Transition of Outpatient Rehabilitation Utilization Management Program effective January 1, 2019

Effective January 1, 2019, Empire HealthPlus will transition its Outpatient Rehabilitation Utilization Management (UM) Program from OrthoNet to Empire (pending New York State Department of Health approval). The Outpatient Rehabilitation UM Program is a pre‑service medical necessity review of physical, occupational and speech therapy services.

 

Empire will continue to use criteria documented in Empire’s clinical guidelines GC.REHAB.04, CG.REHAB.05 and CG.REHAB.06 for review of these services. These clinical guidelines can be reviewed online at https://www.availity.com. Log into Availity, select Payer Spaces, Education and Reference Center application, Clinical Resources and then choose Empire Medical Policy and Clinical UM Guidelines.

 

Pre-service review requirements

For services that are scheduled to be rendered through December 31, 2018, physicians must contact OrthoNet to obtain all prior authorizations for outpatient rehabilitation services. Any authorizations OrthoNet makes prior to the transition date of December 31, 2018, will be honored and claims will process accordingly.

 

For services that are scheduled to be rendered on or after January 1, 2019, physicians must contact Empire to obtain prior authorization for outpatient rehabilitation services. Empire will begin accepting these authorization requests on December 17, 2018. Providers are strongly encouraged to verify that a prior authorization has been obtained before scheduling and performing services.

 

This program will continue to render prior authorization reviews of rehabilitative and habilitative outpatient and office physical, occupational and speech therapy services for medical necessity. Therapy services to be rendered after the initial evaluation will be reviewed against Empire. Clinical guidelines services rendered in an inpatient, emergency, observation or home setting will continue to be excluded from this review. In addition, services rendered by a chiropractor, massage therapist, acupuncturist and home health agency will continue to be excluded from this review.

 

Detailed prior authorization requirements are available online by accessing the Precertification Look-Up Tool under Payer Spaces at https://www.availity.com. Contracted and noncontracted providers may call our Provider Services at the phone number on the back of the member’s ID card for prior authorization requirements or additional questions as needed.

 

How to place a review request

Authorizations will be accepted for outpatient rehabilitation services on December 17, 2018. 

• Providers can fax requests to Empire at 1-844-815-4708.
• Provider can also call 1-212-563-5570 at extension 1062001261 prompt 1or toll free at 1-800-450-8753