Medicaid Reimbursement Policies

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 These policies may be superseded by mandates in provider or Sate contracts, or State, Federal, or Centers for Medicare & Medicaid Services (CMS) requirements.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.