10/16/2019

HIP Pre-Authorization Requests in Addition to for CPT Codes 17110, 64450, 64455, 20550 and 20551

HIP is now requiring prior auth in addition to the patient having a referral for certain CPT codes including 17110, 64450, 64455, 20550 and 20551. This requirement seems very onerous, as these are commonly performed procedures in daily practice. What, if anything, is the insurance committee doing to address this issue?

As per the HIP claims department the following changes were effective as of 09/11/18

• Minor procedures performed in an office POS require an authorization in addition to a referral (if needed by the patient’s plan)
• Changes affect all HIP plans (Commercial, Medicare Advantage, and Medicaid Managed Care)
• Injections and minor surgical procedures are included, but other services may require prior authorization       

Emblem Health requiring authorization on these minor procedures is a requirement that has been in place for some time for patients enrolled in managed care plans (whether commercial, Medicare or Medicaid)- while we agree that this is a time consuming and labor intensive process, HIP plans do have this requirement in order to have services covered.

Please note that no documentation is currently available on the Emblem Health website on what plans, specialties, or specific service codes require prior authorization.

We will further discuss this matter with the insurance committee and see what other actions can be taken.