New Utilization Management Pre-authorization Rules Coming Into Effect

EmblemHealth is aligning its Utilization Management (UM) pre-authorization (PA) requirements across all lines of business.  

What is new?

  • Reduced number of codes that require PA
  • Pre-authorization requirements will be based on the type of plan the member has, on diagnosis, site of service, and member age

 The changes will apply to most members on January 1, 2020.  Those with large group plans underwritten by Group Health Incorporated (GHI) who are not affiliated with the City of New York (non-CNY) will adopt these new rules as their plans renew and they are migrated to a new claims system and are given a new member ID number that will begin with the letter “K”.  For a sample of the new ID card, GHI PPO non-CNY members will receive upon renewal, click here.  Until renewal, members will continue to follow the existing GHI PA List.

The new rules will be applied by all Managing Entities (EmblemHealth, Montefiore CMO, and HealthCare Partners) and delegates who conduct UM on behalf of EmblemHealth.

The new rules will be applied for

  • HMO All Products – Commercial, PPO, POS, EPO, ASO, Medicaid /HARP, Medicare. 
  • GHI PPO (non-City of New York) Commercial and Medicare lines.

No changes for GHI PPO (City of New York)


For more information, visit EmblemHealth