Understanding that hospitals and other facilities must dedicate their teams and resources to patient care during the COVID-19 outbreak, on March 20, 2020, the New York Department of Financial Services issued guidance to insurers that certain standard prior authorization, concurrent review, retrospective review, and discharge planning services for inpatient hospital and emergency services must stop for 90 days. This period ends on Jun 18, 2020.
Read the DFS Insurance Circular Letter 8.
April 14 UPDATE: EmblemHealth has chosen to include its Medicare Advantage plans in the utilization review and emergency admission notification suspension. This suspension is also retroactive to March 20, 2020 and will end on June 18, 2020.
The affected services include:
- Prior authorization for scheduled surgeries or hospital admissions. *
- Concurrent review of inpatient hospital services. *
- Retrospective review of inpatient hospital services and emergency services at in-network hospitals. *
- Hospital discharge planning and preauthorization for:
- Home health care services, inpatient rehabilitation services, and skilled nursing facilities following an inpatient hospital stay.
- Inpatient substance use disorder treatment and inpatient mental health services.
- Notification for Emergency Hospital Admissions
*At the end of the 90-day suspension of the affected services, EmblemHealth is permitted to conduct retrospective review of all affected services rendered during the suspension period.
Please note that the State of New York has not altered timely filing or prompt pay requirements at this time. That is, all claims for health care services must be filed and adjudicated within standard timeframes.
In addition, facilities may postpone filing internal and external appeals (e.g. for adverse determination and final adverse determination) during the suspension period. Standard timeframes for filing appeals will resume after the suspension period ends, beginning on June 18, 2020.
Lastly, EmblemHealth will stop all audits of hospital payments and overpayment recoveries during the emergency period. We will resume those activities upon authorization by the State.
If your facility wants to continue to coordinate care for your patients, our teams are available to work with you.
- Call 877-833-2729 if you wish to speak with a clinician about any of the affected services described above.
If you have questions about the State’s guidance or your continued interactions with EmblemHealth, please contact your relationship manager.
Thank you for caring for our members during this unprecedented time.