Contact Us

Prior Authorization Process

Prior Authorization

A request for Prior Authorization can be submitted to HCP in one of two ways.

  1. The preferred and most efficient way to submit a Prior Authorization (PA) request is via the HCP Web-based data interface, EZ-Net

    Login credentials for EZ-Net are required. Learn More

  2. PA requests may also be submitted via FAX by sending a completed request form to 888-746-6433 or 516-746-6433.

View and download a printable copy of HCP’s Authorization Request form here.

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), as well as services performed in hospital-owned sites such as provider offices and imaging centers, as examples, also 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, EmblemHealth Cohort 2, 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 1(800) 877-7587 for assistance.

The following groups of services require 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, as examples. 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 of Prior Authorization requests based on request type

Non-urgent (routine) Preservice requests. The most common request type, these 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 that meet the CMS definition that states 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 are 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.

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

Provider should anticipate Prior Authorization needs well in advance where feasible and be sure to submit all applicable clinical information supporting the reason for the request.

1 Parts 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.

Clinical Review Criteria used to make Prior Authorization decisions

HealthCare Partners utilizes the following resources to adjudicate requests for coverage:

Medicare

    • CMS Local and National Coverage Determinations
    • Health Plan Medical Policy
    • MCG (Formerly Milliman Care Guidelines)
    • AIM for Empire MA radiology
    • eviCore for EmblemHealth Cohort 2 Radiology and Cardiac Imaging
    • OrthoNet for EmblemHealth Cohort 2 Spine and Pain Management services
    • 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
    • eviCore for EmblemHealth Cohort 2 Radiology and Cardiac Imaging
    • OrthoNet for EmblemHealth Cohort 2 Spine and Pain Management services
    • 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