Blank Empire Referral PDF Template

Frequently Asked Questions about the Empire Referral Form:

1. What is the Empire Referral Form used for?

The Empire Referral Form is a document designed for use within specific health plans managed by Empire BlueCross BlueShield. It is used by a primary care physician (PCP) to refer a patient to a specialist or for specific healthcare services that require approval. Importantly, this form is part of the managed care program, ensuring that patients receive coordinated and approved care within the Empire network for services like HMO, Child Health Plus, Healthy NY, and others.

2. How can I submit the Empire Referral Form?

To submit the Empire Referral Form, you need to fill out all required fields accurately and then fax it to 1-800-522-5793. The form requires information about the patient, referring physician, specialist to whom the patient is being referred, and the authorization information including service start and end date. Make sure to double-check all sections for accuracy before sending.

3. What services require a call to Empire Medical Management instead of using this form?

There are specific services for which referrals cannot be processed using this form and instead require direct approval from Empire Medical Management. These include services from a non-participating provider, inpatient admissions to hospitals or facilities, emergency or maternity admissions, home care, hospice, private duty nursing at home, Empire Baby Care, and surgeries not performed in a doctor’s office. For these, you should contact Empire Medical Management directly at 1-800-441-2411 for approval.

4. How long is the referral valid, and what are the limitations?

Once approved, referrals are valid for 90 days from the service start date unless specified otherwise. This means that the referred services must be accessed within this timeframe. It's also important to note that authorized services are subject to limitations and exclusions as per the contract. Make sure to understand these limitations ahead of time to ensure the referred service is covered and to avoid unexpected expenses.

When filling out the Empire Referral Form, individuals often encounter several common pitfalls that can lead to its rejection or delay in processing. Recognizing and avoiding these mistakes can streamline the referral process, ensuring timely access to necessary healthcare services.

1. Not providing complete patient information: It is crucial to fill out all required fields in the patient information section, including the patient ID number, last name, first name, and date of birth. Missing any required field marked with an asterisk (*) can result in the referral form being rejected.

2. Failure to specify non-participating providers: The form clearly states that referrals are not valid for services from non-participating providers or for certain types of admissions such as emergency or maternity. It's essential to contact Empire Medical Management for approval of these services, and overlooking this step is a common mistake.

3. Omitting referring physician information: Accurate and complete information about the referring physician, including their last name, first name, service address, Empire provider ID or NPI, and phone number, is required. Sometimes, individuals miss one or more of these critical details.

4. Incorrectly filling out the "Referring To" section: Similar to the referring physician information, the specialist's details need to be complete and accurate. This includes the specialist's last name, first name, service address, Empire provider ID or NPI, and phone number. Inaccurate information here can lead to processing delays.

5. Neglecting authorization information: The form requests specifics like the number of visits authorized, service start and end dates, and a detailed referral reason/remarks/limitations. Failure to provide any of these essential details can invalidate the referral.

6. Forgetting the referring physician’s signature and date: A common oversight is the absence of the referring physician's signature and the date. This final step is crucial as it validates the form. Without it, the document is considered incomplete and will not be processed.

To avoid these mistakes, individuals are advised to review the form thoroughly before submission, ensuring that all necessary information is accurately provided and complete. This careful attention to detail can significantly reduce the risk of rejection and facilitate a smoother, quicker referral process.

When navigating healthcare services, especially for those within managed care networks like Empire, a number of documents and forms complement the referral process. Each document serves a specific purpose, aiding in a streamlined, comprehensive approach to healthcare management and access. Understanding these documents will empower individuals and healthcare providers, ensuring that necessary care is not just accessed but also properly documented and authorized according to the healthcare plan's guidelines.

• Prior Authorization Request Form: This form is necessary for certain medications or services. It is used to request approval from the insurance provider before the service is rendered or the medication is prescribed, ensuring that the cost is covered under the patient's health plan.
• Medical Claim Form: After receiving care, this form is used to request reimbursement or direct payment to the healthcare provider. It's crucial for services rendered outside of the preferred network, emergency care, or when a provider doesn't bill insurance directly.
• Pharmacy Benefits Form: Essential for managing and understanding an individual’s prescription coverage. This form details the medications covered under the insurance plan, including any generic or brand-name requirements, and may require completion for specialty medications.
• Specialist Referral Form: Similar to the Empire Referral Form but specific to referrals to specialist providers. This form documents the need for specialized medical services, outlining the referring physician's information and the specialist’s details.
• Appeal Form: When a service or medication request is denied, this form is used to formally dispute the decision. It provides a pathway for patients and providers to present additional information or clarification, seeking reconsideration of the denial.
• Patient Information Update Form: This form is used to update any changes in the patient's personal information, insurance details, or health status. Keeping this information current is vital for accurate billing and ensuring that all correspondence reaches the patient.
• Health Risk Assessment Form: Often used at the beginning of a healthcare plan enrollment or annually, this form collects comprehensive information about the patient's health status, lifestyle, and risk factors. It aids in tailoring healthcare services to the patient's specific needs.

Together, these documents form a comprehensive toolkit, facilitating a smoother healthcare management and delivery process. They ensure that both patients and healthcare providers have the necessary information at hand, streamlining access to care, reimbursement, and the accurate management of healthcare benefits. Knowledge and proper utilization of these forms can significantly enhance the healthcare experience, ensuring that the focus remains on health and well-being.

• Prior Authorization Form: Much like the Empire Referral form, a Prior Authorization Form is used within healthcare to obtain approval from a health insurance company before a specific service is rendered. Both documents are designed to ensure the requested service is covered under the patient's health plan and to help manage costs. The key similarity lies in their function to facilitate communication between healthcare providers and insurance companies to secure approval before proceeding with treatment or services.

• Referral Request Form: This document closely matches the Empire Referral form in the way it facilitates the process of a primary care physician (PCP) sending a patient to a specialist or another provider. Both forms typically include patient information, insurance details, and the reason for referral. They play a pivotal role in managed care systems that require patients to see a PCP before consulting a specialist, ensuring the care is coordinated and authorized by the insurance.

• Insurance Claim Form: An Insurance Claim Form shares similarities in that it is integral to the process of communication and billing between healthcare providers and insurance companies. Like the Empire Referral form, it collects detailed patient information, provider details, and necessary treatment or visit information required by insurance companies to process and approve healthcare expenses. Both forms support the logistical and financial sides of healthcare provision.

• Pre-treatment Estimate Form: Similar to the Empire Referral form, a Pre-treatment Estimate Form is used by healthcare providers to give patients and insurers an estimation of how much a particular treatment or series of treatments is likely to cost. It often requires detailed information about the proposed services, patient details, and the healthcare provider’s information. This similarity lies in their preventative nature, aiming to provide clarity and prevent surprises in billing and insurance coverage.

• Medical Service Request Form: Often used in various healthcare settings, a Medical Service Request Form shares the purpose of the Empire Referral form: to request a particular medical service. These forms may include details about the patient, the requested service, and provider information. Both serve as a formal request within a healthcare context, ensuring that all necessary approvals are obtained, and the requested service aligns with the patient's healthcare plan requirements.

When filling out the Empire Referral Form, it is essential to ensure accuracy and completeness to facilitate timely and appropriate medical care. Below are several recommended do's and don'ts to guide you through the process:

• Do ensure all required fields are filled out. These fields are marked with an asterisk (*) and are necessary for the referral to be processed.
• Do provide accurate patient information, including the Patient ID number, full name, and date of birth, as this helps in identifying the correct individual within the system.
• Do list the referring physician's details, including their Empire provider ID or NPI, to ensure the referral is correctly attributed and processed.
• Do include the specialist's information whom the patient is being referred to, making sure to verify their participation in the Empire network to ensure coverage.
• Don't leave the service start date and end date fields blank. These dates provide critical information regarding the validity period of the referral.
• Don't use the referral form for services that are listed as requiring direct approval from Empire Medical Management, such as non-participating provider services or inpatient admissions.
• Don't forget to obtain the signature of the referring physician and the date at the bottom of the form, as this is a necessary step to authorize the referral.
• Don't submit the form without double-checking all the information for accuracy and completeness to avoid any delays in processing.

Correctly completing and promptly submitting the Empire Referral Form ensures that patients receive the care they need without unnecessary delay, aligning with healthcare guidelines and insurance requirements.

When it comes to navigating healthcare documents, the Empire Referral Form often comes up, especially for those under certain health plans that require referrals. Despite its importance, there are numerous misconceptions surrounding this form. Let’s debunk some of the common misunderstandings:

• Misconception #1: You can use the referral form for any healthcare provider.

  This is incorrect. The form clearly states that referrals are not valid for non-participating providers. It means you must choose a provider within the Empire network for the referral to be valid.

• Misconception #2: The referral form can cover hospital admissions.

  Actually, the form specifies that inpatient admissions to hospitals or facilities require separate approval from Empire Medical Management. This means that for hospital stays, you need to go through a different approval process.

• Misconception #3: Referrals are optional for every plan.

  Not quite. The referral form mentions specific health plans that require a referral to see an Empire participating provider, such as HMO and Child Health Plus. If you’re enrolled in one of these plans, getting a referral is necessary.

• Misconception #4: You don’t need a referral for emergency or maternity admissions.

  This statement is misleading. While the form states referrals are not valid for these services and advises contacting Empire Medical Management directly, it implies that these situations still require some form of prior approval, just not through the referral form.

• Misconception #5: The form is valid indefinitely.

  Referrals have a 90-day validity period from the service start date unless the form specifies otherwise. It’s important to note the time frame to ensure your referral is utilized within this period.

• Misconception #6: All sections of the form are optional.

  The form has clearly marked required fields, indicated with an asterisk. If these fields are left blank, the referral will not be accepted. This highlights the need to complete the form accurately.

• Misconception #7: Home care services are covered with a referral.

  Contrary to this belief, the form lists home care, hospice, and private duty nursing (at home) as services that are not valid for referral. Approval for these services must be sought through Empire Medical Management.

• Misconception #8: Any physician can sign the referral form.

  Referrals need to be signed by the referring physician, with their signature being one of the required fields on the form. It’s essential for the legitimacy and acceptance of the referral.

• Misconception #9: Surgery at a doctor’s office doesn’t need a referral.

  This is not entirely true. While the form indicates that surgeries not performed in a doctor's office require separate approval, this suggests that in-office procedures might still require a referral but under different stipulations or guidelines.

Understanding the intricacies of the Empire Referral Form can save time and prevent potential frustration. Always review the specifics of your health plan and the requirements outlined in the referral form to ensure you're correctly navigating your healthcare services.

Understanding the Empire Referral Form is crucial for accessing specialized healthcare services. Here are key takeaways for its completion and use:

• Referral Criteria: Referrals are mandatory for seeing Empire participating providers under specific health plans such as HMO, Child Health Plus, Healthy NY, Direct Pay HMO, and Direct Pay HMO/POS.
• Exclusions: Referrals are not valid for services like care from non-participating providers, inpatient and emergency/maternity admissions, home care, hospice, private duty nursing, Empire Baby Care, and surgeries not performed in a doctor’s office. These require prior approval from Empire Medical Management.
• Required Information: The form demands detailed patient information, including ID number, name, date of birth, alongside referring physician details such as provider last name, first name, address, and Empire provider ID or NPI.
• Authorization Validity: Once completed, referrals are valid for 90 days from the service start date, subject to any specified limitations or exclusions mentioned in the contract.
• Service Limitations: It’s important to note that authorized services have limitations and may not cover all types of care needs.
• Completion Accuracy: To ensure the referral is accepted, all required fields, indicated with an asterisk (*), must be accurately filled out.
• Contact Information: For services excluded from the referral form, Empire Medical Management’s contact number is provided for necessary approvals.
• Submission Details: The form should be sent to the specified PO Box in New York or faxed to the provided number for processing.
• Digital Resources: Additional information and support can be found on Empire’s website, enhancing convenience for users.

Completing the Empire Referral Form correctly ensures patients can timely receive the care they need, underlining the importance of attention to detail and adherence to the outlined procedures and requirements.