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New Pre-Certification Requirements for Behavioral Health Outpatient Visits
PW_AD091787
Effective immediately, Empire is changing the pre-certification requirements for routine outpatient services for behavioral health. Members and Providers will no longer need to obtain authorization for their first twelve routine outpatient visits per provider each calendar year. Here’s what you should know:
 | A routine outpatient visit is defined as an individual, group, or family therapy visit, typically lasting under one hour. If you have questions about this definition please call the number on the back of your patient’s ID card. |
| Prior authorization is required prior to the 13th outpatient visit per provider each calendar year. Participating providers will need to complete an Outpatient Treatment Report (OTR) form prior to the member’s thirteenth visit. |
| Any visits authorized by Empire for visits in 2008 are additive to the twelve pass-through visits. |
| The member’s benefit maximums for annual outpatient visits still apply. |
Exclusions: This new policy does not apply to outpatient visits for alcohol or substance abuse treatment provided by non-participating providers, intensive treatment services including Intensive Outpatient Program (IOP) treatment, Partial Hospitalization Program (PHP) treatment, and all inpatient treatment services. These services continue to require prior authorization. Psychological testing will also continue to require prior authorization.
This change does not pertain to accounts that do not require prior authorization for routine outpatient services.
*For National Account members, please check the plan benefit description to see if prior authorization rules apply for outpatient services. If prior authorization is required, please contact the number indicated on the member identification card.
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