Posted in Insurance, Payers and CPT reinbursement, Training, Updates

The Empire Plan (NYSHIP)- Prospective Procedure Review and Advance Imaging Procedure Programs Information-getting paid!

The purpose of this post is to go over the needed information on when Prior Procedure Notification is required for The Empire Plan (NYSHIP) members.

According to The Empire Plan Prior Notification is required when The Empire Plan is the primary insurance NOT when it is secondary or tertiary.

The following list of Advance Outpatient Imaging Procedures require a Prior Notification:

1. CT- Computerized Tomography

2. MRI- Magnetic Resonance Imaging

3.MRA- Magnetic Resonance Angiography

4. Nuclear Medicine

5. Nuclear Cardiology

6. PET-Positron Emission Tomography

Q: Are there any exclusions to this?

A: Yes. If the services are performed in Inpatient setting*, Emergency Room, observational unit, or urgent care center they do not require a Prior Notification.

*Note: Inpatient services do not require PPR notification. However, hospital admission might. BCBS is responsible for mandatory pre-admission certification portion of (BMP) Benefits Management Program. This requires a call prior to any elective (scheduled) hospital admission that includes an overnight stay. If the patient is admitted into the hospital please call BCBS with 48 hours.

Q: Does outpatient surgery require a notification call?

A: No

Options for ordering a notification number:

1. Online- UHCprovider.com/Radiology- where providers can select to go to Prior Authorization and Notification APP.

2. Phone: Radiology Notification Line: 866-889-8054, M-F 7am to 7pm EST or

3. Phone: Empire Plan- 877-NYSHIP (877-769-7477) M-F 8:30am- 4:30pm

Q: What information will I need to request a Notification #?

A:  Information about Ordering provider and Rendering provider:

 1. Ordering provider: name, TIN./NPI, Address, Phone#, Fax# and Email

 2. Rendering Provider: name, TIN/NPI (if different), address, Phone#

In addition you need to include Clinical Information:

1. Working Diagnosis with appropriate ICD code(s)

2. Enrollee’s clinical information that should include symptoms, prior treatments, dosage and duration of any medications, plus dates of other therapies.

3. Examination(s) or type of services that are being requested with appropriate CPT code(s)

4. Any other information that ordering provider believes would be useful in evaluating the request.

Remember: in order to ensure that the proper payment is dispersed, the number should be obtained and communicated by the ordering physician/provider to the rendering physician/provider that is scheduled to perform the advanced outpatient imaging procedure(s).

Q: If the procedure was done outside the standard business hours and on urgent clinical basis, is there a retrospective review?

A: Yes. If the services were done outside of UHC normal business hours, the provider needs to contact the Radiology Notification Phone line within the 2 business days of the service(s). Also documentation must have an explanation why the procedure was required on an urgent basis and was done outside of UHC normal business hours.

Author:

My name is Kate Patskovska, CPB. I am an Independent Medical Biller CPB (AAPC) and an owner of KR2 Medical Billing. KR2 Medical Billing is a full service Consulting/Medical Billing Business that is dedicated to educating, consulting, and overall improving the "financial health" of your medical practice.

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