Prior Authorization Guidance for Providers in the New York State Early Intervention Program

Many health plans (plans) require that providers obtain authorization to ensure payment of various health care services including, but not limited to: occupational, physical, and speech therapy.  Authorization requirements may apply to services provided by in-network and/or out-of-network providers.

Plans often approve or deny authorization requests based on whether the benefit is covered under the plan. If the early intervention (EI) services are covered, plans may review health services to determine whether the services are or were medically necessary, or experimental or investigational. This process is called utilization review. Utilization review includes review activities, whether they take place prior to the service being performed (prior authorization/preauthorization); when the service is being performed (concurrent authorization); or after the service is performed (retrospective authorization). Some plans may also deny coverage, following a utilization review, if a comparable but more cost-effective treatment could be provided.

Some plans apply the same authorization requirements for services provided under the EI Program while others apply less stringent prior or concurrent authorization requirements, or choose not to apply authorization requirements to EI services.

When authorization is required for services included in a child’s and family’s Individualized Family Service Plan, and the services are covered by the child’s insurance policy, the NYS Department of Health Bureau of Early Intervention (BEI) expects all EI providers to request authorization from that insurance payer if the child’s policy is regulated by NYS, or the parent has provided informed consent for billing the insurer – if the policy is not regulated by NYS.

EI providers should NOT delay performing multidisciplinary evaluations or providing any EI service while the prior or concurrent authorization is being sought. Please note that many plans do not require prior authorization for initial evaluation services. 

If an EI provider’s claim for payment is denied because prior or concurrent authorization was not obtained, the provider should take the necessary steps to obtain this authorization for future EI claims as soon as possible to ensure payment by regulated plans or non-regulated plans when parents have given consent to bill. Many plans will accept a request for a retrospective authorization if the request is made within a reasonable time period after the service is provided; this time period following the service varies based by plan – this information should be included in the policy, contract, plan document, summary plan description, or Collection of Insurance Information requested. 

The following steps are recommended for submission of prior authorization requests:

• Submit a copy of the subrogation notice to all plans who cover the child prior to or at the same time a prior authorization request is submitted
• Confirm the child’s plan(s) on file is accurate and complete before submitting a prior, concurrent, or retrospective authorization request
• Verify the child is covered under the policy on file
• Confirm the benefits for which you are billing are covered under the plan
• Confirm the services provided to the child under the EI Program are covered benefits under the child’s plan(s), Medicaid or other government programs such as Child Health Plus[i]
• Include a copy of the physician referral, other referrals, information from other providers regarding diagnoses, past and current evaluation reports and any supplemental information that may demonstrate medical necessity with all prior, concurrent, or retrospective authorization requests
• Comply with all plan requests for clinical documentation and treatment plans to support medical necessity determinations
• Document the prior authorization reference or approval number assigned by the plans or third party administrators[ii] and share it/them with the Service Coordinator for entry into NYEIS and include the prior authorization number in EIP claims submissions for authorized services
• Continually follow the tasks above if the authorization contains visit limits or an expiration date and the IFSP includes visits above the authorization limits or beyond the expiration date
• Submit follow-up authorization requests at least one week prior to the expiration of the current authorization to ensure no gaps in coverage

If the covered benefit is determined to be “medically necessary” by the plan, the services may be authorized and claims paid if the provider is an in-network provider or the plan covers out-of-network providers. These services may also be covered by an out-of-network provider--even if the plan requires services be provided by an in-network provider--when there are no in-network providers currently available to see the child within a reasonable amount of time.

An interactive companion tutorial is available by clicking here.

For plan-specific practices related to prior authorization, click here.

The plan specific guidance includes the most recently available information as of the date of release. Because plans may make periodic changes to their requirements, BEI recommends reaching out to the plans. Providers should use the contact numbers found in the guidance.

When prior authorization is required under a regulated policy, NYS Insurance Law requires payers to respond to prior authorization requests within three days of receipt of all necessary information. For extension or continuation of services already being provided, payers must respond to authorization requests within one business day after receiving all necessary information. NOTE: These rules apply only to NYS regulated plans.

If providers do not receive responses to prior authorization requests within the required amount of time, they should contact the payer’s provider/customer service representatives to follow up. Providers that do not receive a prompt satisfactory response during, or after, their follow up call with the payer should file a complaint directly with the NYS Department of Financial Services (DFS). For questions regarding filing a complaint, please contact James Favorito at James.Favorito@dfs.ny.gov.