FAQs
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When can I make changes to my group's plan?
Changes to benefits, tiers of coverage, riders or eligibility must wait until your policy comes up for renewal.
Changes to your group’s enrollment and additions or deletions of members and dependents can, and should, be made as soon as you become aware of them. You can make these changes instantly by logging in to Employer Online Services, or by faxing (1-800-780-1224) or mailing the appropriate forms to us.
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How can I get enrollment changes processed quickly?
The fastest way to notify Empire of membership changes, additions and terminations is through Employer Online Services. Registration is easy and any changes you make are processed in real time. If you're submitting changes on forms, you can fax them to our secure, dedicated fax line at 1-800-780-1224. Keep your original forms and fax confirmation for your records. Do not include any forms with your billing payment. Doing so can delay processing.
Mail the forms to:
 | Empire BlueCross BlueShield |
| PO Box 1407 |
| Church Street Station |
| New York, NY 10008-1047 |
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What is Empire's payment policy?
Pay-As-Billed Policy: You must pay the exact amount on your invoice. Please do not increase/decrease your payment of this invoice to reflect any adjustments that you have submitted or plan to submit. Also, do not modify your billed amount to reflect any benefit changes made at renewal. Any credits allowed or additional charges due as a result of processing adjustments will be reflected on a future invoice. Payment is due in full upon presentation of the invoice. Pay using a the group’s bank check or certified check. Make checks payable to Empire. Write your group number on the check. Please make one payment in full per group; do not send multiple checks. For prompt processing, please do not mail the Change/Termination/Reinstatement Worksheet or other forms with your bill.
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What must I do if someone wants coverage under COBRA?
Empire handles COBRA-covered individuals in much the same way it handles other members of your plan. Employers must enroll, terminate or otherwise administer to those individuals enrolled under COBRA. The U.S. Department of Labor (DOL) issued new rules concerning the timing and content of required COBRA notices, as well as new notice requirements. These new COBRA notices and procedures, effective November 26, 2004, must be in place for calendar year plans as of January 1, 2005. The new COBRA rules now require six different notices:
1. The initial notice to the employee of the availability of COBRA;
2. The notice that the employer must provide to the plan administrator regarding the occurrence of an event that triggers a loss of coverage under the plan ("qualifying event");
3. The notice that the plan administrator must provide to covered employees and dependents at the occurrence of certain qualifying events;
4. The notice that a covered employee or dependent must provide to the plan administrator at the occurrence of certain qualifying events (e.g., divorce or a child's loss of dependent status under the terms of the plan);
5. A new notice from the plan administrator to an individual that he or she is determined to be ineligible for COBRA coverage; and
6. A new plan notice from the plan administrator regarding the termination of COBRA coverage prior to the maximum period permissible under COBRA.
Model notices are available under the Forms section of our website. You can make all necessary COBRA transactions at Employer Online Services. Additional information about COBRA is also available at the Department of Labor website at http://www.dol.gov/dol/topic/unemployment-insurance/index.htm. Information is also available in your GBA handbook. back to top
Can coverage be cancelled for late payment?
Late Payment Guidelines: Empire grants a 30-day grace period after the due date. Small groups (2 — 50 employees) are automatically cancelled if payment is not received by the end of the 30-day grace period. When a group is reinstated, Empire mails a letter to inform the group that it has been reinstated and to remind the group that we allow only two such reinstatements within a 12-month period.
Small groups (2 — 50 employees) who have been cancelled three times for nonpayment in a rolling 12-month period are not eligible for reinstatement. If payment is received after the 30-day grace period, payment is refunded. After the first or second automatic cancellation for late payment, the group may apply for reinstatement.
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How can I make sure dependents who are full-time college students are covered?
Your group's benefit plan will determine the extent and age to which dependent full-time college students are covered. Your employees with children who are full-time college students must submit a completed Student Coverage Questionnaire before December 31 each year to ensure uninterrupted coverage into the next calendar year. You can find a copy on the GBA Handbook CD or by clicking here. You can always request forms through your Empire Representative or call the GBA Contact Center at 1-866-422-2583. Members must complete the form to include the school's name and address, type of school and enrollment details, sign to certify that the information is correct and fax it to us at 1-800-780-1224.
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How can I make sure that I do not pay for ineligible dependents?
Empire automatically discontinues coverage for all dependents who reach the maximum coverage age as defined under your group's benefit plan and are no longer eligible for coverage.* In these cases, and only where applicable: the corresponding account contract type is automatically downgraded to reflect this change. The account invoice reflects the premium change as of the month coverage for the dependent is terminated. Empire generates and mails a HIPAA Certificate of Prior Health Plan Coverage (HIPAA Certificate) to the newly ineligible dependent at the time of termination, except in cases where your group has elected to do so.
*This change DOES NOT apply to mentally challenged, developmentally disabled, mentally ill or physically handicapped dependents, or to those dependents that may qualify as college students.
You are still responsible for associated premiums for other ineligible dependents under your group's benefit plan until you make the appropriate change at Employer Online Services or notify Empire in writing. This includes dependents who become ineligible for coverage because they marry, begin working full time, or their primary address is no longer the same as the covered member's. You must notify Empire once a dependent is no longer eligible for coverage under your plan or you will continue to be responsible for premiums associated with that individual.
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STANDARD RETROACTIVE TERMINATION RULES
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Empire will retroactively apply a credit to your account for employees who have left your group, but for whom you have already paid for coverage. The standard rules of retroactivity are 30 days for groups with 2 – 50 eligible employees, 45 days for groups with 51 – 500 eligible employees and 60 days for groups with more than 500 eligible employees.
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An employee is questioning an Empire decision. What should he/she do?
An appeal is an oral or written request to review and change a service authorization decision by Empire stating that the service is not medically necessary or is experimental or investigational. For example, an employee may think Empire should have authorized a certain medical procedure. A grievance is an oral or written request to change an adverse determination that was based on administrative policies, procedures or guidelines. For example, a claim was denied because a member did not obtain precertification for services. To submit an appeal or grievance, your employees should call the Member Services phone number on the back of their Empire identification card, or they can write to the address below with the reason why they believe the coverage request was improperly denied or the claim was improperly paid. They should submit any data to support the request, which should include their member ID number and, if applicable, their claim number and date of service.
The address for filing an appeal or grievance is:
| Empire BlueCross BlueShield |
| Appeal and Grievance Department |
| PO Box 1407 |
| Church Street Station |
| New York, NY 10008-1407 |
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What is Medicare Part B and when should employees enroll in it?
Medicare is for people 65 years or older, certain people with disabilities, and people with end-stage renal disease (ESRD). Medicare has two parts — Part A, which is hospital insurance, and Part B, which covers doctors' services and outpatient hospital care as well as other medical services that Part A does not cover, like physical and occupational therapy. Except in certain cases, if an employee did not enroll in Medicare Part B during his initial enrollment period (which starts three months before he turns age 65 and lasts for seven months), he will have to wait until the next General Enrollment Period to enroll. General Enrollment periods are between January 1 and March 31 each year. Should the employee sign up for Medicare Part B during a general enrollment period, his Medicare Part B coverage starts on July 1 of that year. As a result of the late enrollment, Medicare Part B premium may go up for each 12 month period that an employee could have had Medicare Part B, but elected not to take it.
A Special Enrollment Period is available for an employee who waits to enroll in Medicare Part B after the initial enrollment period because he or his spouse is working and has group health coverage through an employer or union based on this current employment. If this applies, an employee can sign up for Medicare Part B any time while still covered by the employer or union group health plan through his or his spouse's current or active employment, or during the eight months following the month the group health plan coverage or the employment ends (whichever is first). Medicare Part B coverage will then begin the month an employee enrolls in Medicare Part B, if he enrolls while covered under the group health plan based on current or active employment, or during the first full month after the coverage or employment ends (whichever comes first). An employee can also delay the start date for Medicare Part B coverage until the first day of any of the following three months; or the month after the month he enrolls if he enrolls during the remaining 7 months of the Special Enrollment Period.
Note: If your employee has further questions, you may direct him to the State Health Insurance Assistance Program to help him decide the best time to enroll in Medicare Part B. When an employee signs up for Medicare Part B, he automatically begins his Medigap (Medicare Supplement Insurance) open enrollment.
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How can employees ensure coverage under Behavioral Health Management?
To help ensure that your employees receive the appropriate care if they are admitted in an emergency to a hospital or other inpatient facility for behavioral health problems, the member or someone on his behalf must contact the Behavioral Healthcare Management Program by calling the telephone number on the back of the ID card within 48 hours or as soon as reasonably possible. The employee should always call the Behavioral Healthcare Management Program to precertify behavioral healthcare services. By not calling and/or if a call is made and their recommended treatment plan is not followed, a denial of the services or reduction in benefits may result. Please refer to your group's benefit plan and schedule of benefits to determine the extent of Behavioral Healthcare coverage and precertification requirements. Remember, behavioral healthcare provider must be participating in the Behavioral Healthcare Management Network. To verify your provider's participating status, please call Behavioral Healthcare Management.
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