Most office-based services and many freestanding Ambulatory Surgery Center (ASC) services provided by PCPs and Preferred Specialists are covered without Prior Authorization required.
All services performed in a hospital setting (both inpatient and outpatient centers and facilities) and services performed in hospital-owned sites such as provider offices and imaging centers, for example, 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 a Preferred Specialist or an HCP Primary Care Physician, your patient’s medical coverage, and the services rendered.
Start by determining the provider’s status.
Preferred Specialist Physician
Services performed by a Preferred Specialist in Specialist’s offices or freestanding ASCs and Imaging centers.
Non-HCP Preferred Specialist
- The patient is covered by EmblemHealth.
- The Services provided are:
- Office-Based and certain Ambulatory Care Center Services, or
- Preventive Care Services, or
- Plain X-rays and certain urgent imaging studies in office or freestanding imaging center (non-hospital affiliated)
- Prior Authorization Not Required
- The patient is covered by EmblemHealth.
- 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 by Humana, Aetna®, Elderplan, Fidelis Care (Medicaid), Anthem, Centers Plan for Healthy Living, UnitedHealthcare, or VillageCareMAX.
- Any Services provided.
- Not Managed by HCP
- The patient is covered by EmblemHealth.
- The Services provided are Behavioral Health.
- Not Managed by HCP
Services performed by a Non-HCP Preferred Specialist.
HCP Primary Care Provider
- The patient is covered by EmblemHealth.
- Any Services provided.
- Prior Authorization Required
- The patient is covered by Humana, Aetna®, Elderplan, Fidelis Care (Medicaid), Anthem, Centers Plan for Healthy Living, UnitedHealthcare, or VillageCareMAX.
- Any Services provided.
- Not Managed by HCP
- The patient is covered by EmblemHealth.
- The Services provided are Behavioral Health.
- Not Managed by HCP
Services performed by HCP Primary Care Provider in PCP’s offices or freestanding ASCs and Imaging centers.
Do not know if Specialist Provider is a Preferred Specialist
- The patient is covered by EmblemHealth.
- The Services provided are:
- Preventive Care Services, or
- Office Based Specialty Services, or
- Plain X-rays in an office or freestanding imaging center (non-hospital affiliated)
- Prior Authorization Not Required
- The patient is covered by EmblemHealth.
- 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 by Humana, Aetna®, Elderplan, Fidelis Care (Medicaid), Anthem, Centers Plan for Healthy Living, UnitedHealthcare, or VillageCareMAX.
- Any Services provided.
- Not Managed by HCP
- The patient is covered by EmblemHealth.
- The Services provided are Behavioral Health.
- Not Managed by HCP
