Medicare AdvantagePrior AuthHigh impact
November 2019 In The Know
EmblemHealth·NY · Physical Therapy, Occupational Therapy, Radiology·Provider News
Effective date
Jan 1, 2020
We identified it
Jun 20, 2026
Summary
EmblemHealth eliminated referral requirements for initial physical/occupational therapy evaluations and routine diagnostic x-rays effective immediately. New preauthorization requirements will reduce PA codes by half starting January 1, 2020, with changes varying by plan type (Commercial, Medicaid, Medicare).
Action Required
Immediately: Stop requiring referrals for initial PT/OT evaluations and routine diagnostic x-rays that don't need preauthorization. By January 1, 2020: Review updated preauthorization requirements on EmblemHealth's UM and Medical Management page in Claims Corner. Update billing workflows to reflect reduced PA requirements based on member plan type (Commercial, Medicaid, Medicare). Services managed by eviCore still require preauthorization.