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Empire Reimbursement Policies

Facility Reimbursement Policies
As part of Empire's ongoing commitment to transparency in our relationships with our participating physicians and other participating healthcare professional providers, and to promote a better understanding of the reimbursement rules and claims editing logic that may impact payment for specific services covered under the applicable member's benefit plan, we have listed below Empire's core reimbursement policies.  
Please keep in mind that Empire's reimbursement policies are only one of the many factors that impact payment. Payment is also subject to and impacted by the scope of benefits included in the applicable member's benefit plan, state and federal law, Empire's medical policies or clinical guidelines, the terms of the participating provider contracts and the provider manual. Empire's medical policies, clinical guidelines and Empire's provider manual can be found online at www.empireblue.com. In addition, when you log in to the empireblue.com provider site you may access the Clear Claim Connection inquirer to input professional claim scenarios to check possible payment results. This allows you to see how specific CPT codes may be impacted by specific policies. These results are not guarantee of payment which is also subject to factors noted above.  
In the event of a conflict between a reimbursement policy described below and the applicable member's benefit contract or the terms of the participating provider contract, these documents, along with applicable state and federal law, shall control. The appearance of a service, item or procedure on the below list indicates that Empire has a reimbursement policy that covers that particular service but it does not mean that the particular item or procedure is a covered service, or medically necessary, for that member; nor is it a guarantee for payment.  
These reimbursement policies are current as of the date of this document. Empire revises reimbursement policies from time to time and publishes updates in our provider newsletter. Every effort will be made to update this document as new policies are created or existing policies are added.
As the owner of these reimbursement policies, Empire has the sole right to interpret them. If you find any reimbursement policy unclear, please let us know so that we may take the opportunity to clarify our policies.
Empire's reimbursement policies do not determine how Empire's affiliates or other BlueCross BlueShield plans reimburse providers under BlueCard plans. Empire's reimbursement policies apply to Empire only.
Certain reimbursement policies may not apply to claims submitted by non-participating providers for Medicare Advantage members (which follow CMS rules) or FEHB enrollees. Reimbursement policies will be applied to claims submitted by participating providers for Medicare Advantage members.
3D Rendering of Imaging Studies
After Hours, Emergency, and Miscellaneous E/M Services
Anesthesia Services
Assistant Surgeon Coding
Assistant Surgeon Services
Bundled Services and Supplies
Cancer Treatment Planning and Care Coordination
Claim Editing Overview
Claims Requiring Additional Documentation
Co-Surgeon/Team Surgeon Services
Documentation and Reporting Guidelines for Adaptive Behavior Assessments and Treatments for Autism Spectrum Disorder
Documentation and Reporting Guidelines for Consultations
Documentation and Reporting Guidelines for Evaluation and Management Services
Documentation Guidelines for Central Nervous System Assessment / Tests
Documentation Guidelines for Psychotherapy Services
Drug Screen Testing
Duplicate Reporting of Diagnostic Services
Durable Medical Equipment
Evaluation and Management Services and Related Modifiers -25 & -57
Frequency Editing
Global Surgery
Health and Behavior Assessment/Intervention
Incident to Services
Injection and Infusion Administration and Related Services and Supplies
Injectable Substances and Related Injection Services
Laboratory and Venipuncture Services
Moderate (Conscious) Sedation Coding
Moderate Sedation
Modifier 22
Modifier 59 (Distinct Procedural Service)
Modifier Rules
Multiple and Bilateral Surgery Processing
Multiple Diagnostic Imaging
Multiple Diagnostic Cardiovascular Procedures
Multiple Diagnostic Ophthalmology Procedures
Observation Room Billing
Office Place of Service
Once per Lifetime Procedures
Overhead Expense For Office Based Surgery and Diagnostic Testing
Pharmaceutical Waste
Physical and Manipulative Maintenance Services
Place of Service
Preventable Adverse Events
Prolonged Services
Prolonged Services Coding
Qualitative Drug Screen Testing
Routine Obstetric Services
Rule of Eight Reporting Guidelines for Physical Medicine and Rehabilitation Services
Screening Services with Evaluation & Management Services
Sleep Studies & Related Bundled Services and Supplies
Standby Services
Surgical Pathology and Related Needle Biopsy
Three Dimensional (3D) Radiology Services
Telemedicine and Telehealth Services
Unit Frequency Maximums for Drug and Biologic Substances
Urgent Care (Coding and Bundled Supplies)
Empire's reimbursement policies are the property of Empire. For purposes of this document, Empire refers to Empire HealthChoice HMO, Inc. and Empire HealthChoice Assurance, Inc. 
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