Prior authorization requirements
Our Interactive Care Reviewer (ICR) tool via Availity is the preferred method for submitting prior authorization requests, offering a streamlined and efficient experience for providers requesting inpatient and outpatient medical or behavioral health services for our members.
Empire BlueCross BlueShield HealthPlus (Empire) is available via phone or the Interactive Care Reviewer (ICR) 24 hours a day, 7 days a week to accept prior authorization (PA) requests. You can access the ICR from the Availity home page:
- The ICR allows detailed text, photo images and attachments to be submitted along with your request.
- Providers can also use this tool to make inquiries on previously submitted PA requests, regardless of how they were sent (phone, fax, ICR or another online tool).
- To request or check the status of a PA request or decision, log in to Availity. Once logged in, select Patient Management | Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry as appropriate.
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Prior authorization contact information for Empire
Providers and staff can also contact Empire for help with prior authorization via the following methods:
Empire Provider Services
- Phone: 1-800-450-8753
- Hours: Monday to Friday 8:30 a.m. to 5:30 p.m.
- Fax: 1-800-964-3627
Empire Pharmacy Department
- Hours: Monday to Friday 8 a.m. to 7 p.m.; Saturday 10 a.m. to 2 p.m.
- Retail Pharmacy Fax: 1-844-490-4877
- Medical Injectables Fax: 1-844-493-9206
The Medicaid-Approved Preferred Drug List (PDL) includes information such as mandatory generic requirements, prior authorization (PA), quantity limits, age limits or step therapy.
Pharmacy services billed with the following revenue codes always require prior authorization:
- 0632 — Pharmacy multiple sources
Behavioral health
Behavioral health services billed with the following revenue codes ALWAYS require prior authorization:
- 0240–0249 — All-inclusive ancillary psychiatric
- 0901, 0905–0907, 0913, 0917 — Behavioral health treatment services
- 0944–0945 — Other therapeutic services
- 0961 — Psychiatric professional fees
Long-term services and supports (LTSS)
Services billed with the following revenue codes always require prior authorization:
- 0023 — Home health prospective payment system
- 0570–0572, 0579 — Home health aide
- 0944–0945 — Other therapeutic services
- 3101–3109 — Adult day and foster care
Related resources
- Prior Authorization Lookup Tool Online for Empire can assist with identifying services requiring prior authorization or determining a code's prior authorization requirements.
- You can also refer to the provider manual for information about services that require prior authorization.