

• Requesting Provider
• Requesting Facility
• Servicing Provider
• Servicing Facility
• Discharging Facility

Once Part One screens are completed, clinical information will be requested. If the clinical criteria are met, approval may be issued at the end of the transaction. Otherwise, the request will pend for further review. In either case, for the preauthorization request to be considered complete and submitted, the Submit Request button on the MCG screen must be clicked.

TIP: Once the request is submitted, it will no longer appear on the Incomplete Drafts list.

NOTE: The Authorization field on the MCG screen will display a number. This is not an approval number. It is the Draft Number for the request.

Clinical Information Required:

The diagnosis code entered in Parill prepopulate and determine whether additional clinical information is needed. If it is, you will see one or more orange Document Clinical buttons. You need to address these by checking off the clinical criteria that apply to the preauthorization request. You also need to use the blue Attach File button to share supporting documentation such as medical records and test results.

The Submit Request button will remain inactive until each Document Clinical button is addressed and expected documentation attached. Once the clinical information is entered and all documents are attached, click the Submit Request button to finish the transaction.

NOTE: If the Document Clinical button displays, but on the next screen you do not see an applicable guideline or are unsure of which guideline to choose, click add in the Action column for “No Guideline Applies.” This will display a notes screen where you can explain why the listed guidelines are not appropriate and why the services are needed.

No MCG/Clinical Guideline Is Required:

If no additional information is needed, you will see a screen with the message “MCG Guideline Documentation Not Required.” If supporting documentation is required, the Submit Request button will be inactive until it is attached.

The diagnosis code entered determines which MCG/Clinical Guidelines will be required. If guidelines are required, you will see orange Document Clinical button(s) you will need to address by checking off the clinical criteria that apply to the notification. You must also click the blue Attach File button to share supporting documentation such as medical records and test results.

Once you click the Document Clinical button, you will be shown a list of potential clinical guidelines that may apply.

EXAMPLE: Diagnosis M54 Dorsalgia where the Cervical Diskectomy or Microdiskectomy, Foraminotomy, Laminotomy guideline applies.

To pick the guideline for the diagnosis M54 Dorsalgia, click add in the Action column for the Guideline Title Cervical Diskectomy or Microdiskectomy, Foraminotomy, Laminotomy.

If none of the guidelines shown apply to the member’s diagnosis, click add in the Action column for the Guideline Title No Guideline Applies.

Once a guideline is selected, you will be shown criteria that could apply.

Click all boxes that apply to your patient. If you see the Add Notes symbol, you can click it to open a pop-up screen where you can add notes up to 250 characters in length.

Once appropriate criteria have been selected and notes entered, click the Save button.

Use the blue Attach File button to upload medical records and other supporting documentation.

The File Description is optional. If you do not enter a description, the file name will used. When you are done attaching documents and all the clinical guidelines have been addressed, click the Submit Request button.

Examples of supporting documentation include:

• Specialist’s consultation summary.
• Patient characteristics such as age, gender, height, weight, vital signs, or other historical and physical findings pertinent to the condition proposed for treatment.
• Precise information confirming the diagnosis or indication for the proposed medical service.
• Details of treatment for the index condition, or any related condition, including names, doses, and duration of treatment for pharmacotherapy, and/or detailed surgical notes for surgical therapy.
• Appropriate laboratory or radiology results.
• Office or consultation notes related to the proposed medical service.
• Peer-reviewed medical literature, national guidelines, or consensus statements of relevant expert panels.

To request ambulance services for a commercial member:

After you click the Document Clinical button, select “This is a Commercial member (not Medicare or Medicaid) that is going to one of the following appropriate designations AND has at least one of the following medical conditions …”

Once clicked, you will be shown additional statements that apply to commercial members with check boxes next to them. 

2. Click the box next to the statement that begins “The member’s condition at the time of the transport is….” and the member’s clinical condition (must select at least one item from the list).

Once all boxes are selected, click Save.

Home Health Aides and Social Workers

Requests for home health aides and social workers will need the following Clinical Indications completed.

If the statements shown are true, click the box. Then click Save.

If the statements are not true, click Cancel.

For in vitro fertilization (IVF) and intrauterine insemination (IUI) for commercial members, we ask that you use the Attach File button to upload:

• Infertility Treatment – Commercial Members form.
• All applicable clinical notes. Diagnostic imaging of uterine cavity and fallopian tubes within last two years.
• Follicle-stimulating hormone (FSH), anti-müllerian hormone (AMH), antral follicle counts (AFC), estradiol (E2) (day three labs) dated within six months.
• Semen analysis dated one within one year (two within one year for intracytoplasmic sperm injection (ICSI)).
• Carrier screening report for PGT requests.
• Results of any previous IUI/IVF cycles.
• Documentation of substance abstinence (e.g., alcohol, tobacco, opioids, marijuana, cocaine) for three months by both member and partner.

Note: All medication/drug management requests are reviewed by Express Scripts (ESI).

If no additional information is needed, you will see a screen indicating “MCG Guideline Documentation Not Required.” The Submit Request button will be inactive until supporting documentation is attached.

NOTE: If the Document Clinical button displays, but on the next screen you do not see an applicable guideline or are unsure of which guideline to choose, click add in the Action column for “No Guideline Applies”. This will display a notes screen. Describe the reason why the listed guidelines are not appropriate.

If you do not have all required clinical information, you may use the Back button to save the information entered. You will still have the remainder of the 120 hours to finish adding the clinical information and submit the request.

If all clinical criteria are met, you may see a screen with the message “Your case has been approved.” No additional information will be requested. Other cases will be pended for further review.

TIP: Make note of your Reference ID so you can look up the status of the decision.