New York City Account Claim Submission Guide The purpose of this guide is to help determine which insurance carrier to send a claim to for certain hospital versus medical services. For instructions on how to submit a claim to Empire, see our claim submission references on our website. In some instances, Empire is responsible for payment of both the and Medical benefits for certain New York City accounts. For group numbers starting with 157800, 157801, 157802, and 157803, Empire pays for and Medical benefits and does not split coverage. In some circumstances, Empire splits coverage for New York City accounts and is NOT responsible for payment of both and Medical benefits. The following grid does not include all of the New York City account plans but rather reflects the PPO -Only Contracts for groups starting with 157000 to 157699. The services described pertain to Empire Primary non-medicare members, retirees and their dependents. While this grid is provided as a general guideline for where to submit claims, you should refer to the Empire Web site for additional information or to the telephone number located on the member's ID card if you have particular claim submission questions. Service Rendered EBCBS GHI Health Plan Notes Alcohol Detox/Rehab (IP or OP) Ambulance by Air Ambulance by Air, Facility to Facility Ambulance by Land Ambulance by Land, Facility to Facility Not Covered Ambulette Blood Services rendered in the outpatient department of the hospital Must be billed by a hospital and the hospital has incurred expenses for blood and blood products. Take home blood, blood products and blood derivatives for Hemophiliacs Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. Page 1 of 7
Cancer Chemotherapy Inpatient Cardiac Rehab (IP or OP) Clinic DME (IP or OP) Drug Detox/Rehab (IP or OP) Emergency Room Services If bundled in rates If unbundled only available if authorized by NYC Healthline. Emergency Room services for certified emergency physicians, noninvasive cardiology, noninvasive pathology, noninvasive radiology. All others, submit to GHI. For medical services rendered with psychiatric component Psychiatric only Hemodialysis Pre-cert Required by NYC Healthline for initial approval. Benefits available in a hospital or in a participating approved free standing facility. Page 2 of 7
Inpatient Homecare Hospice Care Hyperbaric Oxygen Therapy Infusion Therapy (Non-Cancer) Inpatient Inpatient Facility - Inpatient Emergency Admission Notification of admission required through NYC Healthline. Benefits available based on medical necessity as Patient is responsible for ER admit notification within 48 hours. may notify on patient's behalf. Facility - Inpatient Elective Admission IVF available based on medical necessity. Patient is responsible for admission pre-cert. may pre-cert on patient's behalf. Page 3 of 7
Laboratory (OP) If part of payable OP claim/procedure If NOT part of OP payable claim/procedure Claims: If unbundled (OP): - Non-emergency Room - Emergency Room If Bundled (OP or IP) If Unbundled (IP) Maternity Encounters Inpatient Admissions For non-invasive pathology Emergency Room services only. Pre-cert Required by NYC Healthline for maternity admit if stay is greater than 48 hours for vaginal delivery or greater than 96 hours for c-section delivery. Labor and Delivery urgent outpatient services Empire does not require notification when the urgent visit is for a labor and delivery evaluation where the patient remains outpatient. Scheduled outpatient services - such as, ultrasounds and nonstress tests Behavioral Health Services Phone - GHI's Behavioral Management Program- Beacon Health- 1-800-692-2489 Nutritional Counseling Diagnostic testing/procedures EPS TEE Diagnostic Cardio version Surgery - Both Free Standing or Based Ambulatory Surgery Center or Unit, Same Day Surgery Pre-cert Required by NYC Healthline for the following procedures: possible/cosmetic procedures, reconstruction, outpatient /Facility transplants, optical/vision related procedures, Page 4 of 7
Pharmacy breast reconstruction, cochlear implants, functional endoscopy/nasal surgery, spinal stimulator implants, joint replacements, experimental/investigational procedures, hyperbaric oxygen chamber, infertility with underlying condition, pain management, stimulatory implants, wound vac, bariatric surgery, and spinal surgery. Inpatient Physical Therapy Not covered unless part of a payable outpatient claim. All non-experimental drugs and medicines that are available for purchase and readily obtainable. Take home drugs not covered. Not covered unless part of a payable inpatient claim. All non-experimental drugs and medicines that are available for purchase and readily obtainable. Take home drugs not covered. Rehabilitation or Specialty Facility (IP) See SNF Rehabilitation or Specialty Facility (OP) Pre-cert by NYC Healthline after the 16 th visit. Preadmission Testing/Presurgical Testing if: A. The tests are ordered by a physician as a preliminary step to an inpatient or outpatient surgery encounter; and B. The testing is necessary for and consistent with the diagnosis and treatment of the condition for which surgery is to be performed; and C. There is a scheduled reservation for the hospital and for the operating room before the tests are performed; and Page 5 of 7
D. The patient is physically present at the hospital when the tests are performed; and Radiation Therapy (IP) Radiation Therapy (OP) Radiology (OP) If part of payable OP claim If NOT part of OP payable claim/procedure Claims: If unbundled (OP): - Non-emergency Room - Emergency Room If Bundled (OP or IP) If Unbundled (IP) Mammograms Screening Mammograms Diagnostic Skilled Nursing Facility SNF E. Surgery actually takes place within 21 days after the tests are performed./surgery is cancelled as a result of the preadmission tests./surgery is cancelled due to an unrelated condition that manifests after completed PST/PAT where the new condition prevents surgery. Only 1 annual routine mammography screening per calendar year in hospital Pre-cert Required through NYC Healthline. Up to 90 days per calendar year. NYC Healthline may substitute benefits if medically appropriate. 2 ½ outpatient visits=1 day in a SNF. 1 day in an acute rehabilitation facility =2 days in a SNF. Of the 90 Page 6 of 7
Transplants days there are 30 occupational and speech therapy visits combined allowed. IP Precert Required by NYC Healthline. Benefits OP No precert for outpatient. Wound Care If surgical debridement is performed If no surgical debridement is performed Page 7 of 7