Review medical policy and clinical guidelines when referring services to a facility
In our December of 2010 Network Update, we reminded that you should review Empire’s on-line medical policies and clinical guidelines when referring members for services at a facility that are considered not medically necessary or investigational. Services which are determined to be not medically necessary are the liability of the rendering provider pursuant to Empire’s participating provider agreements unless a waiver is signed by the member satisfying certain criteria.
Effective November 10, 2018, we will be implementing coding updates in the claims system for the following policy listed below which may result in investigational/not medically necessary determinations for certain services.
- CG-DME-40 - Electrical Bone Growth Stimulation
- CG-SURG-61 - Cryosurgical Ablation of Solid Tumors Outside the Liver
- CG-SURG-77 - Refractive Surgery
As a reminder, Empire’s medical policies and clinical guidelines are available online at empireblue.com/provider. You may search by procedure code, diagnosis code, clinical guideline or medical policy number or name. Please be sure to review medical policy and clinical guidelines when referring services to a facility to ensure services are consistent with medical policy.
August 2018 Empire Provider Newsletter