Prior authorization and notification requirements, Empire Plan supplement - 2021 Administrative Guide

We require advance notification of the procedures and services listed in the chart below. These services are likely to identify members with unmet health care needs who will benefit from UnitedHealthcare’s programs, or those of other Empire Plan vendors. In general, depending on the program, members are responsible for either notifying Empire Plan program vendors of certain services or for using network care providers for these services.

Call 1-877-7-NYSHIP (1-877-769-7447) and follow the prompts to notify the appropriate program carrier/vendor as outlined below, or go to UHCprovider.com/paan

This notification list may be modified. The presence or absence of a procedure or service on this list does not mean that benefit coverage exists for that procedure or service. The member benefit contract will determine whether a procedure or service is covered.

Service

Contact


Advanced diagnostic imaging services

(CT/CTA scans, MRI/MRA, PET scans, nuclear medicine/cardiology)

UnitedHealthcare Benefits Management Program


Alcoholism treatment

Beacon Health Options, Inc. Behavioral Health Program


Chiropractic services

Managed Physical Network, Inc. (MPN) Managed Physical Medicine Program


Durable medical equipment (DME) and integral supplies

  • Mastectomy prosthetics over $1,000
  • Diabetic shoes (when the Empire Plan is primary coverage)
  • DME items listed on the DME Notification List at UHCprovider.com/paan

Advanced Notification and Plan Requirement Resources > Empire Plan Notification Lists > Empire Plan Durable Medical Equipment (DME) Notification List for Members with Primary Empire Plan Coverage

UnitedHealthcare Home Care Advocacy Program


Home health services that take the place of hospitalization

UnitedHealthcare Home Care Advocacy Program


Home infusion therapy and enteral formula

(except administration of enteral formula through a tube for patients whose primary coverage is Medicare)

UnitedHealthcare Home Care Advocacy Program


Hospital admissions

  • Elective, including maternity
  • Emergency/urgent (within 48 hours)

Empire BlueCross Benefits Management Program


Mental health services

Beacon Health Options, Inc. Behavioral Health Program


Physical therapy

Managed Physical Network, Inc. (MPN) Managed Physical Medicine Program


Prescription drugs

CVS Caremark Prescription Drug 

As noted in Preferred Drug List or Flexible Formulary List Program


Skilled nursing facility admissions

Empire BlueCross Benefits Management Program


Substance abuse services

Beacon Health Options, Inc. Behavioral Health Program