Implementation of new strategic provider system in June 2023

In June 2023, Empire BlueCross BlueShield (Empire) will replace our legacy internal provider data management system for Empire contracted providers. This investment in advanced technology will significantly improve data accuracy and transparency — enhancing the overall provider experience. New system features strengthen Empire’s ability to match submitted claims for more accurate pricing and processing.

System upgrades special notice

Empire will implement system upgrades beginning May 30, 2023. Provider updates submitted during this time will be processed after June 6, 2023. We appreciate your patience as we upgrade our systems.

Critical billing requirements

As part of this system upgrade, Empire is enforcing the billing guidelines of CMS that hold providers accountable for billing claims data correctly. (See link below to CMS Regulations and Guidance.)

Effective December 9, 2023, claims submitted with missing or incorrect billing NPI will be rejected and returned. Submitting claims with complete and correct data is critical to ensure Empire is able to process your claims efficiently and accurately. All data fields on claims are used when building your claim records.

You should bill according to standard billing guidelines. As we approach the implementation date for our strategic provider system, we encourage you to review your billing practices carefully to ensure proper TIN, billing NPI, and rendering provider information (if applicable) are submitted in the appropriate fields. As a reminder, if claims are submitted incorrectly, they will be rejected and returned for correction.

Electronic claims filing

If you are filing professional claims electronically (supported by electronic data interchange [EDI]), below are some tips for a successful claim submission:

• Billing provider— Loop (section) 2010:
  • When the billing provider is an organization healthcare provider, the organization’s NPI number is reported in field NM109.
  • The TIN of the billing provider must be reported in the REF segment of this loop.
  • The billing provider may be an individual only when the healthcare provider performing the services is an independent, unincorporated entity.
  • The billing provider address must hold a physical address and should not contain any of the following: Post Office Box, P.O. Box, PO Box, Lock Box, or Lock Bin.
• Rendering provider— Loop 2310:
  • This loop or section of the EDI file is required when the rendering provider’s NPI is different from that carried in Loop ID-2010AA-billing provider. If not required by the EDI implementation guide, do not send.
  • The rendering provider is the person or company who rendered the care.

Mail claims filing

If you are filing a professional claim via mail:

• Facility information:
  • Include the address of the servicing facility — the address where services were rendered — in Box 32.
  • Include the servicing facility’s NPI — service location NPI — in Box 32a.
• Billing provider:
  • The billing provider’s complete name, address, and phone number must be in Box 33.
  • NPI must be reported in Box 33a (group’s organization or individual provider is an independent, unincorporated entity).
  • The TIN of the billing provider must be reported in Box 25.
• Rendering provider:
  • For claims that require a rendering provider, report the rendering provider NPI in Box 24J.

 If using a clearinghouse, we suggest that you contact the clearinghouse to ensure proper claims filing and to alert the vendor of Empire’s upcoming system change. Regular check-ins with your clearinghouse are key to identifying claim issues early.

Critical data requirements

Please ensure that all your contracted providers are submitted to Empire and are on file prior to rendering services. This will alleviate claim processing delays and helps to ensure the Provider Directory reflects correct information. It is a contractual requirement to submit physicians joining your group in a timely manner, prior to the physician rendering care to members.

Looking ahead

Going forward, we will continue to share information about our plans to move to the strategic provider system and the impact to our care provider partners. Watch for upcoming editions of Provider News.

For more information, review:

• https://www.empireblue.com/provider/policies/
• CMS Regulations and Guidance