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 medical policies are available on the 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 online. Go to empireblue.com/provider > See Policies, Guidelines & Manuals > View Medical Policies and Clinical UM Guidelines.

 

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

• Call us toll free from 8:30 a.m. to 5 p.m. Monday through Friday (except on holidays). More hours may be available in your area. Federal Employee Program hours are 8 a.m. to 7 p.m. Eastern.
• 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	To discuss peer-to-peer UM denials with physicians	To request UM criteria	TDD/TTY	Business hours
800-982-8089   Transplant: 800-255-0881 Fax: 800-447-5523 National transplant: 844-644-8101 Fax: 888-438-7051   Behavioral health: 800-626-3643   Autism Call customer svc number on back of member’s ID card   FEP Phone: 800-860-2156 Fax: 800-732-8318 (UM) Fax: 877-606-3807 (ABD)	Please refer to the phone number on the denial notification letter.     Behavioral health: 800-626-3643   Adaptive Behavioral Treatment Call customer svc number on back of member’s ID card     FEP phone: 800-860-2156	Call number on back of member’s ID card   Behavioral health: 800-626-3643   FEP phone: 800-860-2156  Fax: 800-732-8318 (UM) Fax: 877-606-3807 (ABD)	711   Or 800-676-3777 TTY/ASCII/ Voice/VCO/ STS	Call us toll free from 8:30 a.m. to 5 p.m. Monday through Friday (except on holidays). More hours may be available in your area. Federal Employee Program hours are 8 a.m. to 7 p.m. Eastern.

 

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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