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Prior Authorization Process

Submitting a Prior Authorization Request

There are two ways to submit a request for Prior Authorization (PA) to HCP:

  1. EZ-Net is the preferred and most efficient way to submit a Prior Authorization request. Login credentials for EZ-Net are required.

    Learn more about EZ-Net.

  2. Prior Authorization requests may also be submitted via FAX.

Send a completed Authorization Request form to (888) 746-6433 or (516) 746-6433.

Services Covered Without Prior Authorization

Most office-based services and many freestanding Ambulatory Surgery Center (ASC) services provided by PCPs and PSN Specialists are covered without Prior Authorization required.

All services performed in a hospital setting (both inpatient and hospital outpatient centers and facilities) or in hospital-owned sites, such as provider offices and imaging centers, require Prior Authorization.

For all other outpatient services, the determination of whether or not a Prior Authorization or Notification is required is determined by the following:

  1. Provider type: PCP or Specialist
  2. If Specialist, participation in the Provider Specialist Network (PSN) or not
  3. Plan: EmblemHealth, Empire
  4. Procedure/Procedure Code being considered

The Prior Authorization Tool will help you determine if a Prior Authorization is required for a service planned for a specific member. When in doubt, please contact the HCP Customer Engagement Center at (800) 877-7587 for assistance.

Services Requiring Prior Authorization

  1. Inpatient care:
    • Emergent Hospital admissions (within 24 hours after admission)
    • Elective hospital admissions
    • Skilled Nursing Facility/Sub-Acute Rehabilitation admissions
    • Acute Rehabilitation Facility admissions
    • Long-Term Acute Care Hospital admissions
    • Inpatient Hospice admissions
    • Inpatient Behavioral Health admissions (within 24 hours of admission)
  2. Hospital-based outpatient services
  3. All procedures, regardless of location, that require an assistant surgeon, co-surgeon who are not in the Preferred Specialist Network, or an anesthesiologist who is not in the health plan Provider Network
  4. Reconstructive Surgery or other procedures that may be considered cosmetic 
  5. Outpatient cardiac and pulmonary rehabilitation
  6. Non-emergent primary care services rendered by a non-plan network provider
  7. Non-emergent services rendered by a non-PSN provider
  8. All procedures considered experimental or investigational
  9. All home healthcare services, including home care agency visits, uterine monitoring, sleep studies, and hospice care. Note that home visits billed as an E&M service are exempted from Prior Authorization
  10. Home-based, office-based, and Ambulatory Surgery Center-based infusion services and associated medications
  11. Elective transportation services
  12. Genetic testing
  13. Durable Medical Equipment
  14. Assisted Reproductive Infertility Treatments
  15. Stem Cell and Organ Transplant evaluations and procedures
  16. Services not otherwise identified as not requiring a Prior Authorization

Timeframes for Submission & Response for Prior Authorization Requests

Providers should anticipate Prior Authorization needs well in advance when feasible. Be sure to submit all applicable clinical information supporting the reason for the request.

Non-Urgent (Routine) Preservice Requests.

The most common request type. Non-urgent (routine) preservice requests must be completed prior to rendering the service under consideration, or reimbursement cannot be guaranteed.

Decision time is no more than 14 calendar days.

Urgent (Expedited) Preservice Requests

As defined by CMS, failure to expedite the review would “seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function” 1,2.

Decision time is no more than 72 hours.

Concurrent Review Requests

Made when a service is actively being delivered, most commonly an ongoing facility or home-based service, and are always handled as urgent.

Decision time is no more than 72 hours.

Post Service Requests

Occur after a service has been delivered.

Decision time is no more than 30 days.

1 Part C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance (Released February 2019), CMS.

2 Any Expedited request requires a licensed provider’s signature on the PA form attesting to the validity of this statement of urgency.

Note that decisions are made as expediently as possible. The process may be slower due to a lack of sufficient clinical information to effectively process the request, requests for providers outside of the PSN, or requests for providers who are non-participating with the payor.

Clinical Review Criteria Used to Make Prior Authorization Decisions

Medicare

    • CMS Local and National Coverage Determinations
    • Health Plan Medical Policy
    • MCG (Formerly Milliman Care Guidelines)
    • AIM for Empire MA radiology
    • NCCN (National Cancer Care Network) criteria for Medical, Surgical and Radiation Oncology
    • FDA labels and Prescribing Information for Injectable Medications
    • UpToDate
    • Hayes, Inc. Technology Assessment

Commercial and Medicaid Products

    • Health Plan Policy
    • MCG (Formerly Milliman Care Guidelines)
    • AIM for Empire MA radiology
    • NCCN (National Cancer Care Network) criteria for Medical, Surgical and Radiation Oncology
    • FDA labels and Prescribing Information for Injectable Medications
    • CMS Local and National Coverage Determinations
    • UpToDate
    • Hayes, Inc. Technology Assessment