Posted in In The Know Series, My services, Training, Updates

Empire NYSHIP Plans and member cost-sharing for diagnostic allergy and asthma testing: year 2020 and beyond

This post is for Allergy & Asthma providers that accept Empire NYSHIP (TPA UHC) patients and perform diagnostic asthma/allergy testing in the office setting (POS 11).

Commonly used CPT codes in Office Setting (w/ short description)

1. 95004- skin prick allergy testing

2. 95024- intradermal allergy testing

3. 95044- patch allergy testing

4.95018- Medication (Penicillin) allergy testing

5. 94200- Peak flow

6. 95012- NIOX or FENO

Member cost-sharing/patient co-pays for year 2020 and beyond:

Most of the Empire NYSHIP plans (there are various types), have updated their co-pay to $25 per office visit (specialist) Please click here to visit my post on the updated Empire NYSHIP co-pays.

However, as recent as last year, the Empire NYSHIP plans also started to add, an extra $25 member cost-sharing fee, to the above mentioned CPT codes. In order for your office not to leave this uncollected revenue on the table, please make sure to inform your front office staff of this change!  

Now  let’s take a look at 2 (TWO) examples.

Ex. 1. Patient comes in for the first time and has the environmental skin prick testing done the same day. The billing would be:  99204 25 with 95004X40 -the total patient financial responsibility would be $50: $25 for OV and $25 for testing.

Ex. 2. Patient with DX of Allergic Asthma (J45.30) is coming in for a follow up visit. The billing would be: 99213 25 with 94200 59 and 95012 59. In this instance the second co-pay would be applied to 94200 and 95012 would be paid. So, the patient will still pay only $50 co-pay.

Now, If you have any more questions about this post, Empire NYSHIP patients cost-sharing or something else, please go on my (SERVICES) page and contact me for a free 30-min Evaluation ($250 Value).

Posted in In The Know Series, Insurance, Training

The Empire Plan (NYSHIP)- Office Visit co-pay changes for 2020

This past year there were a number of employee groups that are under The Empire Plan NYSHIP and had some changes in their benefits, including office visit co-pays.

With the new year (2020) around the corner The Empire Plan NYSHIP has released a list of more employee groups that will be affected by the office visit co-pay changes.

Please refer to the following list:

1. The office visit $20 co-pay will still apply to the following employee groups:
-Council 82

2. Student Employee Health Plan will still continue to have a $10 Office Visit co-pay

3. Effective 01/01/2020 the following employee groups will have a $25 office visit co-pay:
PIA( NYS Police Investigative Unit)
-Unified Court System-COBANC

4. Effective 01/01/2020- Excelsior Plan members will have the office visit co-pay of $35.

Posted in In The Know Series, Insurance, Training, Updates

NY State Empire Plan-Announcement-claim submission time frames deadline-2020

*Please do not forget that UnitedHealthCare is the administrator for this plan and processes the claims for its members.*

Therefore the providers need to adhere to the following timely claim filing frames:

+No later than 120 days from the end of the calendar year in which the services were rendered (initial claim submission)


+Within 120 days after Medicare or another insurance plan process the claim (secondary claims), whichever is later.

+Empire Claims (for 2019 services) need to be submitted to UHC for processing by April 29,2020


If the claim is denied due to late submission, the participating provider or health care professional may NOT bill the patient for the charges on that claim!