Policy Update Regarding Site of Service Approval for
EMBLEMHEALTH All Lines of Business and EMPIRE Medicare Members
HealthCare Partners has updated their review criteria for Place of Service (POS) approval for EmblemHealth members who are in Commercial, Medicare and Medicaid health plans and Empire Medicare members. This change will now require prior authorization for POS 19 (Outpatient Hospital-Off Campus) and POS 22 (Outpatient Hospital-On Campus) requests effective November 6, 2020 for the procedures indicated on attachment.
As reflected in our payers’ Site of Service policies:
When there is more than one option for the site of surgery, and in the absence of any clinical contra-indication, the lowest level of site will be approved.
Requests for POS 19 or 22 will require an authorization for site of service, in addition to the standard medical necessity review. If you are requesting utilizing either of these places of service, please submit appropriate supporting documentation for an efficient medical review. If you are requesting that services be performed at POS 24 (Ambulatory Service Center) or POS 11 (In the office) they will continue to follow their regular review process, which may include a medical necessity review, but not a site of service review.
This site of service medical review will determine if your requested location for this procedure is medically necessary and appropriate based on your patient’s needs. As part of our review, we will determine if this procedure can be safely performed at a non-hospital based site. As always we are available to discuss pertinent clinical details that may not be clear in your submitted documentation.