Provider claim payment disputes for Empire’s Commercial lines of business
As 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. 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.
The Availity tool allows a more cohesive and efficient approach for providers when:
- Filing a claim payment dispute.
- Sending supporting documentation to Empire.
- Checking the status of a claim payment dispute.
- Viewing the history of a claim payment dispute.
* 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.
Reminder on how the provider claim payment dispute process works
For Empire, the provider claim payment dispute process consists of two steps:
- Claim payment reconsideration: As the first step, the reconsideration represents providers’ initial request for an investigation into the outcome of the claim. Most issues are resolved at the claim payment reconsideration step. 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. Providers are encouraged to submit all reconsiderations via Availity. Providers are only allowed one claim payment reconsideration per claim.
Empire will make every effort to resolve the claims payment reconsideration within 30 calendar days of receipt. If additional information is required to make a determination, the determination date may be extended by 30 additional calendar days. We will mail you a written extension letter before the expiration of the initial 30 calendar days.
- 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. However, we cannot process an appeal without a reconsideration on file. Providers may submit the claim dispute in writing or effective October 5th, 2021 via Availity; providers are encouraged to submit all appeals via Availity.
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. If a claim payment appeal requires clinical expertise, it will be reviewed by appropriate Empire clinical professionals.
Empire will make every effort to resolve the claim payment appeal within 60 calendar days of receipt. If additional information is required to make a determination, the determination date may be extended by 60 additional calendar days. We will mail you a written extension letter before the expiration of the initial 60 calendar days.
Submitting claim payment disputes in writing
When submitting a claim payment dispute in writing, providers must include the Claim Information/ Adjustment Request Form and submit to:
Empire BlueCross BlueShield
Provider Payment Disputes
P.O. Box 1407, Church Street Station
New York, NY 10008
Submitting claim payment disputes via Availity- preferred method, as of October 5th, 2021
For step-by-step instructions to submit a claim payment dispute through Availity:
- Log into Availity at availity.com .
- Select Help & Training | Find Help.
- Under Contents, select Overpayments and Appeals.
- Select Dispute a Claim.
Through Availity, you can upload supporting documentation and receive immediate acknowledgement of your submission.
Empire’s review and providers’ other options
Empire will review the claim payment dispute once received and communicate an outcome in writing or through the Availity Portal. Providers can check the status of a claim payment dispute on the Availity portal at any time.
If a provider still disagrees with the reconsideration, the provider can then choose to submit the claim payment appeal. Once the claim payment appeal is submitted, the decision is final. A claim payment dispute may not be submitted again. Providers can contact their state regulatory agency for additional assistance.
Empire requires providers to use our claims payment reconsideration process if providers feel a claim was not processed correctly.
Once providers complete both the Reconsideration and Appeal processes, providers can contact their Provider Experience Consultant for further assistance. However, providers are required to complete both the Reconsideration and Appeal processes before contacting their Provider Experience Representative for further assistance.
To learn more about the claim dispute tool, register for a live webinar:
- Log in to Availity and select Help & Training | Get Trained.
- Select Sessions and go to Your Calendar to locate a webinar.
- Select View Course and then select Enroll.
- The Availity Learning Center will email you with instructions to attend.
As always, providers can refer to the Provider Manual, as the manual includes additional information about inquiries, the provider claim dispute process, reconsiderations and appeals.
October 2021 Newsletter