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Important Portal Update: Starting September 3, 2025, all users of the current OrthoNet Provider Portal will be automatically redirected
to the new Optum Spine, Pain, and Joint Provider Portal. If users have not already created a One Healthcare ID (OHID), they will have the opportunity to create one at
login.
Important Provider Letter Update: Effective September 3, 2025, Provider letters will be accessible via the Optum Provider Portal;
physical letters will no longer be mailed for Determination and Non-Determination letter types. Providers will have the ability to view and download copies of letters
on the portal beginning September 3, 2025.
Letter types that will be posted to the portal: Approvals. Expedited/Urgent, Initial Adverse Determination (Full & Partial),
Administrative Withdrawals, Pends, Lack of Information. The following letter types will continue to be mailed until further notice: Appeals, and Member letters.
EmblemHealth has delegated utilization management for select spine surgery and interventional pain management therapy procedures to OrthoNet.
The Program requires that the treating clinician obtain prior approval for spine surgery and interventional pain management procedures defined by a list of CPT/ICD codes.
For a full list of spine surgery and interventional pain management therapy codes that require prior approval please visit emblemhealth.com. As with all utilization management programs,
this Program will determine if the proposed service meets the definition of medical necessity under the member's benefit plan.
This program applies to services, provided by practitioners, either in:
Practitioner's Office (POS 11)
Inpatient Hospital Setting (POS 21)
Outpatient Hospital Setting (POS 22)
Ambulatory Surgery Center (POS 24)
The Program includes members from the following EmblemHealth provider networks:
*HIP members assigned to a Montefiore CMO, St Barnabas or HealthCare Partners primary care practitioner (PCP) are excluded from this Program (Members can be identified by the Montefiore
or HCP logos on the ID card and on the Member Details page of the Eligibility/Benefits lookup feature on emblemhealth.com.
Clinical Criteria used for Pain and Spine Utilization Management
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