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This guide combines an overview of prior authorization processes, why it matters, and an extensive list of services typically requiring approval, offering a comprehensive resource for NYC providers and patients.

What is Prior Authorization?

Prior authorization is a process that requires healthcare providers to obtain approval from an insurer, like a Medicare Advantage plan, before performing certain medical services. The insurer reviews the service, treatment, or medication against clinical guidelines to confirm:

• Medical necessity.
• Coverage eligibility under the patient’s specific plan.

Why is Prior Authorization Important?

Prior authorization serves several purposes, benefiting both patients and providers:

For Patients:

• Cost Control: Ensures coverage for necessary treatments, reducing out-of-pocket expenses.
• Avoiding Unnecessary Procedures: Confirms that treatments align with the best clinical practices.

For Providers:

• Improved Cash Flow: Reduces claim denials, ensuring timely reimbursement.
• Streamlined Care: Facilitates appropriate treatment plans with fewer administrative hurdles post-service.

For example, a patient with NYC Medicare Advantage might require prior approval for an MRI to determine the root cause of chronic back pain. Without prior authorization, the insurer may deny payment, leaving the patient or provider responsible for the cost.

How Prior Authorization Works in NYC Medicare Advantage Plans

Step 1: Identifying the Need for Authorization

Providers should determine if a planned service requires prior authorization. NYC Medicare Advantage plans often provide detailed lists for reference, but it’s always best to confirm with the insurer.

Step 2: Submitting the Request

The provider compiles necessary documentation, such as medical records, diagnostic results, and treatment plans, and submits these to the insurer via an online portal or direct contact.

Step 3: Insurer Review

The insurer evaluates the request based on clinical guidelines.

• Routine Requests: Typically reviewed within 2-5 business days.
• Urgent Cases: Expedited for emergencies, often within 24 hours.

Step 4: Approval or Denial

• If approved, the provider proceeds with the service.
• If denied, the provider and patient are notified of the reasons, and appeals can be initiated if needed.

Questions About Prior Authorization? Here’s What You Need to Know

Q: What does prior authorization mean?
Prior authorization is the process where your healthcare provider must obtain approval from your Medicare Advantage plan before you receive certain types of care, services, or medications. This step ensures that the treatment meets the plan’s criteria for coverage.

Q: Why is prior authorization needed?
Prior authorization ensures you receive appropriate care by allowing your healthcare provider and insurer to evaluate whether the service or treatment is medically necessary before it’s provided. This process helps prevent unnecessary procedures and ensures the service is covered under your plan.

Q: What is medical necessity?
Medical necessity refers to services, supplies, or medications required to prevent, diagnose, or treat a medical condition in line with accepted medical standards. Insurers use your medical records and established clinical guidelines to determine if a service is medically necessary.
Your NYC Medicare Advantage Plus Plan will cover medically necessary care as long as it is listed in your Evidence of Coverage and benefits chart.

Q: How do I know if I need prior authorization before receiving care?
If you’re seeing a provider who accepts NYC Medicare Advantage Plus, they are responsible for requesting prior authorization. You don’t need to handle this step when using an in-network provider.
For out-of-network providers, prior authorization is not required but highly recommended to ensure coverage and avoid out-of-pocket costs.

Q: How long does it take for a prior authorization request to be approved?
The time for approval depends on your health condition:

• Routine requests are typically processed within a few business days.
• Urgent or emergency cases are expedited to ensure there are no delays in critical care.

Q: How does prior authorization work?

• In-Network Providers:
  • Providers must request prior authorization from your NYC Medicare Advantage Plus plan before delivering specific services.
  • Once approved, you are only responsible for your copay or coinsurance.
  • If the provider fails to obtain authorization, the claim will be denied, but you cannot be billed for the service.
• Out-of-Network Providers:
  • These providers are not required to request prior authorization.
  • You should ask them to submit a prior authorization request to avoid denial of coverage.
  • If prior authorization is not obtained, the claim will undergo a post-treatment review.
    • If deemed medically necessary, the claim will be processed according to plan rules.
    • If deemed not medically necessary, the claim will be denied, and the provider may bill you for the service.

Q: What happens if prior authorization is denied?

• You will receive a notification explaining the denial.
• You can choose to proceed with the treatment but will be responsible for the full cost.
• You have the right to appeal the decision, and your plan will provide details on how to initiate the appeal process.

Important Reminder:

• You are not responsible for requesting prior authorization if you use an in-network provider.
• For out-of-network care, always ask your provider to request prior authorization to protect yourself from unexpected costs.

Services Requiring Prior Authorization

Understanding which services typically require prior authorization can save time and avoid surprises. Below is a comprehensive guide, although specifics may vary by insurer.

1. Inpatient Services

• Elective admissions (e.g., surgeries, rehabilitation).
• Skilled nursing facility admissions.
• Long-term acute care (LTAC).

2. Outpatient Services

• Orthotics: Ankle, back, foot, and knee braces.
• Surgical Procedures:
  • Bariatric/gastric obesity surgery.
  • Breast reconstruction.
  • Knee and hip replacements.
• Diagnostic Tests: Genetic testing, endoscopies, sleep studies.
• Therapies: Occupational, physical, and pain management therapies.

3. Durable Medical Equipment (DME)

• Power wheelchairs and accessories.
• Insulin pumps.
• Ventilators and wound care equipment.

4. Behavioral Health Services

• Inpatient mental health admissions.
• Intensive outpatient programs.
• Transcranial magnetic stimulation (TMS) for depression.

5. Transplant Services

• Heart, liver, kidney, and lung transplants.
• Stem cell and bone marrow transplants.

6. Imaging and Advanced Diagnostics

• CT, MRI, and PET scans.
• Radiation therapy and oncology-related diagnostics.

Challenges with Prior Authorization

Despite its benefits, prior authorization can create challenges:

• Administrative Burden: Providers must dedicate significant time to managing requests and follow-ups.
• Delays in Care: Lengthy approval processes may delay non-urgent treatments.
• Denials and Appeals: Missteps in documentation or coding can result in denied claims.

How Staffingly Can Help NYC Providers

Managing prior authorizations doesn’t have to drain your practice’s resources. Staffingly, Inc. specializes in taking on this administrative load, offering solutions tailored to NYC Medicare Advantage providers:

Our Services Include:

• Comprehensive Documentation Management: Ensuring all necessary records and details are submitted accurately.
• Real-Time Status Tracking: Keeping you informed of every step in the authorization process.
• High Approval Rates: Leveraging expertise with major insurers like Empire BlueCross BlueShield, Aetna, and UnitedHealthcare.
• Expedited Processing: Handling urgent cases promptly to ensure timely patient care.

By partnering with Staffingly, your practice can save up to 70% on administrative costs, focus on patient care, and avoid the hassles of denied claims.

Frequently Asked Questions

Q: How long does prior authorization take?
A: Routine cases typically take 2-5 business days, while urgent cases are reviewed within 24 hours.

Q: Does prior authorization guarantee payment?
A: Approval minimizes the risk of denial, but accurate coding and documentation are still required.

Q: Who handles prior authorization?
A: Providers are responsible for submitting and managing requests. Outsourcing to Staffingly can help alleviate this burden.

The NYC Medicare Advantage Plus Plan is offered through an alliance between Empire BlueCross BlueShield Retiree Solutions and EmblemHealth. Empire and EmblemHealth have come together to create a new, customized, fully insured group Medicare Advantage program for the City of New York. Empire BlueCross BlueShield Retiree Solutions is an LPPO plan with a Medicare contract. Enrollment in Empire BlueCross BlueShield Retiree Solutions depends on contract renewal. Empire BlueCross BlueShield Retiree Solutions is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross Blue Shield Association. EmblemHealth insurance plans are underwritten by EmblemHealth Plan, Inc., EmblemHealth Insurance Company, and Health Insurance Plan of Greater New York (HIP). EmblemHealth Services Company, LLC provides administrative services to EmblemHealth companies. The EmblemHealth companies are separate companies from Empire BlueCross BlueShield.