These updates list the new and/or revised Empire BlueCross BlueShield (“Empire”) medical policies, clinical guidelines and reimbursement policies*.  The implementation date for each policy or guideline is noted for each section.  Implementation of the new or revised medical policy, clinical guideline or reimbursement policy is effective for all claims processed on and after the specified implementation date, regardless of date of service.  Previously processed claims will not be reprocessed as a result of the changes.  If there is any inconsistency or conflict between the brief description provided below and the actual policy or guideline, the policy or guideline will govern.


Federal and state law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over medical policy and clinical guidelines (and medical policy takes precedence over clinical guidelines) and must be considered first in determining eligibility for coverage.  The member’s contract benefits in effect on the date that the services are rendered must be used. This document supplements any previous medical policy and clinical guideline updates that may have been issued by Empire.  Please include this update with your Provider Manual for future reference.


Please note that medical policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication.  Empire’s medical policies and clinical guidelines can be found at


*Note: These updates may not apply to all ASO Accounts as some accounts may have non-standard benefits that apply.


Clinical Guideline Updates

Archived Clinical Guidelines Effective 12-08-2020

(The following adopted guidelines have been archived and have been replaced by AIM guidelines.)

  • CG-REHAB-04 - Rehabilitative and Habilitative Services: Medicine/Physical Therapy
  • CG-REHAB-05 - Rehabilitative and Habilitative Services: Occupational Therapy
  • CG-REHAB-06 - Rehabilitative and Habilitative Services: Speech-Language Pathology
  • CG-REHAB-11 - Cognitive Rehabilitation


Coding Updates

As a result of coding updates in the claims system, the claim system edits for the clinical guideline listed below will be revised. This will result in the review of claims for certain diagnoses before processing occurs to determine whether the service meets medical necessity criteria. As a result, these coding updates may result in a not medically necessary determination.


Effective February 13, 2021, we will be implementing coding updates in the claims system for the following clinical guideline listed below which may result in not medically necessary determinations for certain services.

  • CG-SURG-09 - Temporomandibular Disorders




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November 2020 Empire Provider News