Important information about utilization management

Empire BlueCross BlueShield (“Empire”) 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’s medical policies are available on our website at empireblue.com.

 

You can also request a free copy of our UM criteria from our medical management department, and each Treating and Ordering Provider directly involved in the member’s care may discuss a UM denial decision with a physician reviewer by calling us at the toll-free number listed on the UM denial letter, if they haven’t already done so, and before all applicable appeals are completed. UM criteria are also available on the web.  Just go to empireblue.com/provider > For Providers > Provider Resources > Policies, Guidelines & Manuals > View Medical Policies and Clinical UM Guidelines.

 

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. to 5 p.m. ET. Monday through Friday (except on holidays). More hours may be available in your area. Federal Employee Program (FEP) hours are 8 a.m. to 7 p.m. ET.
• 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 12 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 Authorization	To Discuss Peer-to-Peer UM Denials w/Physician	To Request UM Criteria	TTY/TDD
800-982-8089   Transplant 800-255-0881 National Transplant 844-644-8101 Fax: 888-438-7051   Behavioral Health 800-626-3643   Autism 844 269 0538   FEP 800-860-2156  Fax: 800 732-8318 (UM) Fax: 877 606-3807 (ABD	Please refer to the phone number on the denial notification letter.      Pre-service Appeals 800-634-5605, option 2   Adaptive Behavioral Treatment 844-269-0538   FEP 800-860-2156	Call number on back of member’s ID card   FEP 800-860-2156  Fax: 800-732-8318 (UM) Fax: 877-606-3807 (ABD)	711, or TTY: 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.

 

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