CommercialPrior AuthHigh impact
Reminder: New Site of Service Rules Aug. 1
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 will require preauthorization for certain hospital outpatient surgeries (places of service 19 and 22) starting Aug. 1, 2025, for all members under age 75. The same surgeries performed in ambulatory surgery centers or physician offices will not require preauthorization, encouraging providers to obtain ASC privileges.
Action Required
By August 1, 2025: Billing team must update system to require preauthorization for hospital outpatient surgeries (POS 19 and 22) for EmblemHealth members under age 75. Review the 'Notable Changes' document for specific affected procedure codes. Update encounter forms and scheduling workflows to identify when preauthorization is needed versus ASC/office settings. Contact EmblemHealth Provider Customer Service for the complete list of affected codes and preauthorization requirements.