IMPORTANT: On August 28, 2022, Governor Hochul issued Executive Order No 4.12, which terminated the suspension of utilization review for hospitals. Preauthorization and review requirements for the following resume August 29, 2022: scheduled surgeries in hospital facilities, hospital admissions, hospital outpatient services, home health care services following a hospital admission, inpatient and outpatient rehabilitation services following a hospital admission, concurrent review for inpatient and outpatient hospital services and retrospective review for inpatient and outpatient hospital services at in-network hospitals. For additional information, please refer to Supplement No. 1 to Insurance Letter No. 9 (2021).

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 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.
 
For certain member contracts, the Health Plan has delegated utilization management of the following services to eviCore Healthcare MSI, LLC d/b/a eviCore Healthcare: implantable cardiac devices, radiology/imaging, radiation therapy, and musculoskeletal services (large joint replacement, pain management, and spine services). The Health Plan has adopted eviCore’s medical policies and guidelines as a basis for the determination of medical necessity and appropriateness of care. 

Please refer member-specific questions to the Customer Care number on the back of the member ID card. Final determination of coverage is subject to the member’s benefits and eligibility on the date of service.

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- January 1, 2023.Open a PDF

Medical, Durable Medical Equipment, eviCore and Behavioral Health Prior Authorization Code List- November 21, 2022.Open a PDF

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

Medical, Durable Medical Equipment, eviCore and Behavioral Health Prior Authorization Code List - September 15, 2022.Open a PDF

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

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

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

Medical Specialty Drugs List:

IE Browser Modal