![]() ![]() ![]() Providers can contact their state regulatory agency for additional assistance.Įmpire requires providers to use our claims payment reconsideration process if providers feel a claim was not processed correctly. A claim payment dispute may not be submitted again. Once the claim payment appeal is submitted, the decision is final. If a provider still disagrees with the reconsideration, the provider can then choose to submit the claim payment appeal. Providers can check the status of a claim payment dispute on the Availity portal at any time. Through Availity, you can upload supporting documentation and receive immediate acknowledgement of your submission.Įmpire’s review and providers’ other optionsĮmpire will review the claim payment dispute once received and communicate an outcome in writing or through the Availity Portal. Under Contents, select Overpayments and Appeals.Submitting claim payment disputes via Availity- preferred method, as of October 5th, 2021įor step-by-step instructions to submit a claim payment dispute through Availity: When submitting a claim payment dispute in writing, providers must include the Claim Information/ Adjustment Request Form and submit to: Submitting claim payment disputes in writing We will mail you a written extension letter before the expiration of the initial 60 calendar days. If additional information is required to make a determination, the determination date may be extended by 60 additional calendar days. If a claim payment appeal requires clinical expertise, it will be reviewed by appropriate Empire clinical professionals.Įmpire will make every effort to resolve the claim payment appeal within 60 calendar days of receipt. When submitting a claim payment appeal, please include as much information as you can to help us understand why you think the reconsideration determination was in error. Providers may submit the claim dispute in writing or effective October 5th, 2021 via Availity providers are encouraged to submit all appeals via Availity. However, we cannot process an appeal without a reconsideration on file. Claim payment appeal: In this second step, providers who disagree with the outcome of the reconsideration may request an additional review as a claim payment appeal.We will mail you a written extension letter before the expiration of the initial 30 calendar days. If additional information is required to make a determination, the determination date may be extended by 30 additional calendar days. Providers are only allowed one claim payment reconsideration per claim.Įmpire will make every effort to resolve the claims payment reconsideration within 30 calendar days of receipt. Providers are encouraged to submit all reconsiderations via Availity. Providers may submit the claim dispute via customer service (refer to the phone number on the back of the member’s ID card), in writing, or effective October 5th, 2021 - via Availity. Most issues are resolved at the claim payment reconsideration step. Claim payment reconsideration: As the first step, the reconsideration represents providers’ initial request for an investigation into the outcome of the claim.Reminder on how the provider claim payment dispute process worksįor Empire, the provider claim payment dispute process consists of two steps: * Reminder- we will consider reimbursement of a claim that has been denied due to failure to meet timely filing if you can: 1) provide documentation that the claim was submitted within the timely filing requirements or 2) demonstrate good cause exists. Viewing the history of a claim payment dispute.Checking the status of a claim payment dispute.Sending supporting documentation to Empire. ![]() The Availity tool allows a more cohesive and efficient approach for providers when: Some examples include claim disputes regarding manual processing errors, contract interpretation, reduced payments, code editing issues, Other Health Insurance denials, eligibility issues, timely filing issues *, and so forth. This does not include members covered under the Federal Employee Program.Īs a reminder, unlike inquiries about claims status, provider appeals, or requests for additional information, provider claim payment disputes occur after a claim is finalized, and a provider disagrees with the claim payments Empire has issued. Effective October 5th, 2021, providers will now also be able to submit claim payment disputes via Availity for Empire’s Commercial lines of business. Some time ago, Empire BlueCross BlueShield (“Empire”) introduced the ability to submit claim payment disputes via Availity, for members enrolled in our Empire Medicaid and Medicare Advantage benefit plans, as part of our more streamlined provider claims payment dispute process. ![]()
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