In accordance with NYS Executive Order #4Open a PDF, we will suspend preauthorization requirements for dates of service September 27 - October 27, 2021 for scheduled hospital surgeries and admissions, hospital outpatient services, home health care services following a hospital admission and inpatient and outpatient rehabilitation services following a hospital admission for our fully insured and Medicare Advantage members. Review our communication for additional details. Please continue to notify us of all inpatient admissions and discharges to ensure continuity and coordination of care.
CareAdvance Expedited Requests: If an authorization is an expedited request, the provider must call Medical Intake with a case number to expedite. 

Authorizations

  • Please review the eMedNY website for benefit coverage of specific codes prior to submitting a preauthorization request for MMC or HARP members.

The medical services including provider administered drugs below require prior review by the plan to determine clinical medical necessity.

The services below require prior review by the Plan to determine clinical medical necessity for all places of service.  Not all services are covered by all medical plans. There may be services that require preauthorization or notification that do not require clinical review. Final determination of coverage is subject to the member’s benefits and eligibility on the date of service. 

  • All eviCore services can also be validated for prior authorization requirements via eviCore.com

Who Can Request: For HMO/POS plans, the member’s PCP or specialist with a valid referral. Other members, the member's PCP or treating provider.

Medical and Behavioral Health Procedure Codes Requiring Prior Authorization:

Providers please note that as of the 2/1/2022 Prior Authorization release, we are moving to one document that includes authorization requirements for Medical, Durable Medical Equipment, eviCore, and Behavioral Health rather than individual documents for each specialty.

New single Prior Auth document:

Medical, Durable Medical Equipment, eviCore and Behavioral Health Prior Authorization Code List - February 1, 2022Open a PDF

Older individual Prior Auth documents:

Behavioral Health Prior Authorization Code List

Medical Specialty Drugs Requiring preauthorization (For Commercial, Exchange and Medicare)Open a PDF

Medical Specialty Drugs Requiring preauthorization (For Medicaid, Essential Plan and Child Health Plus)Open a PDF

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