Clinical appeals

The clinical appeal process is designed to provide appropriate and timely review when providers disagree with a decision made by Empire BlueCross BlueShield (“Empire”). The procedures also meet requirements of state laws and accreditation agencies. Appeals can be made verbally, in writing, or by using Interactive Care Reviewer through the Availity portal.

 

Clinical appeals refer to a situation in which an authorization or claim for a service was denied as not medically necessary or experimental/investigational. Medical necessity and prior authorization appeals are different than claim payment disputes and should be submitted in accordance with the clinical appeal process. 

 

To learn more about our appeals process in detail, we encourage you to go to Empire’s provider manual, available on our website at https://www.empireblue.com/provider.

 

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