CommercialPrior AuthHigh impact
Policy Updates That Impact Where Members Get Care
EmblemHealth·NY · Oncology, Hematology, Infectious Disease +3 more·Provider News
Effective date
Jul 14, 2024
We identified it
Jul 17, 2026
Summary
EmblemHealth updated its Site of Service Medical Policy for infusions and injectables effective July 14, 2024, to allow members to receive specialty pharmacy infusions and injections in alternative settings (infusion centers, doctor's offices, or home) instead of hospitals when medically appropriate. Prior authorization is now required and must be submitted to Prime Therapeutics; the payer may direct members to settings different from provider/member preference.
Action Required
Immediately: Billing team must implement prior authorization requirement for all specialty pharmacy infusions and specialty pharmacy injections administered by healthcare professionals. Update billing software and encounter forms to route prior auth requests to Prime Therapeutics via fax (888-656-6671), phone (833-519-4548, 8am-6pm M-F), or online (gatewaypa.com). Train providers to submit prior auth BEFORE administering these services at any site of service (hospital, infusion center, office, or home). Establish process to document Prime Therapeutics' site-of-service direction and communicate to patients. Create appeal workflow for cases where provider/patient preferred site differs from payer's directed site. Failure to obtain prior authorization will result in claim denials. Document all peer-to-peer discussions with Prime Therapeutics when requested by providers.