Important Information about Utilization Management

Our utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as the member’s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service or care. Nor, do we make decisions about hiring, promoting, or terminating these individuals based on the idea or thought that they will deny benefits.  In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in under-utilization.  Empire BlueCross BlueShield’s (“Empire”) medical policies are available on empireblue.com/provider.

 

You can also request a free copy of our UM criteria from our medical management department, and providers may discuss a UM denial decision with a physician reviewer by calling us at the toll-free numbers listed below.  UM criteria are also available on empireblue.com/provider > Review Policies, View Medical Polices & UM Guidelines.

 

We work with providers to answer questions about the utilization management process and the authorization of care.  Here’s how the process works:

• Call us toll free from 8:30 a.m. - 5 p.m. Monday through Friday (except on holidays). More hours may be available in your area.  Federal Employee Program hours are 8:00 a.m. – 7 p.m. Eastern.
• If you call after normal business hours, you can leave a private message with your contact information. Our staff will return your call on the next business day.  Calls received after midnight will be returned the same business day. 
• Our associates will contact you about your UM inquiries during business hours, unless otherwise agreed upon.

 

The following phone lines are for physicians and their staffs.  Members should call the customer service number on their health plan ID card.

 

To discuss UM Process and Authorizations:

1-800-982-8089

Transplant: 1-800-255-0881

Behavioral Health: 1-800-626-3643

Autism:  1-844 269 0538

FEP: Phone 1-800-860-2156, FAX 1800 732-8318 (UM), FAX 1-877 606-3807 (ABD) 

 

To Discuss Peer-to-Peer UM Denials w/Physicians:

Please refer to the phone number on the denial notification letter. 

Pre-service Appeals: 1-800-634-5605 – opt2

FEP: Phone 1-800-860-2156

To Request UM Criteria:

Call number on back of member’s ID card

FEP: Phone 1-800-860-2156, FAX 1-800 732-8318 (UM), FAX 1-877 606-3807 (ABD) 

TDD/TTY:

TTY: 1-800-662-1220

Voice: 800-421-1220

 

For language assistance, members can simply call the Customer Service phone number on the back of their ID card and a representative will be able to assist them. Our utilization management associates identify themselves to all callers by first name, title and our company name when making or returning calls.  They can inform you about specific utilization management requirements, operational review procedures, and discuss utilization management decisions with you.