Member Preauthorization

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 abdomen

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 (Blood Sugar) monitoring devices, short term. Long term CGM now done in pharmacy
  • Cochlear (ear) implants
  • Durable Medical Equipment
    • Customized items/equipment
    • Electrical Stimulators (Devices that use electricity to stimulate healing)
    • Jaw motion rehabilitation system and accessories
    • Lift equipment/devices
    • Negative Pressure Wound Therapy (Device that uses suction to drain a wound)
    • Non-standard wheelchair accessories
    • Oral (mouth) appliances for sleep apnea (sleep disorder)
    • Power wheelchairs and accessories
    • Total electric Hospital Beds
    • Wearable defibrillator vests (Device to correct heartbeat or restore normal heartbeat)
  • Elective hospital/facility admissions to include, but not limited to:
    • Admissions for transplants
    • Inpatient rehabilitation and habilitation admissions (physical, speech and occupational therapy)
    • Medical admissions
    • Mental health admissions except for members under age 18 at Independent Health participating hospitals licensed by the Office of Mental Health (OMH)
    • Skilled nursing facility admissions
    • Substance use inpatient admission except for Independent Health participating providers which are New York State Office of Alcoholism and Substance Abuse Services credentialed facilities
    • Surgical admissions
  • Extracorporeal Shock Wave Therapy (ECSWT) for Chronic Plantar Fasciitis
  • Gender Dysphoria (Surgical Treatments)
  • Genetic Testing
  • Home Births
  • Home Health Care Services
    (including Home Infusion Nursing Visits)
  • Hyperbaric (high pressure) Oxygen Therapy (Systemic and Topical)
  • Lutathera (medication to treat specific types of tumors)
  • Non-Emergent Ambulance, Planned Transfer
  • Partial Hospitalization for Mental Health Services
  • Partial Hospitalization for Substance Use
  • Prosthetic Devices External
    • Custom Orthopedic braces and footwear (Device that replaces, supports, or corrects a body part or the function of a body part including feet)
    • Electric Artificial Limbs (device that replaces, supports, or corrects the function of an arm or leg)
  • Residential Treatment (except inpatient substance use admissions to New York State Office of Alcoholism and Substance Abuse Services credentialed facilities contracted with Independent Health)
  • Surgical Procedures:
    • Back and neck surgery
    • Bariatric surgery (weight loss surgery)
    • Breast surgery(male and female): implant removal, non-cancer diagnosis breast reconstruction, breast reduction mammoplasty (cosmetic breast reduction)
    • Cosmetic procedures (medically necessary)
    • Oral (Mouth) surgeries
    • Reconstructive procedures
    • Septorhinoplasty and rhinoplasty (Nose procedures)
    • Temporal mandibular (Jaw) joint disorder
    • Transcranial (Brain) magnetic stimulation
    • Uvulopalatopharyngoplasty (UPP) (surgical procedure to remove or remodel tissue in the throat)
  • Total Artificial Heart
  • Transcatheter Aortic Valve Replacement (TAVR) (Surgical procedure to fix a heart valve that does not open properly)
  • Transplant Procedures
  • Varicose (swollen) Vein Procedures
  • Wireless Capsule Endoscopy (procedure to look inside the body) (WCE)