New Preauthorization Requirements for Outpatient Services

Preauthorization is one way we help you get the most from your benefits and help you avoid unexpected health care expenses. This step determines whether a particular service, supply, therapy or medication meets Empire’s clinical criteria for necessary and appropriate treatment before the services are rendered. It’s an important part of your policy/plan to help promote high quality care through the right treatment.  
You may have heard that Empire is expanding its preauthorization requirements for outpatient services. These changes will apply to Empire’s local Commercial plans (including EPO & PPO plans, and HMO plans). These changes will not apply to Empire National Accounts, Federal Employee Plan (FEP), NYS Benefit Management Program, Child Health Plus, Healthy NY, Hospital-only plans, and Medicare Advantage HMO & PPO plans. In addition, if your plan is collectively bargained or self-funded, please talk to your Group Benefits Administrator about whether these changes will apply to you. 
Effective June 1, 2011, the following categories of outpatient services will be added to the list of covered services that currently require preauthorization under certain local commercial plans. Within these new categories, the following outpatient services specifically require preauthorization as of June 1, 2011:  
Air ambulance (scheduled)

Genetic testing for cancer susceptibility

Outpatient treatments, including certain ambulatory surgical procedures

Endoscopic sinus surgery

Nasal surgery for the treatment of obstructive sleep apnea and/or migraine headaches (includes: excision of polyp(s), turbinate(s), ablation of turbinate(s), septoplasty, repair of vestibular stenosis)

Breast procedures including reconstructive surgery and implants (not including post-mastectomy breast reconstructive surgery for members covered under insured plans)

Surgery for clinically severe obesity

Spinal cord stimulator surgery

Cochlear implant surgery

Please note that the list of outpatient services under the above categories require preauthorization for dates of service on or after June 1, 2011. This list is subject to change. 
As we have mentioned above, not all groups or products are affected by this change, so we’ve sent a letter to Benefit Administrators at affected groups explaining the change. We also included a member letter for groups to notify their employees/ members of this change.  
As a reminder, if you are an Empire PPO or EPO plan member, you are responsible for preauthorization unless your plan document states otherwise. Failing to obtain preauthorization may result in a monetary penalty specific to your plan or benefits may not be covered.  
We recognize getting the right treatment can have a big impact on your health. Talk with your doctor or health care provider about your condition(s) and treatment options. You can also ask them about preauthorization for services.  
To find out more information about which outpatient services under the above categories require preauthorization or whether these new outpatient preauthorization requirements apply to your policy/plan, please call Empire Member Services at the number on your ID card or talk with your Group Benefits Administrator.  
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