12/18/2019

Pre-Auth Requirements for Minor Routine Office Based Procedures-Emblem HIP

Emblem HIP is now requiring pre-auth for some minor routine office based procedures, but there is nothing on website as to who, what, when and where we are supposed to send this pre-auth to. Calling them is time consuming and slows down patient flow as everytime one of these procedures is needed the office comes to a grinding halt. Is there a better way? Am I supposed to send a patient in pain home and tell them to come back the next week because their insurance is babysitting me and I can't give them 15 to 20 minutes of waiting on the phone and holding up the room?

Emblem Health does have a website where any services that do require prior authorization due to the restrictions of the HMO can be requested in real time and can be approved without calling. The only requirement is that the CPT code must be known ahead of time and has to be requested at the time of service. For acute care, Emblem Health will not retroactively issue an authorization and the patient will not be liable if a participating provider fails to get the prior approval. Every procedure must be pre-certified at the time of service or they will be denied. If a patient has a managing entity that administers benefits for their HMO (such as Healthcare Partners IPA), authorization will need to be obtained by the TPA.