Update to reimbursement policy usage

Reimbursement policies serve as a guide to assist you with accurate claim submissions and outline the basis for reimbursement if services are covered by the member’s Empire BlueCross BlueShield HealthPlus (Empire) benefit plan. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis as well as to the member’s state of residence. Covered services do not guarantee reimbursement unless specific criteria are met.

 

You must follow proper billing and submission guidelines. You are required to use industry standard, compliant codes on all claims submissions. Services should be billed with CPT^® codes, HCPCS codes and/or revenue codes. The codes denote the service and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities.

 

If appropriate coding/billing guidelines or current reimbursement policies are not followed, Empire may:

• Reject or deny the claim.
• Recover and/or recoup claim payment.

• Adjust the reimbursement to reflect the appropriate services and/or procedures performed.

 

Empire reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by provider or state contract language or state/federal requirements or mandates. System logic or set-up may prevent the loading of policies into the claims platforms in the same manner as described; however, Empire strives to minimize these variations.

 

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your local Provider Relations representative or call Provider Services at 1-800-450-8753.

 

NYE-NU-0267-20 October 2020