Most office-based services and many freestanding Ambulatory Surgery Center (ASC) services provided by PCPs and PSN are covered without Prior Authorization required.
All services performed in a hospital setting (both inpatient and hospital outpatient centers and facilities), as well as services performed in hospital-owned sites such as provider offices and imaging centers, as examples, require Prior Authorization.
Use our Prior Authorization Process Tool and quickly determine if a Prior Authorization is required for the services provided to your patient.
You will need to know if the provider is in our Preferred Specialist Network or an HCP Primary Care Physician, your patient’s medical coverage, and the services rendered.
Start by determining the Providers status.
Preferred Specialist Network (PSN) Specialist
Services performed by Preferred Specialist Network (PSN) Specialist in Specialist’s offices or freestanding ASCs and Imaging centers.
- The patient is covered by Emblem or Empire Medicare.
- The Services provided are:
- Prior Authorization Not Required
- The patient is covered by Emblem or Empire Medicare.
- The Services provided are:
- Not Preventive Care Services, or
- Not Office-Based and certain Ambulatory Care Center Services, or
- Not Plain X-rays or certain urgent imaging studies in office or freestanding imaging center (non-hospital affiliated)
- Prior Authorization Required
- The patient is covered Empire Medicaid, Empire BCBS Commercial, or Fidelis Care.
- Any Services provided.
- Not Managed by HCP
- The patient is covered by Emblem or Empire Medicare.
- The Services provided are Behavioral Health.
- Not Managed by HCP — Emblem
- Not Managed by HCP — Empire
Specialist Not in Preferred Specialty Network (PSN)
Services performed by a Specialist Not in Preferred Specialty Network (PSN)
- The patient is covered by Emblem or Empire Medicare.
- Any Services provided.
- Prior Authorization Required
- The patient is covered Empire Medicaid, Empire BCBS Commercial, or Fidelis Care.
- Any Services provided.
- Not Managed by HCP
- The patient is covered by Emblem or Empire Medicare.
- The Services provided are Behavioral Health.
- Not Managed by HCP — Emblem
- Not Managed by HCP — Empire
Services performed by HCP Primary Care Provider in PCP’s offices or freestanding ASCs and Imaging centers.
- The patient is covered by Emblem or Empire Medicare.
- The Services provided are:
- Preventive Care Services, or
- Office Based Specialty Services, or
- Plain X-rays in office or freestanding imaging center (non-hospital affiliated)
- Prior Authorization Not Required
- The patient is covered by Emblem or Empire Medicare.
- The Services provided are:
- Not Preventive Care Services, or
- Not Office Based Office Based Primary Care Services, or
- Not Plain X-rays in office or freestanding imaging center (non-hospital affiliated)
- Prior Authorization Required
- The patient is covered Empire Medicaid, Empire BCBS Commercial, or Fidelis Care.
- Any Services provided.
- Not Managed by HCP
- The patient is covered by Emblem or Empire Medicare.
- The Services provided are Behavioral Health.
- Not Managed by HCP — Emblem
- Not Managed by HCP — Empire
Do not know if Specialist Provider is in Preferred Specialty Network (PSN)
