Prior authorizations

What is prior authorization?

Prior authorization is when a health care provider, such as a doctor or hospital, receives approval from your health plan before performing certain diagnostic tests or performing a medical procedure. Prior authorizations are safeguards used to make sure procedures prescribed by doctors and hospitals are safe and effective, are being provided in the right care setting and follow all nationally recognized medical guidelines.

Does my current GHI CBP plan require prior authorizations?

Yes, the GHI CBP plan has always required prior authorizations for certain procedures and services.

Does the NYCE PPO plan require prior authorization in certain cases?

Like the GHI CBP plan, the NYCE PPO also requires prior authorizations for certain procedures and services; however, in the NYCE PPO health care plan, fewer procedures and services require prior authorization.

How will the prior authorization process in the NYCE PPO plan differ from the GHI CBP plan?

EmblemHealth and UnitedHealthcare will now internally manage the prior authorization process, rather than relying on a third-party vendor as it does under the current system in the GHI CBP plan.

In the NYCE PPO health care plan, fewer procedures and services require prior authorization.

In the new plan, prior authorizations will decrease by 50%
If this change had been in place in the GHI CBP plan last year, 461,911 claims would not have required prior authorization and 223,036 patients would not have been subject to prior authorization for certain services.
Prior authorizations in the current plan were removed for frequently used services including some MRIs, CT scans, orthopedic surgeries, office-based dermatology, pain injections and home health visits.
Because of emerging technology such as genetic and molecular testing, some prior authorizations will always be required, and services and procedures are constantly being added or removed from the list requiring prior authorization.
To ensure members have access to the care they need, a review committee will be set up to monitor this list and work to keep the procedures our members most commonly need off the list.

What will the review committee do?

A review committee, made up of members from EmblemHealth, UnitedHealthcare, the city and the MLC, will meet monthly to review reports on plan implementation and data trends on issues including costs, prior authorization and claim denials.
If any issues arise, they will be sent to a mediator to be resolved.
If there is no resolution through mediation, any dispute will be sent for an expedited arbitration process.

What protections are in place to make sure prior authorization is determined in an appropriate and timely manner?

The providers will regularly monitor how decisions are made, how quickly the approval process happens, how often care is approved and how well it supports your health care needs. EmblemHealth/UnitedHealthcare has committed to:

Fast Medical Review: All prior authorization requests will be reviewed by trained medical experts using established guidelines and research. Many times this review will occur automatically through an online portal, resulting in an instant approval.
Appeal Rights: If a prior authorization request was denied, it does not necessarily mean the care won't be approved. It will just mean the insurer needs more information, believes the request may not be medically necessary or may suggest a more appropriate alternative. The insurance plan will inform you and your provider about how to appeal the decision and other available options.
Appeal Process: If you appeal a decision, your provider could help by sharing more details about why the care is needed. If the decision still was not approved after this second review, you might be able to request an external review in which an independent medical expert — someone not connected to your health plan — will review your case. These experts help make sure decisions are based on established medical guidelines and research.
Additional support: If you want to appeal a decision, the NYCE PPO plan will provide direct support to you. This support includes fully explaining why they denied the request and helping you gather additional information that might support your appeal.
Transparency: The process and policies will be publicly available on the plan's website, so you fully understand how they approach prior authorization.

Would I need to get new prior authorizations with this plan?

No, prior authorizations that were approved under the GHI CBP plan will all be transferred to the new NYCE PPO for you.

Does NYCE PPO use artificial intelligence (AI) for prior authorizations?

All NYCE PPO prior authorizations will be made by qualified clinicians using clinical judgement, evidence-based guidelines and established clinical policies. At no point will the critical decision-making involved in prior authorizations be done by anyone — or any tool — that is not a licensed health care professional.

I’ve seen things online about UnitedHealthcare and claim denials. Should I be worried about claims being denied more often?

No. This was something the negotiating committee was laser focused on. They took into consideration where and how most claims denials arise and made sure to add protections when negotiating this plan.

Our protections include:

The projected reduction of prior authorizations by 50% given the reduced number of procedures and services requiring prior authorization, which eliminates many of the upfront hurdles where claim denials occurred.
The expansion of the provider network means fewer “out-of-network” situations — another common source of claim denials in the GHI CBP plan.
Monthly joint oversight meetings involving the city, the unions and the insurance companies to track any concerning trends and quickly address issues , including through an expedited binding arbitration process to resolve disputes
An individual appeals process that makes sure members have a right to appeal any denials and that cases are reviewed fairly.

While UHC will determine prior authorization outside the Downstate 13 and EmblemHealth will administer in the Downstate 13 , UHC will follow the same processes and protocols that EmblemHealth will follow within the Downstate 13. There is not a difference in criteria or standards for approving or denying claims regardless of who is administering the benefit.

Remember, every major insurance company, even our current Anthem/Blue Cross Blue Shield, has high denial rates nationally. But here in New York City, city workers don’t experience those rates of denial. Because of our size, and how we bargain and enforce union protections, no city employee ever needs to engage in a fight with a giant health care system alone. Plus, as UFT members, we have the support of the UFT Welfare Fund, which helps us address any unfair denials we might face.

The bottom line: This plan was carefully negotiated to ensure fairness, reduce prior authorizations, reduce denials and give you strong protections against any unfair denials.