A request for Prior Authorization can be submitted to HCP in one of two ways:
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 about EZ-Net.
- Prior Authorization requests may also be submitted via FAX.
Send a completed Authorization Request form to (888) 746-6433 or (516) 746-6433.
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.
Medicare: Up to 7 days
Medicaid: Up to 14 days
Commercial: Up to 45 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.
Up to 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.
Medicare: Up to 7 days
Medicaid: Within 1 business day after receiving required information, no later than 14 days after request received
Commercial: Within 1 business day after receiving required information, no later than 15 days after request received
Post Service Requests
Occur after a service has been delivered.
Up to 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 non-Preferred Specialist providers, or requests for providers who are non-participating with the payor.
Clinical Review Criteria Used to Make Prior Authorization Decisions
- CMS Local and National Coverage Determinations
CMS – Local Coverage Determinations
CMS – National Coverage Determinations
- Health Plan Medical Policy
EmblemHealth Pharmacy Policies
- MCG (Formerly Milliman Care Guidelines)
MCG Guidelines – Emblem MCG Site
- NCCN (National Cancer Care Network) criteria for Medical, Surgical, and Radiation Oncology
