Medicaid Reimbursement Policies

We want to assist physicians, facilities and other providers in accurate claims submissions and to outline the basis for reimbursement if the service is covered by a member’s Empire BlueCross BlueShield HealthPlus (Empire) benefit plan. Keep in mind that determination of coverage under a member’s benefit plan does not necessarily ensure reimbursement. These policies may be superseded by State, Federal or Centers for Medicare and Medicaid Services (CMS) requirements. Providers and facilities are required to use industry standard codes for claim submissions. Services should be billed with Current Procedure Terminology (CPT) codes, Healthcare Common Procedure Coding System (HCPCS) codes and/or Revenue codes. The billed code(s) should be fully supported in the medical record and/or office notes. Industry practices are constantly changing and Empire reserves the right to review and revise its policies periodically.

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 ‭(Hidden)‬ Empire-Reimbursement-Policies

Name (for use in forms)MarketTitleReimbursement CategoryApproval StatusPlan
NYNY_CAID_RP_Abortion.pdfNYAbortion (Termination of Pregnancy)SurgeryApprovedMedicaid
NYNY_CAID_RP_AssistantatSurgery.pdfNYAssistant at Surgery (Modifiers 80/81/82/AS)CodingApprovedMedicaid
NYNY_CAID_RP_ClaimsRequiringAdditionalDocumentation.pdfNYClaims Requiring Additional DocumentationReimbursement Administration - GeneralApprovedMedicaid
NYNY_CAID_RP_ClaimsTimelyFiling.pdfNYClaims Timely FilingReimbursement Administration - GeneralApprovedMedicaid
NYNY_CAID_RP_ClaimswithChargeDiscrepancies.pdfNYReimbursement of Claims with Charge DiscrepanciesReimbursement Administration - GeneralApprovedMedicaid
NYNY_CAID_RP_CodeandClinicalEditingGuidelines.pdfNYCode and Clinical Editing GuidelinesReimbursement Administration - GeneralApprovedMedicaid
NYNY_CAID_RP_Consultations.pdfNYConsultationsEvaluation and ManagementApprovedMedicaid
NYNY_CAID_RP_DiagUsedinDiagnosesRelatedGroupsComputation.pdfNYDiagnoses Used in DRG ComputationCodingApprovedMedicaid
NYNY_CAID_RP_DrugsInjectableLimits.pdfNYDrugs and Injectable LimitsDrugsApprovedMedicaid
NYNY_CAID_RP_DupSubsequentSvsonSameDate.pdfNYDuplicate or Subsequent Services on the Same Date of ServiceReimbursement Administration - GeneralApprovedMedicaid
NYNY_CAID_RP_EligibleCharges.pdfNYReimbursement for Eligible Billed ChargesReimbursement Administration - GeneralApprovedMedicaid
NYNY_CAID_RP_EPSDT.pdfNYEarly and Periodic Screening, Diagnostic, and Treatment (EPSDT)PreventionApprovedMedicaid
NYNY_CAID_RP_ERNonParticProvFac.pdfNYEmergency Services: Non-Participating Providers and FacilitiesReimbursement Administration - GeneralApprovedMedicaid
NYNY_CAID_RP_FacilityTakeHomeDrugs.pdfNYFacility Take-Home DrugsDrugsApprovedMedicaid
NYNY_CAID_RP_GlobalSurgicalPckg.pdfNYGlobal Surgical Package for Professional ProvidersSurgeryApprovedMedicaid
NYNY_CAID_RP_Hysterectomy.pdfNYHysterectomySurgeryApprovedMedicaid
NYNY_CAID_RP_InpatientFacilityTransfers.pdfNYDRG Inpatient Facility TransfersFacilitiesApprovedMedicaid
NYNY_CAID_RP_InpatientReadmissions.pdfNYInpatient ReadmissionsReimbursement Administration - GeneralApprovedMedicaid
NYNY_CAID_RP_MaternitySvcs.pdfNYMaternity ServicesSurgeryApprovedMedicaid
NYNY_CAID_RP_MedicalRecalls.pdfNYMedical RecallsReimbursement Administration - GeneralApprovedMedicaid
NYNY_CAID_RP_Modifier22IncreasedProcSvc.pdfNYModifier 22: Increased Procedural ServiceCodingApprovedMedicaid
NYNY_CAID_RP_Modifier24UnrelatedEMService.pdfNYModifier 24: Unrelated Evaluation and Management Service by the Same Physician during the Postoperative PeriodCodingApprovedMedicaid
NYNY_CAID_RP_Modifier25EMServices.pdfNYModifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other ServiceCodingApprovedMedicaid
NYNY_CAID_RP_Modifier57DecisionforSurgery.pdfNYModifier 57: Decision for SurgeryCodingApprovedMedicaid
NYNY_CAID_RP_Modifier59DistinctProceduralSvc.pdfNYDistinct Procedural Services (Modifiers 59, XE, XP, XS, XU)CodingApprovedMedicaid
NYNY_CAID_RP_Modifier62CoSurgeons.pdfNYModifier 62: Co-SurgeonsCodingApprovedMedicaid
NYNY_CAID_RP_Modifier63.pdfNYModifier 63: Procedure Performed on Infants less than 4 kgCodingApprovedMedicaid
NYNY_CAID_RP_Modifier66.pdfNYModifier 66 Surgical TeamsCodingApprovedMedicaid
NYNY_CAID_RP_Modifier76RepeatProcedurebySamePhysician.pdfNYModifier 76: Repeat Procedure by the Same PhysicianCodingApprovedMedicaid
NYNY_CAID_RP_Modifier77RepeatProcedureAGP.pdfNYModifier 77: Repeat Procedure by Another PhysicianCodingApprovedMedicaid
NYNY_CAID_RP_Modifier78.pdfNYModifier 78: Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure during the Postoperative PeriodCodingApprovedMedicaid
NYNY_CAID_RP_Modifier91RepeatLabTest.pdfNYModifier 91: Repeat Clinical Diagnostic Laboratory TestCodingApprovedMedicaid
NYNY_CAID_RP_ModifierUsagePolicy.pdfNYModifier UsageCodingApprovedMedicaid
NYNY_CAID_RP_ModsLTRTProcedures.pdfNYModifiers LT and RT: Left Side/Right Side ProceduresCodingApprovedMedicaid
NYNY_CAID_RP_MultipleBilateralSurgery.pdfNYMultiple and Bilateral Surgery: Professional and Facility ReimbursementCodingApprovedMedicaid
NYNY_CAID_RP_MultipleRadiology.pdfNYMultiple Radiology Payment ReductionRadiologyApprovedMedicaid
NYNY_CAID_RP_ObsoleteCodes.pdfNYReimbursement of Services with Obsolete CodesCodingApprovedMedicaid
NYNY_CAID_RP_OPPC.pdfNYOther Provider Preventable Conditions (OPPC)Reimbursement Administration - GeneralApprovedMedicaid
NYNY_CAID_RP_PreadmissionSvcsforInpatientStays.pdfNYPre-Admission Services for Inpatient StaysReimbursement Administration - GeneralApprovedMedicaid
NYNY_CAID_RP_PresentonAdmissionIndcator.pdfNYPresent on Admission Indicator for Health Care Acquired ConditionsReimbursement Administration - GeneralApprovedMedicaid
NYNY_CAID_RP_PreventativeandSickVisitsSameDay.pdfNYPreventive Medicine and Sick Visits on the Same DayEvaluation and ManagementApprovedMedicaid
NYNY_CAID_RP_ProfessionalAnesthesiaServices.pdfNYProfessional Anesthesia ServicesAnesthesiaApprovedMedicaid
NYNY_CAID_RP_ProofofTimelyFiling.pdfNYRequirements for Documentation of Proof of Timely FilingReimbursement Administration - GeneralApprovedMedicaid
NYNY_CAID_RP_ProstheticOrthoticDevices.pdfNYProsthetic and Orthotic DevicesProsthetics and OrthoticsApprovedMedicaid
NYNY_CAID_RP_ReimbforItemsUnderWarranty.pdfNYReimbursement for Items under WarrantyReimbursement Administration - GeneralApprovedMedicaid
NYNY_CAID_RP_SanctionedOptOutProviders.pdfNYReimbursement of Sanctioned ProvidersReimbursement Administration - GeneralApprovedMedicaid
NYNY_CAID_RP_ScopeofPractice.pdfNYScope of PracticeReimbursement Administration - GeneralApprovedMedicaid
NYNY_CAID_RP_SiteofSvcPaymtDifferential.pdfNYSite of Service Payment Differential - ProfessionalReimbursement Administration - GeneralApprovedMedicaid
NYNY_CAID_RP_SplitCareSurgicalModifiers.pdfNYSplit-Care Surgical ModifiersCodingApprovedMedicaid
NYNY_CAID_RP_Sterilization.pdfNYSterilizationSurgeryApprovedMedicaid
NYNY_CAID_RP_TransportaionServices.pdfNYTransportation Services: Ambulance and Non-Emergent TransportTransportationApprovedMedicaid
NYNY_CAID_RP_UnlistedorMiscCodes.pdfNYUnlisted or Miscellaneous CodesCodingApprovedMedicaid
NYNY_CAID_RP_VaccinesforChildren.pdfNYVaccines for Children (VFC) ProgramPreventionApprovedMedicaid
NYNY_CAID_RP_PortableMobileHandheldRadiology.pdfNYPortable/Mobile/Handheld Radiology ServicesRadiologyApprovedMedicaid
NYNY_CAID_RP_FacilityTakeHome.pdfNYFacility Take-Home DME and Medical SuppliesDME and SuppliesApprovedMedicaid
NYNY_CAID_RP_ClaimsSubmReqdInfoforFacilities.pdfNYClaims Submission – Required Information for FacilitiesReimbursement Administration - GeneralApprovedMedicaid
NYNY_CAID_RP_LocumTenens.pdfNY Locum Tenens PhysiciansReimbursement Administration - GeneralApprovedMedicaid
NYNY_CAID_RP_ClaimsSubmReqdInfoforProfProv.pdfNYClaims Submission – Required Information for Professional ProvidersReimbursement Administration - GeneralApprovedMedicaid
NYNY_CAID_RP_DocumentationStandardsforEpisodesofCare.pdfNYDocumentation Standards for Episodes of CareReimbursement Administration - GeneralApprovedMedicaid
NYNY_CAID_RP_ReimbforReducedDiscontinuedSvcs.pdfNYReimbursement for Reduced and Discontinued ServicesCodingApprovedMedicaid
NYNY_RP_PreadmissionSvcsInpatientStays.pdfNYPreadmission Services for Inpatient StaysFacilitiesApprovedMedicaid
NYNY_CAID_RP_DMERenttoPurchase.pdfNYDurable Medical Equipment (Rent to Purchase)DME and SuppliesApprovedMedicaid
NYNY_CAID_RP_DMEModifiers.pdfNYDME Modifiers for New, Rented and Used EquipmentCodingApprovedMedicaid
NYNY_CAID_RP_MaxUnitsPerDay.pdfNYReimbursement for Maximum Units Per DayReimbursement Administration - GeneralApprovedMedicaid
NYNY_CAID_RP_CorrectedClaims.pdfNYCorrected ClaimsReimbursement Administration - GeneralApprovedMedicaid
NYNY_CAID_RP_Mod26.pdfNYModifier 26 and TC: Professional and Technical ComponentCodingApprovedMedicaid
Reimbursement Policy Disclaimer

These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement if the service is covered by a member’s Empire benefit plan. The determination that a service, procedure, item, etc. is covered under a member’s benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis as well as to the member’s state of residence. You must follow proper billing and submission guidelines. You are required to use industry standard, compliant codes on all claim submissions. Services should be filled with Current Procedure Terminology (CPT) codes, Healthcare Common Procedure Coding System (HCPCS) codes and/or Revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities.

If appropriate coding/billing guidelines or current reimbursement policies are not followed, Empire may:

  • Reject or deny the claim
  • Recover and/or recoup claim payment

Empire reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider or Sate contracts, or State, Federal, or Centers for Medicare & Medicaid Services (CMS) requirements. System logic or set up may prevent the loading of policies into the claims platforms in the same manner as described; however Empire strives to minimize these variations.

Empire reserves the right to review and revise its policies periodically when necessary. When there is an update we will publish the most current policy to this site.