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).
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:
New single Prior Auth document:
Medical Specialty Drugs List:
- Medical Specialty Drugs list For Commercial, Exchange, Medicare, Essential Plan, Medicaid, Child Health Plus - May 18, 2022Open a PDF
- Medical Specialty Drugs list For Commercial, Exchange, Medicare, Essential Plan, Medicaid, Child Health Plus - May 11, 2022Open a PDF
- Medical Specialty Drugs list For Commercial, Exchange, Medicare, Essential Plan, Medicaid, Child Health Plus - March 4, 2022Open a PDF
- Medical Specialty Drugs list For Commercial, Exchange, Medicare, Essential Plan, Medicaid, Child Health Plus - March 2, 2022Open a PDF
- Medical Specialty Drugs list For Commercial, Exchange, Medicare, Essential Plan, Medicaid, Child Health Plus - March 17, 2022Open a PDF
- Medical Specialty Drugs list For Commercial, Exchange, Medicare, Essential Plan, Medicaid, Child Health Plus - March 16, 2022Open a PDF
- Medical Specialty Drug List - January 11, 2022Open a PDF
- Medical Specialty Drug list - January 1, 2022Open a PDF
- Medical Specialty Drug List - February 3, 2022Open a PDF
- Medical Specialty Drugs list For Commercial, Exchange, Medicare, Essential Plan, Medicaid, Child Health Plus - February 23, 2022Open a PDF
- Medical Specialty Drugs list (For Commercial, Exchange, Medicare, Essential Plan, Medicaid, Child Health Plus) - February 18, 2022Open a PDF
- Medical Specialty Drugs Requiring preauthorization (For Commercial, Exchange and Medicare) - August 25, 2021Open a PDF
- Medical Specialty Drugs Requiring preauthorization (For Medicaid, Essential Plan and Child Health Plus) - August 25, 2021Open a PDF
- Medical Specialty Drugs list For Commercial, Exchange, Medicare, Essential Plan, Medicaid, Child Health Plus - April 6, 2022Open a PDF
- Medical Specialty Drugs list For Commercial, Exchange, Medicare, Essential Plan, Medicaid, Child Health Plus - April 1, 2022Open a PDF
