Understanding the Member Preauthorization Process

Prior to receiving a medical service or procedure, you may be required to obtain approval from your health insurance plan. This is known as “member preauthorization” and ensures that you are receiving safe, appropriate care. A detailed list of services requiring preauthorization is included in your contract (“Certificate of Coverage”).

How It Works

If you require a service on Independent Health’s member preauthorization list, you are responsible for obtaining approval by calling the Member Services Department at (716) 631-8701 or 1-800-501-3439. While your provider may also do this on your behalf, keep in mind that it is your responsibility to ensure preauthorization is obtained from Independent Health prior to receiving these services to avoid potential financial penalties.

The request for member preauthorization should be made 15 calendar days in advance of the service(s) being rendered, or within 48 hours of the first business day following emergency services and/or admission.

Independent Health will review the member preauthorization request, which may take 3 to 5 business days. Once a decision is made, you will be notified in writing of the decision.

EXAMPLE
Photo do woman holding abdomin.

STEP 1:

Kim goes to the doctor for abdominal pain. After a physical exam and subsequent blood work, the doctor diagnoses Kim with gallbladder pain and suggests surgery to remove the gallbladder.


Photo do woman on the phone.

STEP 2:

Kim calls Independent Health Member Services Department at least 15 days prior to her surgery date to request preauthorization for the procedure.

To help us process her request, she obtained the following information from her provider before calling:

  • Requesting provider name, address and tax ID
  • Place of service, address and tax ID
  • Date of service
  • Procedure name and code
  • Diagnosis name and code
  • Type of service
    (e.g., inpatient, outpatient, home care, DME, radiology)


Photo of a paper letter.

STEP 3:

Within 5 business days, Kim receives a letter in the mail with a response to her preauthorization request. Since her request was approved, Kim is all set to go in for her surgical procedure.
Note: This scenario is for illustrative purposes only. Please check your plan benefits to confirm what services require member preauthorization.
 

The following services require member preauthorization:

  • Applied Behavior Analysis (ABA) for Diagnosis and Treatment of Autism Spectrum Disorder
  • Assistive Communication Devices (ACD) for Autism Spectrum Disorder
  • Clinical Trials
  • Continuous Glucose Monitoring Devices (short- and long-term)
  • Durable Medical Equipment
    • Bi-level positive airway pressure spontaneous – timed (Bipap-St)
    • Bi-level positive airway pressure spontaneous (Bipap-S)
    • Customized items/equipment
    • Hearing aids
    • Hospital beds (adult and pediatric including accessories)
    • Jaw motion rehabilitation system and accessories
    • Lift equipment/devices
    • Light boxes
    • Non-standard wheelchair accessories
    • Power wheelchairs and accessories
    • Wearable defibrillator vests
  • Elective hospital/facility admissions to include, but not limited to:
    • Admissions for transplants
    • Behavioral health admissions, including mental health and substance use (except inpatient substance use admissions to New York State Office of Alcoholism and Substance Abuse Services credentialed facilities contracted with Independent Health)
    • Inpatient rehabilitation and habilitation admissions (physical, speech and occupational therapy)
    • Intensive outpatient services for mental health
    • Intensive outpatient services for substance use
    • Medical admissions
    • Skilled nursing facility admissions
    • Surgical admissions
  • Extracorporeal Shock Wave Therapy (ECSWT) for Chronic Plantar Fasciitis
  • Gender Dysphoria (Surgical Treatments)
  • Genetic Testing, including BRCA and BART
  • Home Births
  • Home Health Care Services
    (including Home Infusion Nursing Visits)
    • Medical supplies with approved home care services
      (excluding ostomy)
  • Neuropsychological Testing
  • Non-Emergent Ambulance, Planned Transfer
  • Partial Hospitalization for Mental Health Services
  • Partial Hospitalization for Substance Use
  • Private Duty Nursing
  • Prosthetic Devices External
    • Artificial limbs
    • Orthopedic braces and footwear
  • Psychological Testing (Psychometric)
  • Residential Treatment (except inpatient substance use admissions to New York State Office of Alcoholism and Substance Abuse Services credentialed facilities contracted with Independent Health)
  • Specialized Blood Testing for Breast and Colon Cancer
    (Oncotype Dx)
  • Surgical Procedures:
    • Back and neck surgery
    • Bariatric surgery (weight loss surgery)
    • Breast surgery: implant removal, non-cancer diagnosis breast reconstruction, breast reduction mammoplasty (male and female)
    • Cosmetic procedures (medically necessary)
    • Oral surgeries
    • Reconstructive procedures
    • Septorhinoplasty and rhinoplasty
    • Temporal mandibular joint disorder
    • Transcranial magnetic stimulation
  • Transplant Procedures