Members and Providers do not need to obtain authorization for their first twelve routine outpatient visits per provider each calendar year for many Empire plans. 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.
Prior auth requirements will vary by plan and product, including Federal Employee Plans (FEP), self-insured groups and out-of-region Blue Cross and Blue Shield plans; it is recommended that confirmation be obtained in advance of the first visit.
The member's benefit maximums for annual outpatient visits still apply
Outpatient Treatment Reports (OTR) can be located on www.empireblue.com under the Behavioral Health Management area for Providers.
Late submissions of OTRs will not typically be authorized retrospectively.
Exclusions: This policy does not apply to outpatient visits for alcohol or substance abuse treatment provided by non-participating providers, intensive treatment services including Ambulatory Detoxification, Intensive Outpatient Program (IOP) treatment, Partial Hospitalization Program (PHP) treatment, and all inpatient treatment services. These services require prior authorization. Psychological testing will also require prior authorization after four hours of services
This policy does not pertain to accounts that do not require prior authorization for routine outpatient services.