Services requiring prior authorization

All programs require prior authorization (PA) for all covered specialty medications, where allowable by state. The scope of this notice will include both professional and facility requests for Medicaid business.

 

Specialty medications that are reported with not otherwise classified (NOC) designation codes and

C codes may also require PA before services are provided.

 

Regardless of whether PA is required, all services must be medically necessary to be covered. Even if PA is not required, to avoid a claim denial based on medical necessity, Empire BlueCross BlueShield HealthPlus (Empire) encourages providers to review our medical necessity criteria prior to rendering nonemergent services. Medical necessity criteria can be accessed by visiting http://www.empireblue.com/nymedicaiddoc to view the most current Medical Policies and Clinical Utilization Management Guidelines.

 

If no specific policy is available, the medical necessity review of a drug may be conducted using Medical Policy ADMIN.00006: Review of Services for Benefit Determinations in the Absence of a Company Applicable Medical Policy or Clinical Utilization Management Guideline and/or Clinical Utilization Management Guideline CG-DRUG-01: Off-Label Drug and Approved Orphan Drug Use.

 

Clinical review of specialty medications is in addition to services currently requiring PA. Providers are responsible for verifying eligibility and benefits for Empire members before providing services. We recommend providers visit http://www.empireblue.com/nymedicaiddoc to review the list of services and service categories currently requiring PA, with a reminder that the list of services requiring PA will be updated as needed. For clarification regarding whether a specific code or service requires PA, call the number listed below. Except in an emergency, failure to obtain PA may result in denial of reimbursement.

 

Again, please be reminded that the list of services requiring PA will be updated as needed.

 

Requesting PA

To request PA, report a medical admission or for questions regarding PA, providers may use one of the following methods:

• Web: https://www.availity.com
• Fax: 1-800-964-3627
• Phone: 1-800-450-8753

Providers are strongly encouraged to revisit the Government Business Division Reimbursement Policy Unlisted or Miscellaneous Codes policy, which states NOC codes must be submitted with the correct national drug code (NDC) for proper claim payment. If the required NDC data elements are missing or invalid for the procedure code on a claim line, the claim will be denied.