Empire Bluecross Essential Plan Coverage Update | OpenPayer
CurrentEmpire BluecrossPolicy N/A
Essential Plan 200-250 Subscriber Contract (New York) - member coverage terms
Governs benefits, definitions, provider network rules, referrals, and covered services for individual Essential Plan enrollees issued by Anthem Blue Cross and Blue Shield HP in New York.
Policy Summary
PayerEmpire Bluecross
PolicyEssential Plan 200-250 Subscriber Contract (New York)
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionProviders must call the number on the member's ID card to request preauthorization at least two weeks prior to planned inpatient hospitalizations or ambulatory surgery.
No material clinical or coverage changes in this revision.
In-network onlyin-network requirement
12 monthsplan year
PCP requiredPCP requirement
10 dayscontract return window
2 weekspreauth lead time
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100%
post-OOP coverage
Coverage criteria and benefit rules
inv-01: General coverage conditions
Covered Services are available when specified conditions are met and based on network and medical necessity rules.
ALL of the following
Service is Medically Necessary (per contract Medical Necessity criteria).
Service is listed as a Covered Service in this Contract.
Service is provided by a Participating Provider, except where this Contract explicitly permits Non-Participating Provider coverage (e.g., Emergency Services, Pre-Hospital Emergency Medical Services, mobile crisis services, authorized exceptions).
Service does not exceed benefit limits in the Schedule of Benefits and is received while the Contract is in force.
inv-02: Non-participating provider exceptions
Out-of-network coverage is limited.
ANY of the following
Emergency Services and Pre-Hospital Emergency Medical Services (treated as covered regardless of network status).
Mobile crisis services (covered and not subject to preauthorization).
When We specifically authorize an Authorization to a Non-Participating Provider because no Participating Provider with appropriate training/experience is available (requires Participating Provider request and approved treatment plan).
inv-03: Primary care and referral exceptions
Referral and PCP rules.
ALL of the following
Member must select a Primary Care Physician (PCP); if none selected, We will assign one.
PCP must be consulted for care and is responsible for referrals to Specialists when required; certain specialists may be designated as PCPs in specific circumstances.
No referral required for
Primary and preventive OB/GYN services (including annual exams).
Emergency Services and Pre-Hospital Emergency Medical Services.
inv-04: Coverage criteria and continuity provisions
Coverage rules, referral exceptions, and continuity/authorization provisions
ALL of the following
Authorizations to Non-Participating Providers, standing authorizations to participating specialists, specialist-as-PCP approvals, and specialty center authorizations require a treatment plan approved by Us in consultation with the PCP, Specialist and Member.
When an Authorization is approved, services performed by the Non-Participating Provider are covered as if provided by a Participating Provider and member pays applicable in-network cost-sharing.
ALL of the following
Covered Services are subject to pre-service, concurrent and retrospective reviews; services must be Medically Necessary per contract criteria to be covered.
ALL of the following
inv-05: Extracted coverage criteria
Key coverage stances and criteria extracted from the provided sections.
ALL of the following
Eligibility: member is in an ongoing course of treatment.
Duration: up to 90 days from provider contract termination; pregnancy continues through delivery and related postpartum care.
Provider requirements: accept prior negotiated fee, provide medical information, adhere to payer policies including Preauthorization and approved treatment plan.
Member responsibility: applicable in‑network Cost‑Sharing applies.
Exceptions: no continuation if provider terminated for fraud, imminent harm, or final disciplinary action.
inv-06: Coverage criteria and rules
Covered services and applicable limits / cost-sharing rules described in these sections include eligibility rules, preventive services (no cost-sharing when meeting federal guideline criteria), mammography, family planning, bone density testing, NDPP, colon and prostate cancer screening, ambulance and air transport, emergency services, and urgent care.
ALL of the following
Subscriber must live in Service Area and meet household income eligibility; coverage effective per NYSOH rules; pregnancy retention and 12‑month postpartum coverage apply.
ALL of the following
Preventive services recommended by HRSA, USPSTF A/B, or ACIP immunizations are not subject to Copayments/Coinsurance when provided by a Participating Provider per guidelines; cost‑sharing may apply for other services during same visit.
ALL of the following
Mammography: baseline at 35–39 and annual screening at 40+; colon cancer screening covered for ages 45–65 per USPSTF; prostate screening covered per criteria.
inv-07: Outpatient and Professional Services coverage items
Coverage positions and key limitations for outpatient and professional services as described in the document.
ALL of the following
Urgent Care is covered in‑ and out‑of‑network; in‑network from participating physicians/urgent care centers; office visits for diagnosis/treatment covered including house calls.
ALL of the following
Advanced imaging (PET, MRI, nuclear medicine, CAT) and Ambulatory Surgical Center services are covered as indicated in the Contract.
ALL of the following
Allergy testing and treatment, chemotherapy/immunotherapy in outpatient settings (oral anti‑cancer drugs under Rx benefit), infusion therapy in appropriate settings, and chiropractic services (per scope) are covered.
ALL of the following
inv-08: Maternity & Newborn
Maternity and newborn coverage rules
ALL of the following
Prenatal (including one genetic testing visit), postnatal, delivery, and pregnancy complications covered when provided by licensed Physicians or midwives meeting NY requirements; midwife services must be affiliated with Article 28 Facility; duplicate routine services by both midwife and physician not paid.
Breastfeeding support and supplies: rental or purchase of one breast pump per pregnancy covered; breastfeeding counseling and support covered.
Donor human milk: outpatient pasteurized donor human milk (and fortifiers) covered when ordered for high‑risk infants meeting criteria (e.g., birth weight <1500g).
Doula services: covered when recommended by Physician/midwife/PA/NP and Doula registered in NY State Community Doula directory; eight prenatal/postpartum visits and one in‑person labor visit covered.
inv-09: Rehabilitation Services
Rehabilitation coverage rules
ALL of the following
Physical, speech and occupational therapy covered outpatient for up to 60 visits per condition per Plan Year (combined therapies).
Therapies must be related to treatment/diagnosis of physical illness or injury, ordered by a Physician, begin within 6 months of triggering event (hospital discharge, surgery or injury), and shall not continue beyond 365 days after such event.
inv-10: Diabetes Benefits
Diabetes equipment, supplies and education
ALL of the following
Covered when prescribed by an authorized prescriber and obtained from a designated diabetic equipment/supply manufacturer or participating pharmacy; includes specified items (glucose monitors, strips, lancets, insulin, pumps, glucagon, etc.).
Supply limits: generally 30‑day supplies with up to 90‑day supply at pharmacy; basic glucose monitors covered unless special needs justify advanced models; unlimited testing supplies available via Diabetic Management Program as described elsewhere.
Step therapy and Preauthorization: diabetic devices, supplies and drugs subject to step therapy and preauthorization; medical exception process available if item not supplied by designated vendor.
inv-11: Durable Medical Equipment & Braces
Durable medical equipment
ALL of the following
Rental or purchase of standard Durable Medical Equipment covered when it meets the definition (repeated use, medical purpose, home use); insurer determines rent vs purchase and covers repair/replacement for normal wear and tear; over‑the‑counter DME and comfort items excluded.
Braces coverage: external braces that assist lost or damaged function covered; replacements covered when medically necessary due to growth or condition change; repairs/replacement due to misuse/abuse not covered.
inv-12: Telemedicine Program
Telemedicine
ALL of the following
Online internet consultations and two‑way video visits covered for non‑emergency conditions when provided by participating Providers in Our telemedicine program; not all participating providers participate; technical requirements apply.
inv-13: Transplants
Transplant coverage
ALL of the following
Only non‑experimental/non‑investigational transplants covered; must be prescribed by Specialists and performed at insurer‑approved hospitals; hospital and medical expenses covered including donor search fees for subscriber‑recipient; travel/lodging/meals and donor fees not covered.
inv-14: Second Opinions
Second opinions
ANY of the following
Second cancer opinion covered from an appropriate Specialist, including Non‑Participating Specialists if attending Physician provides written Referral.
Second surgical opinions covered; third opinion provided if first and second disagree and majority rule applies to approve Covered Services.
inv-15: Surgical Payment Rules
Surgical services payment rules
ALL of the following
When multiple covered procedures performed through the same incision, pay highest Allowed Amount plus 50% for secondary procedures except where coding rules exempt; similar 50% rule applies for different incisions; incidental secondary procedures not paid.
inv-16: Diabetic supplies and step therapy
Diabetic equipment and supplies
ALL of the following
Diabetic glucose meters, test strips, supplies, insulin, injectable and oral anti‑diabetic agents are subject to step therapy and Preauthorization and reviewed for Medical Necessity.
Step therapy overrides may be requested per Utilization Review; step therapy will not be added during a Plan Year except for FDA safety concerns.
inv-17: DME and braces coverage
Durable Medical Equipment and Braces
ALL of the following
Standard DME and external braces covered for rental or purchase; insurer decides rent vs purchase; repair/replacement for normal wear and tear covered; over‑the‑counter DME and comfort items excluded.
Replacements covered for growth or condition change; misuse/abuse exclusions apply.
inv-18: Hearing aids and cochlear implants
Hearing devices
ALL of the following
External hearing aids covered with written Physician recommendation including fitting and testing; one purchase per ear every three years (includes repair/replacement).
Bone anchored hearing aids/cochlear implants covered when Medically Necessary; coverage for one per ear for enrollment duration; repair/replacement only for malfunctions.
inv-19: Hospice coverage
Hospice
ALL of the following
Hospice Care covered when attending Physician certifies prognosis of six months or less; inpatient, home and outpatient hospice services covered including drugs and supplies; coverage provided for 210 days and five supportive family visits before or after death.
Hospice program must be certified under NY law or similar certification out of state; exclusions for funeral arrangements, pastoral/financial/legal counseling, homemaker/respite care.
inv-20: Supplies and prosthetics
Medical supplies and prosthetic devices
ALL of the following
Medical supplies required for treatment of a covered disease/injury and maintenance supplies covered in appropriate amounts; over‑the‑counter supplies excluded.
External prosthetic devices (including wigs when medically indicated) covered with limits (one prosthetic per limb per lifetime; external breast prostheses not subject to lifetime limit); repair/replacement covered for normal wear and tear.
Internal surgically implanted prosthetic devices covered when improving/restoring function; repair/replacement for growth or normal wear and tear covered.
inv-21: Inpatient and related service coverage
Inpatient services and related care
ALL of the following
Acute inpatient hospital services covered when Medically Necessary including room/board, nursing, OR, ICU, diagnostics, drugs, blood, therapies and related supplies; Cost‑Sharing per Schedule of Benefits applies.
ALL of the following
Inpatient maternity: minimum 48 hours for vaginal delivery and 96 hours for C‑section regardless of medical necessity; home care visit within 24 hours if discharge occurs earlier, covered in addition to Home Health visits and not subject to home care cost‑sharing.
ALL of the following
Inpatient Habilitation and Rehabilitation Services each limited to 60 days per Plan Year (combined therapies), with clinical start/timeframe rules as specified.
ALL of the following
inv-22: Skilled Nursing Facility
Skilled Nursing Facility coverage
ALL of the following
Admission must be supported by a treatment plan prepared by the Provider and approved by Us.
Coverage limit: up to 200 days per Plan Year for non‑custodial care.
Custodial, convalescent or domiciliary care not covered.
inv-23: End of Life Care
End-of-life care coverage
ALL of the following
Eligibility: advanced cancer diagnosis with fewer than 60 days to live as certified by attending Physician; Facility medical director must agree care appropriate.
Reimbursement for Non‑Participating Providers: negotiated rate if exists; if none, Medicare Acute care rate; alternate level reimbursed at 75% of Medicare rate.
If insurer disagrees with admission, insurer may initiate expedited external appeal; coverage continues subject to Contract limits until External Appeal Agent decision in insurer's favor.
inv-24: Mental Health & Substance Use Coverage
Mental health and substance use services
ALL of the following
Inpatient mental health services covered comparable to other hospital services; limited to licensed/certified facilities per NY law or equivalent in other states; residential treatment and room/board included where applicable.
ALL of the following
Outpatient services covered including PHP and IOP; up to 20 family counseling visits per Plan Year; providers must be appropriately licensed and facilities accredited or licensed as required.
ALL of the following
Mobile crisis services covered when provided by licensed/certified mobile crisis teams; reimbursement parity for out‑of‑network providers and not subject to prior authorization.
ALL of the following
inv-25: Prescription Drug Benefits
Prescription drug coverage
ALL of the following
Covered Prescription Drugs must be FDA approved, prescribed by an authorized provider, on Our Formulary, dispensed by a licensed pharmacy, and meet legend requirements where applicable.
ALL of the following
Coverage includes diabetes drugs, self‑injectables, inhalers, prenatal vitamins, enteral formulas, oncology agents (including certain off‑label uses supported by compendia), smoking cessation, PrEP/PEP, mental health/substance use drugs (buprenorphine, methadone, long‑acting naltrexone), contraceptives (including OTC when covered), and other specified categories.
ALL of the following
Refills covered when dispensed at retail/mail order/Specialty pharmacy and not beyond one year from original prescription; retail generally limited to 30‑day supply (except contraceptives and exceptions); mail order and designated retail for maintenance drugs up to 90‑day supply.
inv-26: Limitations/Terms of Coverage
Facility limitations and exclusions
ALL of the following
No coverage for special duty nurses, private room charges unless Medically Necessary (coverage based on facility's maximum semi‑private charge if private room not Medically Necessary and member pays difference), or take‑home medications/supplies; radio/telephone/TV/beauty/barber charges not covered.
inv-27: Prescription drug coverage rules and criteria
Coverage, limits, and management rules for prescription drugs under the contract include specialty drug handling, pharmacy designation, supply and quantity limits, cost-sharing rules, formulary management, exception and appeal processes, and exclusions.
ALL of the following
Members may be directed to a Designated Pharmacy (including Specialty) for certain drugs; declining the Designated Pharmacy when it is non‑retail may result in no coverage unless a retail Participating Pharmacy agrees to same reimbursement amount.
Therapeutic classes included in specialty program enumerated in Contract; maintenance drugs may be filled up to 90 days at designated retail pharmacy.
ALL of the following
Tier status can change up to four times/year; 30‑day advance notice for moves to higher tier or removal; formulary exceptions process: standard decisions within 72 hours (written within 3 business days), expedited within 24 hours; approved exceptions covered during treatment.
ALL of the following
inv-28: Diabetes supplies and program
Diabetic Management Program benefits and access
ALL of the following
Preferred access via website with phone alternative for members without internet; member entitled to a cellular‑enabled glucose meter, test strips and lancets per Plan Year with unlimited testing supplies and automatic home refills/delivery; telehealth consults available through program.
inv-29: Vision exams, lenses, frames
Vision benefits
ALL of the following
Vision examination covered one time per Plan Year unless more frequent exams are Medically Necessary with documentation; includes specified exam components.
Standard prescription lenses or contacts and standard frames covered one time per Plan Year; member pays difference for non‑standard items and difference does not apply toward Out‑of‑Pocket Limit.
inv-30: Dental coverage and limitations
Dental benefits and rules
ALL of the following
Emergency dental care covered (not subject to Preauthorization); preventive dental care including prophylaxis at six‑month intervals covered; routine dental care (exams, x‑rays per intervals, fillings, simple extractions) covered per schedule.
Crowns, root canal (endodontics) and implant services covered when Medically Necessary and may require Preauthorization; prosthodontics and denture replacement have timing limits (e.g., dentures not replaced within 8 years unless medically necessary).
Orthodontics covered when used to restore oral structures for health/function or treat specified serious medical conditions; preauthorization requirements apply.
inv-31: Exclusions
Exclusions and limitations
ALL of the following
A non‑exhaustive list of exclusions includes aviation‑related services (except fare‑paying passenger), convalescent and custodial care, conversion therapy (not covered for minors), cosmetic services (except reconstructive when incidental to trauma/infection or congenital functional defects and post‑mastectomy reconstructive services), dental services except as stated, experimental/investigational treatments (unless External Appeal overturns denial), felony participation exclusions (with exceptions), routine foot care (with medical exceptions), and other specific exclusions as listed in Contract.
inv-32: Contract Exclusions
Exclusions — services, conditions, settings, providers, or circumstances not covered under the Contract unless an exception is stated.
ALL of the following
No coverage for conditions due to participation in felony/riot/insurrection (exceptions for victims/domestic violence).
Routine foot care not covered except when related to circulatory deficits or decreased sensation.
Care in government‑owned/operated hospitals not covered except as required by law or for proximate Emergency Services.
Services not deemed Medically Necessary are not covered, but External Appeal Agent reversals of denials result in coverage where otherwise Contractually covered.
Services covered under Medicare or other governmental programs (except Medicaid), military service related conditions, no‑fault automobile insurance recoverable benefits, services not listed as Covered, services by family members, separately billed hospital employee services, services provided with no charge, vision eyeglass/contact fitting/exam, war‑related conditions, and workers' compensation statutory coverages are excluded.
inv-33: Claims Procedures
Claims submission and determination procedures.
ALL of the following
Either the member or provider must file a claim form; claim must include member ID, name, DOB, date of service, type of service, charge, procedure code, diagnosis code, provider name/address and supporting medical records when necessary; incomplete claims not accepted.
ALL of the following
Claims must be submitted within 120 days after the service; if not reasonably possible, submit as soon as reasonably possible.
ALL of the following
Claim determination procedures apply to claims not related to medical necessity or experimental determinations; Utilization Review and External Appeal govern medical necessity/experimental determinations and appeals.
inv-34: Determination Timelines and Procedures
Timelines and required actions for determinations depending on claim type and urgency.
ALL of the following
Non‑urgent pre‑service: decision within 15 calendar days if all info received; request additional info within 15 days and member has 45 days to respond; decision within 15 days of receipt of info. Urgent pre‑service: telephonic decision within 72 hours if all info received; written notice within 3 days; if more info needed request within 24 hours and allow 48 hours to provide; decision within 48 hours of receipt or end of 48‑hour period.
ALL of the following
Non‑urgent preauthorization: decision and notice to member/provider within 3 business days when all info received; if additional info requested, 45 days to respond; decision within 3 business days of receipt of info. Urgent preauthorization: telephone notice within 72 hours if all info received; written notice within 3 business days; info request and response timelines shorter as specified.
ALL of the following
Non‑urgent concurrent: decision and notice within 1 business day of receipt of necessary info; urgent concurrent extension requests submitted ≥24 hours before expiry decided by telephone within 24 hours; retrospective: decision and notice within 30 calendar days if all info received; additional info request/response timelines apply.
inv-35: Utilization Review and Appeal Criteria
Rules for retrospective review reversals and step therapy override determinations, including acceptable grounds, evidence standards, timelines, and effect of approvals.
ALL of the following
A preauthorized treatment may be reversed on retrospective review only when materially different information exists, information was withheld at time of preauthorization, insurer was unaware of such information, and had insurer been aware it would not have authorized the treatment.
ALL of the following
Overrides may be requested when required drug is contraindicated, likely ineffective based on clinical history, previously tried and failed, member is stable on requested drug, or required drug would create adherence barriers or worsen comorbidities; determinations use evidence‑based clinical criteria.
Timelines: standard decision within 72 hours of receiving supporting documentation; expedited within 24 hours if serious jeopardy exists; if requested supporting info not submitted insurer will request within defined timeframes and member/provider have set days to respond; failure to decide within timelines results in approval.
inv-36: External Appeal outcomes and timelines
Outcomes when External Appeal Agent overturns insurer decisions
ALL of the following
If External Appeal Agent overturns Our denial for not medically necessary, experimental/investigational, or out‑of‑network treatment, We will provide coverage subject to Contract terms; for clinical trials coverage limited to costs required by trial design (excludes investigational drug/device and research costs).
External Appeal Agent decision is binding on both member and insurer and admissible in court.
Formulary exception external appeal overturns result in coverage for the drug while member is taking it (including refills); expedited external formulary exceptions decided within 24 hours; filing deadlines and timelines apply (external appeals typically must be filed within four months of final adverse determination).
inv-37: Administrative recovery, liability, and contract operation rules
Administrative financial recovery and third-party recovery provisions:
ALL of the following
We will notify and explain overpayments; member must return overpayment within 60 days of notification; insurer will not initiate recovery more than 24 months after original payment except reasonable belief of fraud.
ALL of the following
Insurer may be subrogated to rights of recovery against responsible third parties and may seek reimbursement from settlements or proceeds; member must notify insurer within 30 days of intent to pursue claim and provide requested information.
ALL of the following
Insurer may offset amounts owed by member against payments due to the member, and insurer reviews claims for fraud and abusive billing; standard recovery and renewal rules and time to sue provisions apply as specified in Contract.
Coding tables and numeric limits
Unlabeled code itemmixed
Allowed Amount definitionmixed
'Allowed Amount' means the maximum amount We will pay for the services or supplies covered under this Contract, before any applicable Copayment or Coinsurance; the Allowed Amount will be the amount negotiated with the Participating Provider or the Participating Provider's charge, if less.
Diabetic equipment and supplies (list)mixedCovered
Acetone reagent strips; Acetone reagent tablets; Alcohol or peroxide by the pint; Alcohol wipes; All insulin preparations; Automatic blood lance kit; Cartridges for the visually impaired; Diabetes data management systems; Disposable insulin and pen cartridges; Drawing-up devices for the visually impaired; Equipment for use of the pump; Glucagon for injection; Glucose acetone reagent strips; Glucose kit; Glucose monitor with or without specula features for visually impaired, control solutions, and strips for home glucose monitor; Glucose reagent tape; Glucose test or reagent strips; Injection aides; Injector (Busher) Automatic; Insulin; Insulin cartridge delivery; Insulin infusion devices; Insulin pump; Lancets; Oral agents such as glucose tablets and gels; Oral anti-diabetic agents; Syringe with needle; Urine testing products for glucose and ketones; Additional supplies as designated by the NY State Commissioner of Health.
Oral surgery (limited dental) codesmixedCovered
Oral surgical procedures for jaw bones or surrounding tissue and dental services for repair or replacement of sound natural teeth required due to accidental injury (replacement only if repair not possible within 12 months); procedures necessary due to congenital disease or anomaly; procedures to correct non-dental physiological conditions causing severe functional impairment; removal of tumors and cysts requiring pathological examination (excluding cysts related to teeth); surgical/nonsurgical procedures for temporomandibular joint disorders and orthognathic surgery.
Diabetic equipment and supplies covered when prescribed by authorized prescriber and obtained from designated manufacturer/supplier; limited to 30-day supply (up to 90-day at pharmacy); step therapy applies to glucose meters, test strips, supplies (syringes, lancets, needles, pens), insulin, injectable and oral anti-diabetic agents; items require Preauthorization and Medical Necessity review; basic models of monitors covered unless special needs.
Durable medical equipment, braces, prostheticsmixedCovered
Durable Medical Equipment: rental or purchase of standard DME that is designed for repeated use, primarily medical purpose, not useful absent disease/injury, appropriate for home use; repair/replacement for normal wear and tear; over-the-counter DME excluded.
Braces: external braces (including orthotic) that assist lost or damaged external body part function; standard equipment only; replacements covered for growth or condition change; misuse/abuse excluded.
External Prosthetic Devices: external prostheses (including wigs) covered for loss/damage due to injury or disease; one prosthetic device per limb per lifetime; external breast prostheses following mastectomy not subject to lifetime limit; repair/replacement covered for normal wear and tear.
Internal Prosthetic Devices: surgically implanted prosthetic devices and special appliances that improve/restore function covered; includes implanted breast prostheses; repair/replacement for growth or normal wear and tear; coverage for standard equipment only.
Hearing aids and cochlear implantsmixedCovered
External hearing aids: covered when purchased after written Physician recommendation, including fitting and testing; one purchase (including repair/replacement) per ear once every three years.
Cochlear implants (bone anchored hearing aids): covered when Medically Necessary (e.g., craniofacial anomalies, severe hearing loss not remedied by wearable aid); coverage for one per ear while enrolled; repair/replacement only for malfunctions.
Prescription drug coverage criteriamixedCovered
Covered Prescription Drugs must be FDA approved, required to bear prescription legend, ordered by authorized provider within scope, prescribed within FDA guidelines, on the Formulary, and dispensed by a licensed pharmacy; includes diabetes drugs, self-injectables, inhalers, enteral formulas and many specified therapeutic categories.
Definitions: formulary and drug cost termsmixed
Brand-Name Drug: manufactured/marketed under trademark or identified by Us; Specialty Pharmacy: pharmacy under agreement to provide specific drugs; Formulary: list of drugs covered (updated up to four times/year); Prescription Drug definition and Prescription Drug Cost defined (amount including dispensing fee and sales tax as contracted between Us and pharmacy benefit manager).
Unlabeled code itemmixed
Required claim coding elementsmixed
procedure code
Procedure code for the service as applicable (required on claims).
diagnosis code
Diagnosis code (required on claims).
member identification number
Member identification number (required on claims).
provider name/address
Name and address of the Provider making the charge (required on claims).
date of service
Date of service (required on claims).
Unlabeled code itemmixed
inv-50: Out-of-Pocket Limit — maximum You pay during a Plan Year before We pay 100% of Allowed Amount (dollar amounts in Schedule of Benefits).
DefinitionOut-of-Pocket Limit = the most You pay during a Plan Year in Cost-Sharing before We pay 100% of the Allowed Amount for Covered Services (specific dollar amounts shown in the Schedule of Benefits).
Measurement periodRuns on a Plan Year basis (12-month period beginning on the Contract effective date or anniversary).
What is excludedBalance Billing charges and costs for services We do not Cover do not count toward the Out-of-Pocket Limit.
Provider requirements, prior authorization and operational rules
Prior Authorization
Preauthorization Required (overview)
Preauthorization is a decision by the insurer made before a member receives a Covered Service, procedure, treatment plan, device, or Prescription Drug that the item or service is Medically Necessary. Participating Providers are responsible for requesting Preauthorization for services listed in the Schedule of Benefits. Preauthorization is required for certain prescription drugs (see Drug list on Our website) and for diabetic supplies/equipment when applicable; exceptions include covered antiretroviral drugs and medications to treat substance use disorder. Emergency Department care and pre-hospital emergency medical services for an Emergency Condition do not require Preauthorization, but members or their representatives must notify the insurer within the required timeframe for emergency admissions.
Preauthorization = insurer decision prior to service confirming Medical Necessity.
Participating Provider must obtain Preauthorization for services listed in the Schedule of Benefits.
Some prescription drugs, diabetic supplies/equipment require Preauthorization; exceptions apply for certain HIV and SUD medications.
Prior Authorization
Preauthorization Request Timing and Method
Key definitions used in the contract
inv-95: Doula — definition and role.
Role and servicesDoula = a trained person who provides continuous physical, emotional, and informational support to the pregnant person and family before, during, and for a reasonable time after childbirth.
SettingsA Doula may provide services in hospitals, birthing centers, at home deliveries, or other community settings.
Coverage noteDoula services are referenced in maternity benefits and may be covered when recommended and registered as specified in the Maternity section (see Schedule of Benefits for limits).
inv-96: Allowed Amount — definition of the maximum payment basis for Covered Services.
DefinitionAllowed Amount = the maximum amount We will pay for services or supplies covered under this Contract, determined as the amount negotiated with the Participating Provider or the Participating Provider's charge if less.
Operational coding references and numeric limits for providers
Unlabeled code itemmixed
Allowed Amount definitionmixed
'Allowed Amount' means the maximum amount We will pay for the services or supplies covered under this Contract, before any applicable Copayment or Coinsurance; the Allowed Amount will be the amount negotiated with the Participating Provider or the Participating Provider's charge, if less.
Diabetic equipment and supplies (list)mixedCovered
Acetone reagent strips; Acetone reagent tablets; Alcohol or peroxide by the pint; Alcohol wipes; All insulin preparations; Automatic blood lance kit; Cartridges for the visually impaired; Diabetes data management systems; Disposable insulin and pen cartridges; Drawing-up devices for the visually impaired; Equipment for use of the pump; Glucagon for injection; Glucose acetone reagent strips; Glucose kit; Glucose monitor with or without specula features for visually impaired, control solutions, and strips for home glucose monitor; Glucose reagent tape; Glucose test or reagent strips; Injection aides; Injector (Busher) Automatic; Insulin; Insulin cartridge delivery; Insulin infusion devices; Insulin pump; Lancets; Oral agents such as glucose tablets and gels; Oral anti-diabetic agents; Syringe with needle; Urine testing products for glucose and ketones; Additional supplies as designated by the NY State Commissioner of Health.
Oral surgery (limited dental) codesmixedCovered
Oral surgical procedures for jaw bones or surrounding tissue and dental services for repair or replacement of sound natural teeth required due to accidental injury (replacement only if repair not possible within 12 months); procedures necessary due to congenital disease or anomaly; procedures to correct non-dental physiological conditions causing severe functional impairment; removal of tumors and cysts requiring pathological examination (excluding cysts related to teeth); surgical/nonsurgical procedures for temporomandibular joint disorders and orthognathic surgery.
Durable medical equipment, braces, prosthetics codesmixedCovered
Durable Medical Equipment: rental or purchase of standard DME; repair/replacement for normal wear and tear; over-the-counter DME excluded; insurer decides rent vs purchase.
Braces: external braces including orthotic braces covered when serving to assist function lost or damaged due to injury, disease or defect; replacements covered when growth or medical condition change necessitates; misuse/abuse excluded.
External prosthetic devices: external prostheses (including wigs) covered for loss/damage due to injury or disease; one prosthetic device per limb per lifetime; external breast prostheses following mastectomy not subject to lifetime limit; repair/replacement covered for normal wear and tear.
Internal prosthetic devices: surgically implanted prosthetic devices covered when they improve or restore function; includes implanted breast prostheses; repair/replacement covered for growth or normal wear and tear; coverage for standard equipment only.
Required claim coding elements — submission checklistmixed
member identification number
Member identification number (required on claims).
name
Member name (required on claims).
date of birth
Member date of birth (required on claims).
date of service
Date of service (required on claims).
type of service
Type of service (required on claims).
charge for each service
Charge for each service (required on claims).
procedure code
Procedure code for the service as applicable (required on claims).
diagnosis code
Diagnosis code (required on claims).
provider name and address
Name and address of the Provider making the charge (required on claims).
supporting medical records
Supporting medical records when necessary (required on claims).
Policy update and revision timeline
08/25document_issueLatest
Essential Plan 200-250 Subscriber Contract (New York) issued by Anthem Blue Cross and Blue Shield HP
Policy Summary
PayerEmpire Bluecross
PolicyEssential Plan 200-250 Subscriber Contract (New York)
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionProviders must call the number on the member's ID card to request preauthorization at least two weeks prior to planned inpatient hospitalizations or ambulatory surgery.
Mobile crisis services, Urgent Care, Outpatient mental health, Outpatient substance use services.
Outpatient Habilitation and Rehabilitation Services, Home Health Care, Diagnostic radiology and Laboratory procedures, Chiropractic services, and all other services from Participating Providers.
If a Participating Provider leaves the network while a member is in an ongoing course of treatment, the member may continue to receive care from that former Participating Provider for up to 90 days (pregnancy extends through delivery and related postpartum care) provided the provider accepts prior negotiated fees and complies with insurer requirements; exceptions if provider was terminated for fraud, imminent harm, or final disciplinary action.
If a new member is in an ongoing course of treatment with a Non-Participating Provider for a life‑threatening or degenerative disabling condition, continuation of care may be provided for up to 60 days if the Non-Participating Provider agrees to accept Our fees and comply with policies and an approved treatment plan.
ALL of the following
Eligibility: entering coverage while in ongoing course of treatment for life‑threatening or degenerative disabling condition.
Duration: up to 60 days from coverage effective date.
Provider requirements: agree to accept payer fees, provide medical info, adhere to policies including Preauthorization and approved treatment plan.
Member responsibility: applicable Cost‑Sharing applies.
ALL of the following
After meeting Out‑of‑Pocket Limit for the Plan Year, We cover 100% of Allowed Amount for Covered Services for remainder of Plan Year; Out‑of‑network cost‑sharing generally does not count toward the Limit except Emergency Services, approved in‑network exceptions, and out‑of‑network dialysis.
Allowed Amount is the negotiated amount with the Participating Provider or the Provider's charge if less; payments may include incentives that do not change member Cost‑Sharing.
ALL of the following
Out‑of‑Area Covered Healthcare Services are limited to urgent and emergent care unless authorized by the PCP; claims outside service area may be processed via BlueCard or Global Core and reimbursement rules vary.
ALL of the following
Subscriber must reside in Service Area and meet income and other eligibility criteria specified; Essential Plan provides Individual coverage only.
ALL of the following
Pre‑Hospital Emergency Medical Services and emergency ambulance covered worldwide when prudent layperson standard met; payment to Non‑Participating Providers uses FAIR Health 80th percentile or billed charges as specified; member held harmless from balance billing beyond cost‑sharing when applicable.
ALL of the following
Emergency Services covered irrespective of network for medically necessary treatment to stabilize Emergency Condition; members should notify insurer within 48 hours of admission; Urgent Care covered in‑ and out‑of‑network and in/out of service area.
ALL of the following
Air ambulance covered for emergency and certain non‑emergency inter‑facility transfers; travel/transport expenses not covered unless connected to emergency or approved facility transfer; IDRE applies to disputes.
Routine patient costs for approved clinical trials for cancer or life‑threatening conditions are covered without Utilization Review if referred by a Participating Provider; investigational drug/device costs and research costs excluded.
ALL of the following
Specified diabetic services (primary care management visits, annual retinal and foot exams, lab tests) have no in‑network cost‑sharing; diabetic equipment/supplies subject to program rules and step therapy.
ALL of the following
Dialysis covered for acute/chronic conditions; Non‑Participating Provider dialysis covered only under conditions (licensure, outside service area, written order, 30‑day notice except emergencies), subject to preauthorization and limited to 10 treatments per Plan Year; member may owe difference between participating rate and provider charge.
ALL of the following
Habilitation/Rehabilitation outpatient: up to 60 visits per condition per Plan Year (combined therapies); Home Health Care covered per physician plan up to 40 visits per Plan Year; inpatient habilitation/rehab limits apply as specified.
ALL of the following
Comprehensive maternity and newborn care covered including prenatal/postnatal/delivery, breastfeeding support and one breast pump per pregnancy; doula services covered with limits (8 prenatal/postpartum visits and one in‑person labor visit) when recommended and registered.
ALL of the following
Laboratory, diagnostic testing, and biomarker precision testing covered at participating CLIA labs when supported by FDA labeling, CMS NCD/LCD, recognized guidelines, or peer‑reviewed literature.
SNF: covered up to 200 days per Plan Year for non‑custodial care; admission must be supported by provider treatment plan approved by Us.
End‑of‑life care: advanced cancer with <60 days to live covered in specialized licensed facilities; insurer may initiate expedited external appeal if admission disputed; reimbursement rules for Non‑Participating Providers described.
Screening, diagnosis and treatment for autism covered when prescribed/ordered and Medically Necessary; applied behavior analysis covered when provided by licensed or certified ABA professionals; therapy limits and licensing requirements apply.
ALL of the following
Inpatient and outpatient substance use disorder services covered when provided at OASAS‑authorized facilities or equivalents (detox, rehab, PHP, IOP, MAT, opioid treatment programs); special concurrent review protections apply for OASAS‑certified facilities.
ALL of the following
Member responsible for Cost‑Sharing per Schedule of Benefits (three‑tier design); insurer may direct certain drugs to a Designated Pharmacy (including Specialty); members have coverage consequences if they decline designated pharmacy terms; mail order available and cost‑sharing is lowest of applicable amounts.
ALL of the following
Tier status may change up to four times per year with notice for upward changes; formulary exceptions may be requested (standard decision within 72 hours, expedited within 24 hours); step therapy limited to up to two required drugs before covering another, with override and look‑back provisions and timelines defined.
ALL of the following
Preauthorization may be required for certain drugs; compounded drugs and high‑cost compounds have special rules; exclusions include non‑legend/non‑prescription drugs (with specified exceptions), drugs dispensed while inpatient/institutionalized (unless outside facility payment), lost/stolen replacements, and non‑medically necessary or experimental drugs.
Retail supply generally limited to 30 days (except contraceptives up to 12 months); mail order up to 90 days; programs such as split‑fill, half‑tablet, and opioid initial supply proration described to manage waste and cost.
ALL of the following
Preauthorization required for certain drugs; step therapy limited to two required drugs before covering another, with look‑back waiver for prior completion within 365 days and defined override timelines (72/24 hours standard/expedited).
ALL of the following
Compounded drugs covered only when containing at least one covered legend drug and from approved compounding pharmacy; compounded products over $250 require preauthorization; exclusions include administration charges, non‑prescription drugs (with limited exceptions), sexual dysfunction drugs (except certain indications), inpatient/institutional dispensed drugs (except allowed cases), and lost/stolen replacements.
Effect of approval: immediate coverage authorized and override remains in effect until the lesser of guideline‑based treatment duration or 12 months following approval.
inv-51: Out-of-Pocket Limit applicability — applies to in-network cost-sharing; exceptions noted in Schedule of Benefits.
ApplicabilityOut-of-Pocket Limit applies to in-network Cost-Sharing; after meeting the Limit We cover 100% of Allowed Amount for Covered Services for remainder of Plan Year.
Out-of-network treatmentCost-Sharing for out-of-network services generally does not apply toward the Out-of-Pocket Limit except for Emergency Services, approved in-network exceptions, and out-of-network dialysis.
ReferenceSee Schedule of Benefits for specific cost-sharing amounts and any exceptions that count toward the Limit.
inv-52: Rehabilitation visit limit — 60 visits per condition per plan year (all therapies combined).
Visit limitUp to 60 visits per condition per Plan Year for outpatient Rehabilitation Services (physical, speech, occupational combined).
ScopeApplies to therapies related to treatment/diagnosis of physical illness or injury, ordered by a Physician, and following hospitalization or surgery when required.
TimingTherapy must begin within six months of the triggering event and in no event continue beyond 365 days after the event.
inv-53: Hearing aid frequency — one purchase per ear every 3 years.
FrequencyOne purchase (including repair or replacement) of hearing aids for one or both ears once every three (3) years.
RequirementPurchase must follow a written recommendation by a Physician and includes fitting and testing charges.
inv-54: Combined therapy visit limit — 60 days per Plan Year (habilitation and rehabilitation as applicable).
Combined inpatient therapy limitUp to 60 days per Plan Year for inpatient Habilitation Services and up to 60 days per Plan Year for inpatient Rehabilitation Services; visit/day limits apply to all therapies combined.
Therapies includedPhysical therapy, speech therapy and occupational therapy counted together toward the 60-day limits for inpatient habilitation/rehabilitation as applicable.
ConditionTherapy must be related to illness/injury, ordered by a Physician, and follow hospitalization or surgery where required; timing rules apply.
inv-55: Skilled Nursing Facility limit — up to 200 days per Plan Year.
Coverage limitSkilled Nursing Facility services covered up to 200 days per Plan Year for non-custodial care.
Admission requirementAdmission must be supported by a treatment plan prepared by Your Provider and approved by Us.
ExclusionsCustodial, convalescent or domiciliary care is not Covered under SNF benefits.
inv-56: Refill time limit — refills not provided beyond one year from original prescription date.
Refill time limitRefills are not provided beyond one (1) year from the original prescription date.
Retail/mail/specialty requirementRefills must be dispensed at a retail, mail order or Specialty pharmacy as ordered by an authorized Provider to be covered.
Emergency 30-day refill during disasterDuring a declared state disaster emergency, a 30-day emergency refill may be provided subject to cost-sharing; certain controlled substances excluded.
inv-57: Maintenance drug supply — up to 90-day supply at Designated retail Pharmacy.
Maximum supplyMaintenance drugs may be filled for up to a 90-day supply at a Designated retail Pharmacy (and mail order up to 90 days where allowed).
Designated supplierDiabetic equipment and supplies are Covered only when obtained from a designated diabetic equipment or supply manufacturer/participating pharmacy; maintenance supplies follow 30–90 day supply rules.
Cost-sharingMember pays the applicable Cost-Sharing per Schedule of Benefits; ask Provider for a 90-day prescription to maximize benefit where appropriate.
Standard retail limitRetail pharmacy fills generally limited to a 30-day supply (one Cost-Sharing amount per up to 30-day supply).
Contraceptive exceptionContraceptive drugs, devices or products may be dispensed up to a 12-month supply and are not subject to Cost-Sharing.
Quantity limitsSome drugs may have additional quantity limits per month; exceptions and appeals available via Utilization Review and External Appeal processes.
inv-59: Mail order supply limit — up to 90-day supply.
Mail order supplyMail order pharmacy may provide up to a 90-day supply for certain Prescription Drugs; member pays the lower of applicable Cost-Sharing or Prescription Drug Cost.
DeliveryMail order fills are delivered directly to the member's home or office; cost-sharing may be applied per mail order vendor terms.
Retail equivalenceParticipating retail pharmacies may be bound to mail order vendor terms if they have an agreement with the mail order vendor to be treated as mail-order equivalent for certain drugs.
inv-60: Non-standard lens/frame cost responsibility — member pays difference; difference does not apply to Out-of-Pocket Limit.
Member responsibilityIf You choose non-standard lenses or non-standard frames, We pay the amount for standard items and You pay the difference; that difference does not apply toward Your Out-of-Pocket Limit.
Standard coverage frequencyStandard prescription lenses/contacts and standard frames covered one time per Plan Year unless Medically Necessary more frequently with documentation.
DeterminationMedical necessity documentation required to exceed the standard frequency or to justify payment for non-standard items in lieu of member cost-share.
inv-61: Claim filing deadline — claims must be submitted within 120 days after the service; exceptions if not reasonably possible.
DeadlineClaims for services must be submitted to Us for payment within 120 days after You receive the services for which payment is requested.
ExceptionIf it is not reasonably possible to submit a claim within 120 days, submit it as soon as reasonably possible and include required information.
Filing responsibilityEither You (Subscriber) or the Provider must file the claim; if Provider will not file, You must file; claim form available by phone or website.
inv-62: Concurrent review timelines — non-urgent determinations within 1 business day after necessary info; urgent determinations within 24 hours for certain inpatient requests.
Non-urgent concurrent reviewsDecisions and notice provided by telephone and in writing within 1 business day of receipt of all necessary information; additional info requested within 1 business day and timelines for response specified.
Urgent concurrent reviewsIf extension request submitted ≥24 hours before expiry: decision by telephone within 24 hours and written notice within 1 business day; other urgent requests decided by telephone/written notice within earlier of 72 hours or 1 business day with expedited request/response timelines.
Inpatient SUD special ruleIf inpatient SUD request submitted ≥24 hours prior to discharge, determination within 24 hours and coverage provided while determination pending; OASAS-certified facilities have additional protections for initial period (first 28 days inpatient; first 4 weeks/28 visits outpatient) when timely notified.
For planned inpatient admissions, ambulatory surgery, or ambulatory care procedures that require Preauthorization, Your Provider must call the number on the member's ID card and request Preauthorization at least two (2) weeks prior to the planned admission or procedure. If two weeks’ notice is not possible, Providers must request Preauthorization as soon as reasonably possible during regular business hours. Air ambulance for non-emergencies also requires prior contact.
At least two (2) weeks prior to planned inpatient admission or recommended surgery.
At least two (2) weeks prior to ambulatory surgery or ambulatory care procedures.
Before non-emergency air ambulance services are rendered.
Prior Authorization
Authorizations to Non‑Participating Providers, Specialists and Specialty Centers
A Participating Provider must request prior approval when an Authorization to a Non-Participating Provider, non-participating Specialist, or a non-participating specialty care center is needed because no appropriately trained Participating Provider exists in-network. Approvals are contingent on insurer review and will be tied to an insurer‑approved treatment plan; covered services will be treated as in-network for Cost‑Sharing when approved. Standing Authorizations to Participating Specialists are available for ongoing specialty care when approved and will include any visit limits or reporting requirements.
Participating Provider must request Authorization to a specific Non-Participating Provider—approvals are not granted for convenience.
If approved, services by the approved Non-Participating Provider are covered as in-network and require an insurer‑approved treatment plan.
Standing Authorizations to Participating Specialists may be granted for ongoing care and may limit visits or require updates to the PCP.
Documentation Required
Continuity When a Provider Leaves the Network
If a Participating Provider leaves the network while a member is in an ongoing course of treatment, the member may continue to receive Covered Services from that former Participating Provider for up to 90 days from the date the Provider’s contractual obligation terminates (through delivery and postpartum care if pregnant). The Provider must accept the negotiated fee in effect prior to termination, provide necessary medical information to Us, and adhere to Our policies and procedures — including obtaining any required Preauthorization, Authorizations, and approved treatment plans. Continued care is not available if the Provider was terminated for fraud, imminent patient harm, or final disciplinary action that impairs practice.
Continuation of care up to 90 days for ongoing treatment.
Provider must accept prior negotiated fee and comply with insurer policies (including Preauthorization).
No continuity if Provider was terminated for fraud, imminent harm or final disciplinary action.
Documentation Required
Continuity for New Members in a Course of Treatment
If a new member is in an ongoing course of treatment with a Non‑Participating Provider for a life‑threatening, degenerative or disabling condition when coverage becomes effective, the member may be eligible to continue receiving Covered Services from that Non‑Participating Provider for up to 60 days from the effective date. The Non‑Participating Provider must agree to accept the insurer's fees for such services, provide necessary medical information, and follow insurer policies and procedures (including obtaining Preauthorization and insurer‑approved treatment plans).
Continuation up to 60 days for qualifying conditions (life‑threatening or degenerative/disabling).
Non‑Participating Provider must accept insurer fees and comply with insurer requirements, including Preauthorization.
Prior Authorization
Dialysis Coverage and Preauthorization
Dialysis for acute or chronic kidney disease is covered. Dialysis by a Non‑Participating Provider is covered only when specific conditions are met: the Non‑Participating Provider is licensed and outside the Service Area; a Participating Provider issues a written order indicating necessity; the member provides written notice at least 30 days before proposed treatment (shortened for emergency travel); and the insurer has the right to Preauthorize the dialysis schedule. Benefits for non‑participating dialysis are limited to ten (10) treatments per Plan Year and the member may be responsible for any difference between what would have been paid in-network and the Non‑Participating Provider's charge.
Non‑Participating Provider dialysis limited to 10 treatments per Plan Year.
30 days written notice required unless shortened for emergency travel.
Insurer may Preauthorize dialysis treatment and schedule; member may owe difference between in‑network payment and provider charge.
Prior Authorization
Inpatient Preauthorization and Referral Requirements
Refer to the Schedule of Benefits for inpatient Preauthorization or Referral requirements. Admissions to certain facilities (e.g., Skilled Nursing Facility) must be supported by a treatment plan prepared by the Provider and approved by the insurer. Transplants must be performed at insurer‑approved hospitals. End‑of‑life facility admissions disputed by the insurer may trigger an expedited external appeal.
Check Schedule of Benefits for Preauthorization/Referral applicability for inpatient services.
SNF admission requires an insurer‑approved treatment plan.
Preauthorization and referral requirements for mental health and substance use services are no more restrictive than those for medical and surgical services in compliance with federal parity laws. Mobile crisis services are covered, reimbursed at the same rate for out‑of‑network providers as participating providers, and shall not be subject to prior authorization requirements.
Parity: MH/SUD Preauthorization requirements are no more restrictive than medical/surgical.
Mobile crisis services: reimbursed equally and not subject to prior authorization.
Note
Diabetic Management Program Access and Supplies
Members may access the Diabetic Management Program primarily through the insurer's website; telephone access is available if internet is not available. The program provides educational resources, supplies (cellular‑enabled glucose meter, test strips, lancets) with automatic home refills, and telehealth consults with participating Providers. Diabetic equipment and supplies must be obtained from designated manufacturers/participating pharmacies; exceptions may be requested via medical exception.
Preferred access via website; phone assistance available.
Entitled to a cellular‑enabled glucose meter, test strips, and lancets per Plan Year with automatic refills.
Diabetic supplies must come from designated suppliers; medical exception process exists.
Denial Risk
Claims for Prohibited Referrals
We are not required to pay claims for services furnished pursuant to referrals that are prohibited by New York Public Health Law Section 238‑a(1). This applies to clinical laboratory, pharmacy, radiation therapy, physical therapy, and x‑ray or imaging services furnished pursuant to prohibited referrals.
Insurer may deny payment for claims resulting from prohibited referral arrangements under NY Public Health Law §238‑a(1).
Affected services include clinical lab, pharmacy, radiation therapy, physical therapy, and imaging services.
Prior Authorization
Preauthorization Timelines — Non‑Urgent and Urgent Reviews
Non‑urgent Preauthorization determinations will be made within three (3) business days if all information is received. If additional information is needed, it will be requested within three (3) business days and the Provider will have 45 calendar days to submit it; determinations follow within three (3) business days of receiving the info or within specified fallback timelines if information is not provided. For urgent Preauthorization requests, determinations will be made by telephone within 72 hours when all information is received, with written notice to follow within three (3) business days. If additional information is requested for urgent reviews, it will be requested within 24 hours and the Provider will have 48 hours to respond; final determination and notice occur within 48 hours of receipt of the information or the end of the 48‑hour period.
Non‑urgent: determination within 3 business days when all info received; 45 days allowed to submit requested info.
Urgent: determination by telephone within 72 hours when all info received; written notice within 3 business days.
If additional info needed for urgent reviews: requested within 24 hours; Provider has 48 hours to submit; determination within 48 hours.
Prior Authorization
Crisis Stabilization and OASAS Facility Protections
Services provided at participating crisis stabilization centers and participating OASAS‑authorized facilities are not subject to Preauthorization. The insurer may conduct retrospective review using clinical review tools designated by OASAS or approved by OMH. If treatment at a participating crisis stabilization center or OASAS‑certified facility is later denied as not Medically Necessary, the member is only responsible for any Cost‑Sharing that would otherwise apply.
Participating crisis stabilization centers and OASAS‑certified facilities: no Preauthorization required.
Insurer may perform retrospective or concurrent reviews using OASAS/OMH‑designated tools.
Member liability limited to applicable in‑network Cost‑Sharing if care later denied.
Prior Authorization
Inpatient SUD Preauthorization Exception and Concurrent‑Review Protections
Inpatient substance use disorder (SUD) treatment at participating OASAS‑licensed/certified facilities is not subject to Preauthorization and is exempt from concurrent review for the first 28 days of an admission if the facility notifies the insurer of the admission and initial treatment plan within two (2) business days. After the first 28 days, the insurer may review the stay for Medical Necessity using OASAS clinical review tools. Outpatient and intensive outpatient SUD at participating OASAS‑certified facilities are not subject to Preauthorization and are exempt from concurrent review for the first four (4) weeks (not to exceed 28 visits) if the facility notifies the insurer within two (2) business days.
Inpatient SUD at participating OASAS facilities: no Preauthorization; first 28 days exempt from concurrent review if timely notification provided.
Outpatient SUD at participating OASAS facilities: no Preauthorization; first 4 weeks/28 visits exempt from concurrent review with timely notification.
Denial Risk
Appeal of Out‑of‑Network Authorization Denials
If a request for an Authorization to a Non‑Participating Provider is denied because the insurer determines an appropriate Participating Provider exists, the member may appeal to an External Appeal Agent if statutory external appeal requirements are met. The attending Physician must certify that the recommended Participating Provider does not have appropriate training/experience and must recommend a qualified Non‑Participating Provider. The attending Physician must be licensed and board certified or board eligible in the relevant specialty.
External appeal available when denial of Authorization to a Non‑Participating Provider is based on availability of an in‑network Provider and statutory criteria are met.
Attending Physician must provide certification and recommend the Non‑Participating Provider; must be appropriately licensed/certified.
Step Therapy
Formulary Exception Appeal Rights
If a formulary exception request for coverage of a non‑formulary Prescription Drug is denied, the member, designee, or prescribing clinician may appeal the denial to an External Appeal Agent pursuant to the formulary exception and Prescription Drug Coverage procedures described in this Contract.
Formulary exception denials may be appealed to an External Appeal Agent.
See Prescription Drug Coverage section for the formulary exception process and timelines.
Billing Rule
Development of Payment Standards and Administrative Rules
We may develop or adopt clinical coverage standards and administrative rules that describe in more detail when payments will or will not be made under this Contract (for example, Medical Necessity standards for inpatient care or surgery). These standards and rules will not contradict the Contract; members and Providers may request explanation or a copy of applicable standards. The insurer has the authority to establish administrative rules required to administer this Contract.
Insurer may issue standards to determine Medical Necessity and administrative rules for enrollment and administration.
Standards will not be contrary to contract language; members/providers may request copies or explanations.
Documentation Required
Furnishing Information for Utilization Review and Certification
Providers must promptly furnish the insurer with all information and records the insurer requires to perform its obligations under the Contract. Providers must provide necessary information by telephone when requested so the insurer can determine level of care, certify authorized care, or make Medical Necessity determinations. Failure to provide requested information may affect Preauthorization, concurrent review, step therapy override, and other utilization review processes.
Prompt furnishing of records and information required; telephone information acceptable for utilization decisions.
Timely submission of documentation affects Preauthorization, concurrent reviews, step therapy override determinations and applicable timelines.
Effect on member cost-sharing
Allowed Amount is the basis for Copayments and Coinsurance; payment practices (e.g., financial incentives to providers) do not change Your Cost-Sharing.
Non-participating providersSee Emergency Services and Ambulance sections for Allowed Amount rules applicable to Non-Participating Providers for emergency/pre-hospital services.
inv-97: Emergency Condition — definition.
DefinitionEmergency Condition = an acute medical or behavioral condition manifesting by Acute symptoms of sufficient severity that a prudent layperson could reasonably expect lack of immediate medical attention to result in serious jeopardy, impairment, dysfunction, or disfigurement.
ExamplesExamples include severe chest pain, severe injuries, severe shortness of breath, sudden change in mental status, severe bleeding, suspected heart attack or appendicitis, convulsions, poisoning.
Relation to coverageEmergency Services to treat an Emergency Condition are covered regardless of provider network status and worldwide subject to medical necessity for stabilization/treatment.
inv-98: Preauthorization — definition as prior approval determination.
DefinitionPreauthorization = a decision by Us prior to Your receipt of a Covered Service, procedure, treatment plan, device, or Prescription Drug that the item is Medically Necessary; Covered Services requiring Preauthorization are indicated in the Schedule of Benefits.
Provider responsibilityParticipating Providers are responsible for requesting Preauthorization; timing and methods described in the Preauthorization procedure section.
ExceptionsCertain services (e.g., emergency department care, some SUD services, mobile crisis) may not require Preauthorization; see applicable sections for specifics.
inv-99: Service Area — geographic service area and listed counties.
DefinitionService Area = the geographical area designated by Us and approved by New York State in which We provide coverage; consists of Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans and Wyoming counties.
Residency requirementSubscriber must live or reside in the Service Area to be covered under this Contract.
Out-of-area careLimited Out-of-Area Covered Healthcare Services (urgent/emergent) may be covered through Inter-Plan Arrangements; other out-of-area services require PCP authorization.
inv-100: Medically Necessary — definition reference.
DefinitionMedically Necessary = services that are clinically appropriate in type, frequency, extent, site and duration; required for direct care/management; would adversely affect condition if not provided; consistent with generally-accepted standards; not primarily for convenience; not more costly than equivalent alternatives; provided in appropriate setting.
Decision basisWe may base determinations on medical records, policies, professional society opinions, peer-reviewed literature, and clinician opinions; provider ordering alone does not make a service Medically Necessary.
External Appeal effectIf an External Appeal Agent overturns a denial for lack of medical necessity, We will Cover the service to the extent otherwise Covered under the Contract.
inv-101: Telehealth — definition.
DefinitionTelehealth = the use of electronic information and communication technologies by a Participating Provider to deliver Covered Services to You when Your location differs from the Provider's location; telehealth services will not be denied solely because they are delivered via telehealth.
Coverage parityCoverage for services delivered via telehealth may be subject to comparable cost-sharing and utilization review requirements at least as favorable as in-person services.
Provider participationNot all Participating Providers participate in telehealth; technical requirements and provider availability apply.
inv-102: Allowed Amount (alternate reference) — payer definition for allowed amount and cost-sharing basis.
Payer definitionAllowed Amount = the maximum amount the payer will pay for covered services before applicable Copayment or Coinsurance; determined as the negotiated rate with a Participating Provider or the provider's charge if less.
Cost-sharing basisMember Copayments and Coinsurance are calculated based on the Allowed Amount for the service.
Emergency and ambulance exceptionsSee Emergency Services and Ambulance sections for Allowed Amount rules applicable to Non-Participating Providers.
inv-103: Out-of-Area Covered Healthcare Services — definition and included services.
DefinitionOut-of-Area Covered Healthcare Services = urgent and emergent care obtained outside the geographic area We serve; other out-of-area services are not covered through Inter-Plan Arrangements unless authorized by the member's PCP.
ProcessingClaims for out-of-area services may be processed through Inter-Plan Arrangements such as BlueCard; Host Blue handles local provider contracts and interactions.
Coverage scopeGenerally limited to urgent and emergent services when receiving care outside the Service Area; non-urgent services require PCP authorization to be covered via Inter-Plan Arrangements.
inv-104: Inter-Plan Arrangements / BlueCard / BCBS Global Core — definitions for out-of-area claim handling.
BlueCard / Global CoreInter-Plan Arrangements (e.g., BlueCard Program, BCBS Global Core) govern claim handling when members access care outside Our Service Area; Host Blue generally contracts with local providers under BlueCard; Global Core may require members to pay and seek reimbursement.
Payment practicesFinancial and payment practices vary by arrangement; Host Blue negotiated rates or billed charges/estimates may be used to determine payment when local contracts exist or not.
Member responsibilityMembers should follow guidance for out-of-area care; reimbursements and precertification rules may differ outside the BlueCard service area.
Implication for coverageEmergency Services to treat an Emergency Condition are covered regardless of provider network status and worldwide when Medically Necessary to stabilize or treat the condition.
inv-106: Pre-Hospital Emergency Medical Services — definition.
DefinitionPre-Hospital Emergency Medical Services = prompt evaluation and treatment of an Emergency Condition and/or non-airborne transportation to a Hospital provided by an ambulance service (certified under NY Public Health Law); covered worldwide when criteria met.
Payment to non-participating providersIn absence of negotiated rates, payment for Pre-Hospital Emergency Medical Services is the lesser of FAIR Health 80th percentile or billed charges; ambulance service must hold member harmless except for applicable Copayment/Coinsurance.
inv-107: Urgent Care — definition.
DefinitionUrgent Care = medical care for an illness, injury or condition serious enough that a reasonable person would seek care right away but not so severe as to require Emergency Department Care.
CoverageUrgent Care is covered in- and out-of-network and in/out of Service Area; in-network from participating physicians/urgent care centers; out-of-network covered outside Service Area.
If escalatesIf Urgent Care results in an emergency admission, emergency admission procedures apply.
inv-108: Iatrogenic infertility — definition.
DefinitionIatrogenic infertility = impairment of fertility caused by surgery, radiation, chemotherapy or other medical treatment affecting reproductive organs or processes.
Related coverageFertility preservation services are covered when medical treatment will directly or indirectly lead to iatrogenic infertility (collection/preservation of ova, sperm, embryos).
ScopeDefinition used to determine eligibility for fertility preservation benefits.
inv-109: Durable Medical Equipment — definition.
DefinitionDurable Medical Equipment (DME) = equipment designed for repeated use, primarily for a medical purpose, generally not useful without disease or injury, and appropriate for home use.
Coverage limitsCoverage limited to standard equipment only; insurer determines rental vs purchase; repair/replacement for normal wear and tear covered; over-the-counter DME excluded.
ExclusionsEquipment for comfort/convenience (pools, hot tubs, air conditioners, exercise equipment) not covered.
inv-110: Diabetes self-management education — definition and delivery.
DefinitionDiabetes self-management education = education provided at diagnosis, when significant change requires it, or for refreshers; delivered by authorized providers or referred certified educators and may include home-based education if medically necessary.
PurposeIntended to help members manage diabetes through training on equipment, supplies and care per clinical guidelines.
Relation to suppliesEducation is provided alongside coverage for diabetic equipment and supplies when prescribed by authorized prescriber.
inv-111: Durable Medical Equipment (repeat) — DME definition.
DefinitionDurable Medical Equipment = equipment designed for repeated use, primarily for a medical purpose, generally not useful without disease or injury, and appropriate for home use (see DME section).
Coverage noteStandard equipment covered; insurer determines rent vs purchase; repair/replacement for wear and tear covered; over-the-counter DME excluded.
ExamplesIncludes items such as bedside commodes, walkers, standard wheelchairs when meeting DME definition and medical necessity.
inv-112: External Hearing Aid — hearing aid definition.
DefinitionExternal Hearing Aid = an electronic amplifying device consisting of a microphone, amplifier and receiver used to correct hearing impairment.
Coverage frequencyOne purchase per ear every three (3) years including fitting and testing when based on a written Physician recommendation.
ScopeCoverage includes associated fitting and testing charges; repair/replacement covered per policy provisions for normal wear and tear.
inv-113: mental health condition — definition referencing DSM.
DefinitionMental health condition = any mental health disorder as defined in the most recent DSM or another generally recognized independent standard of current medical practice such as ICD.
Parity noteMental health/substance use Preauthorization and benefit requirements are no more restrictive than for medical/surgical benefits per federal parity rules.
ScopeUsed to determine coverage for inpatient and outpatient mental health services under the Contract.
inv-114: mobile crisis services — definition for mobile crisis teams.
DefinitionMobile crisis services = community-based interventions provided by licensed/certified mobile crisis teams (behavioral health professionals, certified peers, family/youth peer advocates) offering immediate support and alternatives to hospitalization for mental health/substance use crises.
Coverage and authorizationMobile crisis services are covered, reimbursed at parity for out-of-network providers, and shall not be subject to prior authorization requirements.
Notification and reimbursementOASAS-licensed/certified teams may provide services with protections and reimbursement parity as described in Mental Health & SUD section.
inv-115: assistive communication devices — definition.
DefinitionAssistive communication devices = dedicated devices (e.g., communication boards, speech-generating devices) determined by formal speech-language pathology evaluation and not general-purpose computers; software/apps to enable computers as speech-generating devices may be covered.
Evaluation requirementCoverage requires a formal evaluation by a speech-language pathologist and physician or psychologist order when appropriate.
Repair/replacementRepair, replacement, fitting and adjustments covered when necessary due to normal wear and tear or significant change in condition; exclusions for misuse/theft except limited behavioral-related replacements.
inv-116: Specialty Pharmacy — definition.
DefinitionSpecialty Pharmacy = a pharmacy that has an agreement with Us (or our designee) to provide specific Prescription Drugs, including Specialty Prescription Drugs; Participating status does not automatically mean Specialty designation.
RoleMay be designated as Designated Pharmacy for certain drugs; members may be directed to obtain certain drugs from Designated or Specialty pharmacies per drug management rules.
ImplicationCoverage and supply rules (e.g., 90-day supplies) may depend on whether a drug is dispensed via Designated or Specialty Pharmacy.
inv-117: Formulary and drug-type definitions — definitions used for determining coverage and tiering.
Key termsFormulary, Brand-Name Drug, Generic Drug, Maintenance Drug and Prescription Drug Cost are defined for determining coverage, tiering, and cost calculations; formulary may change up to four times per year.
Maintenance DrugA drug used to treat a chronic/long-term condition typically requiring daily use; maintenance drugs may have 90-day supplies at Designated retail Pharmacy.
Prescription Drug CostAmount contracted between Us and our pharmacy benefit manager including dispensing fee and any sales tax used to calculate member cost at Participating Pharmacies.
inv-118: Custodial care — definition and exclusion note.
DefinitionCustodial care = help in transferring, eating, dressing, bathing, toileting and related activities; custodial care is not Covered (except when specific services are Medically Necessary).
ExclusionServices defined as custodial care are excluded from coverage under the Contract unless otherwise determined Medically Necessary.
ContextMentioned in exclusions and Skilled Nursing Facility section as non-covered care.
inv-119: Conversion therapy — definition and exclusions for minors.
DefinitionConversion therapy = any practice by a mental health professional that seeks to change the sexual orientation or gender identity of a Member under 18 years of age; excluded from coverage.
ExceptionDoes not include counseling/therapy that provides acceptance, support or facilitates coping/transition and does not seek to change sexual orientation or gender identity.
Coverage statusConversion therapy for minors is expressly not Covered under this Contract.
inv-120: Claim — definition.
DefinitionClaim = a request that benefits or services be provided or paid according to the terms of this Contract; either You or the Provider must file the claim form.
Filing responsibilityIf the Provider will not file the claim form, the Subscriber must file it; claim forms available by phone or website.
Required contentsClaims must include member ID, name, DOB, date/type of service, charge, procedure and diagnosis codes, provider info, and supporting medical records when necessary.
DefinitionMedically Necessary (payer) = services determined by Us to be necessary based on clinical appropriateness, medical guidelines and other evidence; denials overturned by an External Appeal Agent will be Covered if otherwise Covered under the Contract.
Decision makersInitial determinations by licensed Physicians or appropriately credentialed professionals in same specialty; appeal determinations by board-certified or eligible Physicians or equivalent specialists.
StandardsDeterminations use our medical policies, peer-reviewed literature, professional standards and clinical guidelines.
inv-122: Pre-service claim — definition.
DefinitionPre-service claim = a request that a service or treatment be approved before it has been received.
TimelinesPre-service determinations have specific timelines described in the Claim Determinations and Utilization Review sections.
RelationPreauthorization decisions are a form of pre-service claim determination.
inv-123: Post-service claim — definition.
DefinitionPost-service claim = a request for a service or treatment that has already been received; decision and notice within 30 calendar days if all info received; additional info request and response timelines apply.
TimelinesIf additional info requested, member has 45 days to provide; decision within 15 days of receipt or end of 45-day period if denial in whole or part.
Appeal optionsAdverse post-service determinations may be appealed through Grievance/Appeal and External Appeal processes per Contract.
inv-124: Utilization Review — definition.
DefinitionUtilization Review = the review process to determine whether services are or were Medically Necessary or experimental/investigational; includes preauthorization, concurrent and retrospective reviews.
ReviewersInitial determinations made by licensed Physicians or credentialed Health Care Professionals in same specialty; appeal determinations by board-certified/eligible Physicians or equivalent specialists.
ScopeIncludes medical necessity reviews and may involve clinical guidelines, peer-reviewed literature and professional standards.
inv-125: OASAS-certified Facility — definition.
DefinitionOASAS-certified Facility = a facility licensed, certified or otherwise authorized by the Office of Addiction Services and Supports to provide substance use disorder treatment services.
RelevanceOASAS-certified facilities have specific preauthorization and concurrent review protections (e.g., first 28 inpatient days not subject to concurrent review if timely notified).
CoverageInpatient and outpatient SUD services at OASAS-certified facilities are covered per treatment and notification rules described in the Contract.
inv-126: Retrospective review — definition.
DefinitionRetrospective review = Utilization Review that takes place after the service has been performed to determine if the previously authorized or provided service was Medically Necessary or should be reversed under specified conditions.
Reversal groundsA preauthorized treatment may be reversed on retrospective review only when materially different or withheld information existed such that authorization would not have been granted.
TimelinesRetrospective determinations follow specified notice timelines when all info received (e.g., decision within 30 calendar days).
inv-127: Attending Physician — requirement that attending physician be licensed/board certified/eligible in appropriate specialty.
RequirementAttending Physician must be a licensed, board certified or board eligible Physician qualified in the appropriate specialty to treat the member when certifying needs for external appeals or specific requests (e.g., out-of-network authorization appeals).
Role in appealsAttending Physician must certify when appealing denials to External Appeal Agent that a recommended Participating Provider lacks appropriate training/experience, and must recommend a Non-Participating Provider.
ApplicabilityUsed in contexts like appeals of out-of-network authorization denials and other External Appeal requirements.
inv-128: External Appeal Agent decision — binding nature of the decision.
EffectAn External Appeal Agent's decision is binding on both the member and the insurer and is admissible in court.
Coverage outcomeIf External Appeal Agent overturns a denial for non-medically necessary, experimental/investigational, or out-of-network treatment, insurer will provide coverage subject to Contract terms; clinical trial approvals limited to trial-required services.
TimelinesExpedited external appeals have specific shorter decision timeframes (e.g., 72 hours standard, 24 hours for expedited formulary exceptions).
inv-129: Identification Cards — ID cards issuance and limitations.
ID card purposeIdentification ('ID') cards are issued for identification purposes only and possession of an ID card does not confer rights to services or benefits under this Contract.
Information sourceID card includes the number to call for Preauthorization and other member services; members should present ID at pharmacies and providers per Contract rules.
LimitationsPossession of an ID card alone does not guarantee coverage; coverage is determined by Contract terms and eligibility.
inv-130: Independent Contractors — Participating Providers are independent contractors, not agents or employees of the insurer.
StatusParticipating Providers are independent contractors and are not agents or employees of the insurer.
LiabilityWe are not liable for claims arising from care received from Participating Providers; Participating Providers are not Our agents or employees.
Contractual relationProvider participation is governed by separate contractual agreements; list of Participating Providers available on Our website or upon request.
inv-131: Force majeure / Significant Change in Circumstances — definition and examples.
DefinitionForce majeure / Significant Change in Circumstances = events outside insurer control (e.g., major disaster, epidemic, destruction of facilities, riot, civil insurrection, disability of a significant part of Participating Providers' personnel) where insurer will make good faith alternative arrangements and neither insurer nor providers are liable for delays caused by such events.
Insurer actionWe will make reasonable attempts to arrange for Covered Services and alternative arrangements when such events prevent normal operations.
Provider and insurer liabilityNeither We nor Participating Providers will be liable for delay or failure to provide/arrange Covered Services caused by such events.