Submit appeals for clinically denied appeals via ICR

Empire BlueCross BlueShield (“Empire”) is committed to reducing cost while improving health outcomes. To that end, effective April 1, 2021 Empire will be changing how you submit Appeals for all clinically denied appeals related to commercial business.

 

Submission through Interactive Care Reviewer (ICR) allows you to request a clinical appeal for denied authorizations.  Now instead of making a phone call or sending a fax you can save time making your request online! This feature is available for authorization requests that were submitted through ICR, phone or fax. It’s as easy as 1,2,3!

 

Here’s how easy it is to request a clinical appeal using ICR:

Logon to ICR from the Availity Portal and locate the case from ICR’s dashboard - My Organization Requests or through Check Case Status if the case was submitted by phone or fax.

• Select the Request Tracking ID link to open the case. If the case is eligible for an appeal you will see the Request Appeal menu option on the Case Overview
• Select Request Appeal to open the Appeal Details screen and complete the required fields on the appeal template. (You also have the option of uploading attachments and images to support your request.)
• Select Submit.

 

Want to check the status of your clinical appeal?

The Check Appeal Status feature was added to ICR in December 2018.

• Select Check Appeal Status from the ICR top menu bar.
• Type the Appeal Case ID and Member ID in the allocated fields (do not include the alpha/numeric prefix).
• Select Submit.
• The appeal status and detail of the decision will open on the bottom of the screen. Additionally, you will be able to access letters associated with the appeal.

 

You can still initiate an appeal by calling or writing to the Empire Medical Management Appeals:

 

Call 1- 800-634-5605, 8:30 a.m. to 5:00 p.m. EST, Monday – Friday,

 

Or

Writing to:

Grievance and Appeals Department

PO Box 5063

Middletown, New York 10940

 

Or

Retro-Service Appeal Fax # (877) 278-2163

Pre-Service Appeal Fax # (888) 694-1545

For all fax and mail in appeal requests, the Provider Clinical Appeal Request cover sheet must be filled out and sent in the with the appeal.

Providers submitting Appeals on behalf of a patient must have a Designation of Representation (DOR) form signed by the patient and submitted with this request if not already submitted.

 

Definition

Expedited Appeal:

An Appeal of a review of continued or extended health care services, additional services rendered in the course of continued treatment, home health care services following discharge from an inpatient Hospital admission, services in which a Provider requests an immediate review, mental health and/or substance use disorder services that may be subject to a court order, or any other urgent matter. ·       If your request does not meet the definition of an expedited appeal, it will follow the standard appeal timeframes.

For your claim payment grievance to be processed, the following information should be included:

• A description of why you believe the claim was not processed correctly (e.g., underpayment; incorrect payment)
• Member Name
• Member ID Number with Prefix
• Date of Service
• Provider Name, NPI and Tax ID Number
• Any other relevant info (EOB, etc.)

Upon receipt of a claim payment grievance and supporting documentation, we will make reasonable efforts to issue a decision within 30 days.

If you submit your request for a claim payment grievance after the 180-day timeframe has expired, you will have waived your right to file a claim payment grievance with Empire. Empire will not accept any grievance requests after 180 days nor make any claim payment adjustments if a grievance is not submitted timely.

Please note: The above relates to the provider’s ability to dispute the payment of a claim that does not involve medical necessity. There is a separate process for member grievances and/or appeals as outlined under their benefit plan and further clarified in this manual.

 

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