We want to help physicians, facilities and other health care professionals submit claims accurately. This page outlines the basis for reimbursement if the service is covered by an Empire member’s benefit plan. Keep in mind that determination of coverage under a member's plan does not necessarily ensure reimbursement. Industry practices are constantly changing, and Empire reserves the right to review and revise these policies periodically.
Definitions and Disclaimers
These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement if the service is covered by a member’s Empire BlueCross BlueShield benefit plan. The determination that a service, procedure, item, etc. is covered under a member's benefit plan is not a determination that you will be reimbursed.
Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member’s state of residence.
You must follow proper billing and submission guidelines. You are required to use industry standard, compliant codes on all claim submissions. Services should be billed with Current Procedure Terminology (CPT) codes, Healthcare Common Procedure Coding System (HCPCS) codes and/or Revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both Participating and Non-Participating providers and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed, may:
- Reject or deny the claim
- Recover and/or recoup claim payment
These policies may be superseded by mandates in provider or State contracts, or State, Federal requirements. We strive to minimize delays in policy implementation. If there is a delay, we reserve the right to recoup and/or recover claims payment to the effective date, in accordance with the policy. reserves the right to review and revise its policies periodically when necessary. When there is an update we will publish the most current policy to the website.
