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Preauthorization Reduction Campaign
Frequently Asked Questions

EmblemHealth and ConnectiCare committed to partnering with our provider network, standing by them as they deliver care. As part of that commitment, we are making changes to preauthorizations and clinical reviews that will make it easier for you to work with our plan and speed up necessary care for our members. This will happen in two phases: A change to our preauthorization lists and the gradual rollout of new provider portal functionality over the next few months that will help providers with faster decisions on their cases.

 

What is changing for preauthorizations?

At the beginning of April, we eliminated the need for preauthorization on scores of CPT codes across EmblemHealth and ConnectiCare. This is in addition to other cuts over the past year that add up to a nearly 15% reductions in preauthorization codes. We believe these cuts slash an administrative burden for providers and frees them up to deliver care more quickly in these situations. The latest version of our preauthorization lists are online, including a list of “notable changes” that includes these removed codes.

At the same time, we will enable new functionality on the provider portal that lets our network practitioners get an answer on their preauthorization requests and clinical reviews significantly faster than if they submitted the request by phone or fax. We are also eliminating Site of Service rules, meaning approvals for procedures are not contingent on the procedure being performed in a specific setting. We will still educate members on how the choice of setting can impact out-of-pocket costs but not their outcomes. 

What changes will hospitals/facilities see?

We are changing the review requirements for approximately 400 inpatient elective/emergent diagnosis codes, removing a barrier to care. In many cases, this means facilities only need to notify us that a member is in a bed so we can help the facility and member prepare for discharge and post-acute care. These changes can also allow hospitals to accelerate the transfer of a patient needing home care or admission to a skilled nursing facility—especially during weekends. By speeding up the authorization process through our portal, hospital nursing staff will spend less time waiting before requesting a SNF bed for the patient and arranging non-emergent ambulance transfers. 

How will the experience for provider portal users improve?

Providers using the portal will be able to check if a code requires preauthorization, though they may verify the code(s) in our preauthorization lists online, too. As we roll out new functionality over the coming months, the portal can prompt providers for more information that will either give the provider an approval on the spot or, if we need more information, assist with collecting documentation we can use for a clinical review. The time savings over the old fax/phone process will be of real value for our providers. This new feature is made possible through an integration with health care software company MCG Health (more information can be found further down in this FAQ).

How can this help? Speeding up the authorization process through the portal can mean that hospital nursing staff can move sooner to requesting a SNF bed for the patient and arranging ambulance transfers. But that’s not all. In addition to speeding up all inpatient auto-approvable diagnosis codes for facilities, the MCG Health integration will improve provider and member experience for the following high-volume services:

  • Inpatient hospice
  • Homecare
  • Non-Emergent Ambulance
  • Sleep Studies
  • Genetic Testing
  • IVF/Fertility

Note: Our training guides have been updated to reflect the new portal features:

EmblemHealth Videos and User Guides                  EmblemHealth FAQs

ConnectiCare Videos and User Guides                    ConnectiCare FAQs

When will these changes happen?

Our updated preauthorization lists have been posted to our website and we are treating requests for these services under the new, streamlined rules. As for our provider portal, the first round of updates will roll out throughout the month of April. In some cases, like emergent inpatient admissions—which don’t require preauthorization but could necessitate concurrent review—the portal feature may not be ready until around May 1. Providers should still use the portal for notifying us of the admission and we will apply the same improved process, but the feature showing approvals online is still being built. We will notify providers through other means until this portal feature is complete. The full project which moves all our utilization management rules/guidelines into the MCG Health system should be complete this summer.

What about procedures and diagnoses that still require a preauthorization?

In cases where additional reviews are necessary, we are building in functionality to our portal to prompt providers with questions or guide them on submitting additional clinical information—the same questions and information we would ask for if they faxed us the request but without all the waiting and illegible documents of the past. Best of all, this will lead to a faster decision on the case than if the provider faxed or phoned in their original request, and no need to call for updates as the case is available online. This new feature is made possible through an integration with health care software company MCG Health (more information can be found further down in this FAQ). 

Is there a benefit to using the provider portal for all preauthorizations?

While reviewing our regularly updated preauthorization lists online is the fastest way to look up if a procedure requires a preauthorization, the provider portal is the fastest way to submit a request for approval. The portal allows for attaching the same clinical documents we would ask for if a provider faxed their initial request—but WITHOUT the delay that comes with having to follow up by phone. 

How else will this change benefit providers?

We expect this change to alleviate a significant administrative burden for our providers. In fact, we estimate this will save large health systems in New York approximately 7,350 hours of staff time per year, while Connecticut health systems could save 3,980 hours per year. We also believe this will shorten the time for facilities to get paid for delivering quality care because patients can be discharged when appropriate for the patient rather than having to wait for the completion of a manual paper process. For individual practices and IPAs that have limited staff, this could free up those staff members from this administrative burden and allow them to focus on more important tasks.

How will provider be prompted to use the MCG Health features?

Providers will submit requests and notifications through the provider portal following many of the same steps they use today. The portal screens may look slightly different once they enter the MCG Health system, but we are updating training material to match this experience (EmblemHealth / ConnectiCare). Before this, providers stopped their transaction after submitting their preauthorization request. Now they will be prompted to answer a few additional questions on a new set of screens where they can do the following to move their request forward:

  • Check off boxes next to statements that apply to member needs.
  • Click icons to open windows where providers can provide additional details.
  • Upload additional documents.

What MCG Health features are available now on the Provider Portal?

While we are phasing in the MCG Health integration over the coming months, the following high-volume services will be active on the portal in April:

  • Inpatient hospice
  • Homecare
  • Non-Emergent Ambulance
  • Sleep Studies
  • IVF/Fertility

Does this change extend to our delegated vendors?

We are continuing to talk with our delegated vendors about their preauthorization processes and whether similar changes can be made. We will share more information as it becomes available. 

How can providers find out more about the portal and the new features for preauthorizations?

If providers need help navigating our provider portals, they can see our videos, quick guides, and Frequently Asked Questions here:

EmblemHealth Videos and User Guides                  EmblemHealth FAQs

ConnectiCare Videos and User Guides                    ConnectiCare FAQs

 

If providers still have questions or need additional support, they may contact Provider Customer Service:

EmblemHealth: 866-447-9717

ConnectiCare: Commercial: 860-674-5850, Medicare: 877-224-8230

Our user guides have been updated to reflect the new MCG Health features on the provider portal that allow providers to answer questions and submit clinical information to support preauthorization reviews and approvals. As more updates become available, we will notify our network and update the related documentation. 

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Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your  plan. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage.