CommercialPrior AuthHigh impact
Site of Service Rule Reminder
EmblemHealth·General Surgery, Orthopedics, ENT (Ear, Nose & Throat) +7 more·Provider News
Effective date
Aug 1, 2025
We identified it
Jun 20, 2026
Summary
EmblemHealth now requires preauthorization for certain hospital outpatient surgeries (places of service 19 and 22) for members under age 75, effective August 1, 2025. The same surgeries performed in ambulatory surgery centers (ASC) or physician offices do not require preauthorization.
Action Required
Immediately: Billing team must update prior authorization workflows to require preauth for hospital outpatient surgeries (POS 19 and 22) for EmblemHealth members under age 75. Review the Notable Changes list for specific surgery codes requiring preauth. Update scheduling staff to verify place of service before booking surgeries. Consider scheduling affected procedures at ASCs to avoid preauth requirements. Claims for non-preauthorized hospital outpatient surgeries will be denied.