Participating provider contractual obligations: Advanced patient notice policy for non-participating provider referrals

As part of our ongoing efforts to offer the highest quality healthcare service while ensuring affordability for our members, Empire BlueCross BlueShield (Empire) recently completed a review of non-participating provider referral patterns, and the results were remarkable. As a reminder to our participating providers, consistent with the terms of the Participating Agreement, providers and facilities are required to refer to participating providers (facilities, physicians, and practitioners).

Please reference Use of a Non-Participating Provider Advance Patient Notice Policy (APN form) in the Empire provider manual to refamiliarize yourself with Empire’s policy implemented in 2009. Empire tracks the use of non-participating providers, and repeated failure to comply with this policy after initial warning may result in termination from Empire’s network.

While certain members may have out-of-network benefits, all members must be made fully aware of the financial implications when they are referred by their provider, on a non-urgent basis, to any non-participating provider. It is especially critical to notify members when referring to non-participating providers for services such as, but not limited to, laboratory, anesthesia, specialty drugs, infusion therapy, durable medical equipment, and/or the use of assistant surgeon and ambulatory surgery centers for scheduled surgeries. A member has no way of knowing that a non-participating provider was involved in their care unless informed, in advance, by their provider.

Empire believes the network is large enough to accommodate the needs of members through participating providers. For a complete listing of Empire’s participating providers, go to https://www.empireblue.com/ and select Find Care. It is important to note which network the member utilizes as a provider’s participation with Empire may vary by network.