The NYS Executive Order #4Open a PDF has been extended to May 30, 2022. We will suspend preauthorization requirements for dates of service September 27, 2021 – May 30, 2022 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 fully insured members and self-insured groups that have opted in. Submission of the completed state-approved certification formOpen a PDF is required. 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 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 - August 1, 2022.Open a PDF

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

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

Older individual Prior Auth documents:

Durable Medical Equipment - November 1, 2021Open a PDF
eviCore Codes Requiring Preauthorization - November 1, 2021Open a PDF
Medical Specialty Drugs list For Commercial, Exchange, Medicare, Essential Plan, Medicaid, Child Health Plus - May 11, 2022Open a PDF
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