Empire BlueCross BlueShield Professional Reimbursement Policy

Empire BlueCross BlueShieldProfessional Reimbursement PolicySubject: Claim Editing OverviewNY Policy: 0027 Effective: 12/01/2013 – 07/31/2014Coverage is subject to the terms, conditions, and limitations of an individual member’s programs orproducts and policy criteria listed below.DESCRIPTIONThe Health Plan uses member benefits, Health Plan reimbursement policies, and a claim editingsoftware package from McKesson Corporation, called ClaimsXten ® ′, in its adjudication of claims.• ClaimsXten applies claim management rules in support of specific claim edits.• These claim management rules are applied to Current Procedural Terminology (CPT ® ) ″,Healthcare Common Procedure Coding System Level II (HCPCS), and InternationalClassification of Diseases, 9 th Revision, Clinical Modifications (ICD-9-CM) codes reported on aForm CMS-1500. The claim management rules assess the relationship of such codes to therules.• The edit(s) that is/are associated with a claim management rule causes an audit action on aclaim that directs how procedure codes and procedure code combinations will be adjudicated.• The edits associated with the ClaimsXten claim management rules identify, for example andwithout limitation: age and gender specific procedures; duplicate codes; incidental procedures;unbundled/rebundled procedures; mutually exclusive and/or redundant procedures; place, timeand type of service; incorrect coding of specific codes; service utilization, such as theadministration of anesthesia and/or use of an assistant surgeon; and services integrally relatedto a surgery (global surgery). A list of ClaimsXten management rules that have been adopted bythe Health Plan and their associated edits can be found in the policy section below.ClaimsXten also provides the editing tools to incorporate the administration of many of the HealthPlan’s reimbursement policies.• The editing logic for the rules considers AMA/CPT and national specialty society publications,The Centers for Medicare & Medicaid Services (CMS) coding guidelines, input from McKessonphysician consultants, and the Health Plan’s guidelines.• The Health Plan reserves the right to make customizations to the ClaimsXten software package.These customizations are made periodically (generally, on a quarterly basis) and may be basedon claims analysis, including the identification of improper coding (e.g., inappropriate use ofmodifier 59).POLICYNY 0027 Page 1 of [10]Empire HealthChoice HMO, Inc.,and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association,an association ofBlue Cross and Blue Shield Plans. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue ShieldAssociation.

Empire BlueCross BlueShieldProfessional Reimbursement PolicyI. Documentation and ReportingAll claims submitted by a provider must be in accordance with the reporting guidelines and instructionscontained in the American Medical Association (AMA) CPT Manual, “cpt Assistant,” HCPCS, andICD-9-CM publications.” Providers are responsible for accurately reporting the medical, surgical,diagnostic, and therapeutic services rendered to a member with the correct CPT and/or HCPCS codes, andfor appending the applicable modifiers, when appropriate. The code(s) and modifier(s) must be active forthe date of service reported, and describe the services provided during the patient encounter.• The member’s medical records must legibly and accurately describe the services that warrantedthe use of a specific CPT /HCPCS code.• The Health Plan reserves the right to perform audits or investigations to confirm appropriatereporting of services provided to our members and initiate recovery for inappropriatereimbursement.• Based on audit findings and/or published reporting guidelines (for example, CPT guidelines),we may update our reimbursement policies and claims editing system.• If a ClaimsXten denial related to one of the rules listed below is received on a remit, pleasereview the billing for the submitted claim prior to initiating an appeal. If an error in coding isdetected, please correct the information and resubmit as needed.II. ClaimsXten ChangesThe Health Plan implements ClaimsXten changes (e.g., customization, updates, upgrades, andreimbursement policy changes) on a periodic basis.• These changes will reflect the addition of new/revised CPT/HCPCS codes and the HealthPlan’s associated edits, Correct Coding Initiative (CCI) updates and/or revisions, and changesidentified through the Health Plan’s regular review or due to inquiry. Additionally, thesechanges will include edits associated with the Health Plan’s reimbursement policies.• The Health Plan reserves the right to change our reimbursement policies and claim editingsystem without prior notice.III. ClaimsXten RulesMany ClaimsXten rules incorporate “same provider” editing which results in the denial ofseparate reimbursement for services rendered on the same day (or across dates of service for Pre-Op/Post Op days and Frequency Validation) by the same provider. This editing identifies “sameprovider” as any provider with the same tax identification number (TIN) or individual provideridentification number. Some rules that incorporate the “same provider” identification are:• Always Bundled Services and Supplies and Supplies for Same Day Surgery• Pre-Op/Post-Op Days• Base Code Validation and Base Code Quantity• Technical/Professional Component Billing• Frequency ValidationNY 0027 Page 2 of [10]Empire HealthChoice HMO, Inc.,and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association,an association ofBlue Cross and Blue Shield Plans. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue ShieldAssociation.

Empire BlueCross BlueShieldProfessional Reimbursement Policy• Bilateral and Endoscopic Surgical Billing• AnesthesiaThe following is a list of many of the ClaimsXten rules adopted by the Health Plan. This list is subjectto change from time to time. Also, where applicable, reference to a Health Plan reimbursement policyis indicated. This is not an exhaustive list of claim edits; refer to individual Health Planreimbursement policies:Age and Gender-Specific: identifies when an age-specific procedure code is reported for a patientwhose age is outside the designated age range, or when a gender specific procedure and/or diagnosiscode is assigned to a patient of the opposite sex. In these instances, when an inconsistency isidentified, the code(s) will not be eligible for reimbursement.Age to Diagnosis: identifies when an age-specific diagnosis code is reported for a patient whose ageis outside the designated age range for that diagnosis. Codes with an age edit are identified in ICD-9-CM by one of the following symbols to the right of the code description: N = Newborn age: 0 years, P= Pediatric age: 0-17years, M = Maternity age: 12-55 years, and A = Adult Age: 15-124 years.Anesthesia: identifies anesthesia services reported in the code range of 00100 - 01999 that are performedon the same date of service by the same provider. Editing for this rule is based on American Society ofAnesthesiologists (ASA) billing guidelines which states: “When multiple surgical procedures areperformed during a single anesthetic administration, only the anesthesia code with the highest base unitvalue is reported.” 1 If two anesthesia services are reported, the less complex procedure (s) will not beeligible for reimbursement. See our Anesthesia reimbursement policyAssistant Surgeon: identifies procedure codes with an assistant surgeon modifier appended that do nottypically require an assistant. If the procedure code is listed in our Assistant Surgery Policy as a codewhich does not allow surgical assistant benefits, the line item will not be eligible for reimbursement. Seeour Assistant Surgery reimbursement policyBase Code Quantity: identifies a claim reporting a primary service with a base-code that has a quantitygreater than one, rather than reporting the appropriate add-on code. The line item with the base codequantity greater than one will be denied and replaced with a line item that allows payment for only oneprocedure. This edit also identifies multiple occurrences of a base code reported on separate lines. Theadditional base code line item(s) will not be eligible for reimbursement. See CPT Appendix D for the listof add-on codes. See our Frequency Editing reimbursement policyBilateral Surgical Billing: identifies when two claim lines are submitted with the same procedure code,and one line (or both lines) has been reported with modifier 50. When a bilateral surgical service issubmitted on two lines, the two claim lines will be denied and replaced with a single line item withNY 0027 Page 3 of [10]Empire HealthChoice HMO, Inc.,and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association,an association ofBlue Cross and Blue Shield Plans. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue ShieldAssociation.

Empire BlueCross BlueShieldProfessional Reimbursement Policymodifier 50, adding the charges. Reimbursement will be made for the added line. This rule is based onCMS and Health Plan guidelines. See our Multiple and Bilateral Surgery Processing reimbursementpolicyBundled Services and Bundled Supplies: identifies certain services and supplies that are consideredpart of overall care and are not separately reimbursed. Editing for this rule is based on CMS,McKesson, and Health Plan sourcing. For example:• Always Bundled Services and Supplies: identifies all-inclusive procedure and supply codesthat are not reimbursed even when reported alone. See our Bundled Services and Suppliesreimbursement policy.• Bundled Services and Supplies: identifies services and/or supplies that are not eligible forreimbursement when billed with another specific service or supply.• Same Day Screening Services with Preventive or Problem Oriented E/M Services:identifies screening services, (e. g., G0101, G0102) that are considered a component of apreventive exam and/or a problem oriented E/M service when rendered on the same date ofservice. Therefore, screening services are not eligible for reimbursement even if billed withmodifier 25. Screening services should be taken into account when determining the correctlevel of the problem oriented E/M service. See our Screening Services with Evaluation andManagement Services Policy• Services and Supplies with Injection and Infusion Services: identifies services and suppliesnot eligible for separate reimbursement with injection and infusion services See our Injectionand Infusion Administration and Bundled Services and Supplies reimbursement policy.• Supplies for Same Day Surgery: identifies inclusive supply codes that are reported by thesame provider reporting a surgical procedure for the same date of service. Surgical supplies andmaterials are not eligible for separate reimbursement when reported by the provider renderingthe primary service. See our Global Surgery reimbursement policy.Code and Modifier Validation: identifies if a code or modifier is valid. If an invalid procedure,diagnosis code, or modifier-procedure combination is detected, the line item will not be eligible forreimbursement.• Procedure validation: editing for procedure code validation uses AMA as the reference source.• Diagnosis code validation: ICD-9-CM validation is based on the World Health Organization(WHO) and CMS when determining additional digit requirements (4 th and 5 th digit).• Modifier to procedure code validation: editing for validation is based on CPT, CMS andMcKesson sourcing. See our Modifier Rules reimbursement policy.Correct Coding Initiative Rules: this rule identifies the CMS National Correct Coding Initiative (NCCI)edits. NCCI edits may be reviewed by visiting:http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html.NY 0027 Page 4 of [10]Empire HealthChoice HMO, Inc.,and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association,an association ofBlue Cross and Blue Shield Plans. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue ShieldAssociation.

Empire BlueCross BlueShieldProfessional Reimbursement PolicyNCCI edits consist of those edits listed in the CMS Column One/Column Two Correct Coding edit file(formerly, the comprehensive/component edits). Column One in this edit file represents allowed codes;Column Two represents denied codes. CMS no longer publishes a separate Mutually Exclusive edit file.The edits previously contained in the Mutually Exclusive edit file have not been deleted but have beenmoved to the Column One/Column Two Correct Coding edit file.Non-site specific modifiers include 24, 25, 57, 58, 59, 78, 79, and 91:• may override an NCCI edit with a superscript of 1 when appended to a code listed in column 2,making the column 2 code eligible for separate reimbursement• will not override an NCCI edit with superscript of 0 when appended to a code listed in column 2and therefore the column 2 code is not eligible for separate reimbursementNCCI edits will be applied to code pairs which, under our other reimbursement rules (such as procedureunbundling), might be eligible for separate reimbursement but under NCCI edits are considered incorrectcoding, therefore, such code pairs are not eligible for separate reimbursement. NCCI edits will beadjudicated after the ClaimsXten unbundling edits have been completed.Durable Medical Equipment (DME) See our Durable Medical Equipment reimbursement policy:• Identifies rental vs. purchase• Tracks number of months an item has been rented (max 10 month rental)• Looks at modifiers to determine if purchase or rental (modifiers are required to determine if itemhas been rented or purchased)• Identifies items that are or are not eligible for repair or maintenanceFrequency/Maximum Occurrences: identifies when a procedure code is reported either more than onceper date of service, or across dates of service which exceeds the number of times its verbiage indicates, orwhen it exceeds the number of times it is clinically appropriate or possible to perform. See ourFrequency Editing reimbursement policy• When inappropriate units or line items are identified, ClaimsXten will default multiple units toone unit; or deny the multiple line items, and replace the line with the appropriate number of unitsor a more comprehensive code.• In the case of procedures that are allowed with more than one unit per date of service (DOS), theline item that exceeds the maximum allowed per DOS will be denied and replaced with a newcorrected line item showing the appropriate number of units.Laboratory Multi-code Rebundling: identifies when codes that are part of a comprehensive multiplecomponent blood test, described in the Laboratory section of CPT, are reported separately. Either theindividual codes will be denied and the code representing the comprehensive code will be added to theclaim for reimbursement; or the total amount eligible for reimbursement for the separately reported codesNY 0027 Page 5 of [10]Empire HealthChoice HMO, Inc.,and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association,an association ofBlue Cross and Blue Shield Plans. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue ShieldAssociation.

Empire BlueCross BlueShieldProfessional Reimbursement Policywill not exceed the maximum allowance for the single comprehensive code. See our Laboratory andVenipuncture Services reimbursement policyMultiple Diagnostic Imaging: identifies that when two or more imaging codes with a multipleprocedure indicator (MPI) of 4 are performed during the same imaging session reimbursement is 100%of the maximum allowance for the imaging procedure with the highest Relative Value Unit (RVU)based on the CMS National Physician Fee Schedule Relative Value File (NPFSRVF), and 50% of themaximum allowance for the technical component only for each subsequent procedure that has an MPIof 4. See our Multiple Diagnostic Imaging reimbursement policy.Multiple Endoscopies: identifies multiple endoscopic surgical procedures within the same family that aresubject to multiple surgery reimbursement rules. Endoscopic surgical procedures in the same base familywill be reimbursed at 100% of the allowed amount for the primary procedure and at a lower percentagefor each subsequent procedure based on the Health Plan’s Multiple Surgery Policy. This will only happenwhen both endoscopic procedures are performed at the same operative session, with the same endoscopicbase code as defined by CMS. See our Multiple and Bilateral Surgery Processing reimbursementpolicyMultiple Evaluation and Management Services: identifies claim lines containing multiple E/Mservices (same or different E/M visit codes) provided on the same day, for the same patient, by the sameprovider. Only one E/M service is allowed per day. See our Evaluation and Management Servicesand Related Modifiers -25 and -57 reimbursement policy.Multiple Surgeries: identifies multiple surgical procedures that are subject to multiple surgeryreimbursement rules. Standard multiple surgery reimbursement is 100% of the maximum allowancefor the procedure with the highest (RVU) based on the CMS NPFSRVF for the date of service and50% of the second highest RVU for the date of service for the second and each subsequent procedure.See our Multiple and Bilateral Surgery Processing reimbursement policyNew Patient Evaluation and Management: identifies new patient E/M procedure codes that aresubmitted for established patients. According to the AMA, “A new patient is one who has not receivedany professional services from the physician/qualified health care professional or anotherphysician/qualified health care professional of the exact same specialty and subspecialty who belongs tothe same group practice, within the last three years.” 3 If our editing system detects a new or establishedE/M reported within the last three years by the same provider, the new patient E/M code will not beeligible for reimbursement.Obstetric Services: identifies when a physician or other provider with the same tax ID has reported aroutine maternity E/M or antepartum care service within 270 days of a global maternity delivery code. Ifdetected, the additional E/M and antepartum care services may be ineligible for reimbursement based onNY 0027 Page 6 of [10]Empire HealthChoice HMO, Inc.,and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association,an association ofBlue Cross and Blue Shield Plans. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue ShieldAssociation.

Empire BlueCross BlueShieldProfessional Reimbursement PolicyCPT coding guidelines on what is included in the total obstetric package. See our Routine ObstetricServices reimbursement policyPlace of Service: identifies the reporting of an inappropriate place of service for a particular procedure,either due to the code description or due to published CPT coding guidelines that indicate that a specificprocedure is not intended to be reported in a certain setting. See our Place of Service reimbursementpolicyFor example:• If an after hours office visit (99050) was reported in a facility setting the service would not beeligible for reimbursement.• If intravenous infusion hydration (96360) were reported in a facility setting, the service would bedenied.Pre-Op/Post Op Rule: identifies E/M visits that are reported one day prior to a 90-day surgicalprocedure or during the 10 or 90-day aftercare period. If the E/M code is within the global surgery period,then no additional reimbursement will be made. The evaluation and management service will be deniedas part of the global surgical reimbursement. See our Global Surgery reimbursement policy Note: Forglobal obstetrical E/M services see our Routine Obstetric Services reimbursement policyProcedure to Diagnosis Rule: identifies certain procedures that are not eligible for reimbursementwith the reported diagnosis code in accordance with the Health Plan’s reimbursement policy and/orcorrect coding guideline. For example:• 99050 reported with a preventive diagnosis See our After Hours reimbursement policy• 99140 reported with a routine pregnancy and/or delivery diagnosis See our Anesthesiareimbursement policy• 96150 – 96154 reported with a diagnosis classified as a mental disorder See our Health andBehavior Assessment/Intervention reimbursement policy• 64450, 64640, and 20550 with a diagnosis of lesion of plantar nerve (Morton’s Neuroma)In addition, please see our Prolonged Services reimbursement policy for a list of diagnosis codes thatare eligible for reimbursement when reported with CPT codes 99354 and 99355.Procedure Unbundling: occurs when two or more procedure codes are used to describe a service when asingle, more comprehensive procedure code exists that more accurately describes the complete serviceperformed. In some instances, the codes may be replaced with the more appropriate code by our editingsystem. Additional details regarding unbundling rules are described by the following edits.• Incidental/Integral: “An incidental procedure is one that is performed at the same time as amore complex primary procedure and is clinically integral to the successful outcome of theprimary procedure.” A procedure determined to be incidental/integral to another procedure willnot be eligible for reimbursement.NY 0027 Page 7 of [10]Empire HealthChoice HMO, Inc.,and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association,an association ofBlue Cross and Blue Shield Plans. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue ShieldAssociation.

Empire BlueCross BlueShieldProfessional Reimbursement Policy• Mutually Exclusive/Redundant: “Mutually exclusive edits consist of combinations ofprocedures that differ in technique or approach but lead to the same outcome. In someinstances, the combination of procedures may be anatomically impossible. Procedures thatrepresent overlapping services or accomplish the same result are considered mutually exclusive.In addition, reporting an initial service and subsequent service is considered mutuallyexclusive.” A procedure determined to be mutually exclusive to another procedure will be deniedreimbursement.• Procedure Rebundling: identifies unbundled procedure codes used to describe a procedure (e.g.a blood panel) when a single more comprehensive code exists. The correct procedure code thatmost accurately represents the service will be added to the claim. The identified unbundledprocedures will be denied, and the appropriate added code will be eligible for reimbursement. Forblood panel rebundling, see our Laboratory and Venipuncture Services reimbursementpolicySame Day Medical Visit: identifies when an E/M visit is billed on the same day as a surgical procedureor substantial diagnostic or therapeutic (such as dialysis, chemotherapy and osteopathic manipulativetreatment) procedure. Our reimbursement policies indicate that an E/M code reported by the sameprovider on the same day as a procedure is rendered by that provider is included within the globalreimbursement for the procedure. See our Global Surgery reimbursement policyTechnical/Professional Component Billing: identifies proper coding of professional, technical, andglobal procedures. Modifier 26 signifies the professional component and Modifier TC signifies thetechnical component.When the CMS NPFSRVF designates that modifier 26 is applicable to a procedure code (PC/TC indicatorof 1 or 6), and the procedure code (e.g. radiology, laboratory, or diagnostic) has been reported by aprofessional provider with a facility place of service, the procedure code must be reported with modifier26 or it will not be eligible for reimbursement.When the NPFSRVF designates that the concept of a separate professional and technical component doesnot apply to a laboratory procedure (PC/TC indicator of 3 or 9), and a professional provider has reportedthe laboratory procedure code with a modifier 26, the laboratory procedure code will not be eligible forreimbursement. When a laboratory procedure with a PC/TC indicator of 3 or 9 is reported by aprofessional provider with a facility place of service, the laboratory procedure code will be deniedsince the facility will bill for performing the laboratory procedure.A global procedure code includes reimbursement for both the professional and technical componentstherefore:NY 0027 Page 8 of [10]Empire HealthChoice HMO, Inc.,and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association,an association ofBlue Cross and Blue Shield Plans. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue ShieldAssociation.

Empire BlueCross BlueShieldProfessional Reimbursement Policy• If both components are performed by the same provider, the appropriate code must be reportedwithout the 26/TC modifiers.• If a provider has reported a global procedure and also reported the same procedure with aprofessional (26) or technical (TC) component modifier on a different line or claim, the procedurereported with the 26 or TC component modifier will not be eligible for reimbursement.• If a professional provider bills the global code (no modifiers) with a facility place of service, thecode will not be eligible for reimbursement.Clear Claim Connection TM ″′:For informational purposes, a web-based tool called “Clear Claim Connection TM ” developed byMcKesson Health Solutions is available on the Health Plan’s secure Online Provider Services web site.This claims editing tool allows the provider to enter a specific coding scenario and view the editingresults in place on the date of the inquiry (not the actual claim date of service). If a denial is issued forthe coding scenario, the clinical rationale for the denial is usually provided. The results of a codinginquiry may differ from the results of an actual claim payment since a claim may be affected by systemedits outside of ClaimsXten (e.g. member eligibility, or other claim processing and/or pricing logic).IV. Definitions: Customized Claim Edit: A customized claim edit is an edit that is added ormodified for the commercially available claims editing software product in use by the Health Plan.The Health Plan uses ClaimsXten editing software from McKesson as our editing system.Editing: the practice or procedure pursuant to which one or more adjustments are made to CPTcodes or HCPCS codes included in a claim that result in:• payment being made based on some, but not all, of the CPT/HCPCS′ codes included in theclaim• payment being made based on different CPT/HCPCS codes than those included in theclaim• payment for one or more of the CPT/HCPCS codes included in the claim being lowered byapplication of multiple procedure logic• payment for one or more of the CPT/HCPCS codes being denied, or any combination of theabove.History Editing: identifies historical claims that are related to current claim submissions,resulting in adjustments to the previously processed historical claim(s).• History editing capability can auto-adjudicate reimbursement policies including, but notlimited to: global surgery, same day multiple E/M visits, pre/post-operative visits, newpatient visits, frequency rules, incidental, mutually exclusive and rebundle edits andmaternity services.• For example: When reimbursement is made for an E/M visit code submitted on one claim,and then another claim is submitted with a surgical code for the same date of service,NY 0027 Page 9 of [10]Empire HealthChoice HMO, Inc.,and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association,an association ofBlue Cross and Blue Shield Plans. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue ShieldAssociation.

Empire BlueCross BlueShieldProfessional Reimbursement Policyhistory editing may identify the paid E/M visit code as part of the global surgicalallowance. An adjustment of the E/M claim is made for overpayment recovery.Significant Edit: an edit that, based on experience with submitted claims, will cause, on initialreview of submitted claims, the denial or reduction in payment for a particular CPT″/ HCPCS codemore than two-hundred and fifty (250) times per year in any state in which Health Plan operates.POLICY HISTORY04/07/2009 Adopted by Enterprise Professional Reimbursement Committee11/03/2009 Revised11/18/2009 Revised07/06/2010 Revised07/12/2011 Revised04/03/2012 Revised06/05/2012 Revised08/07/2012 Revised02/05/2013; 03/05/2013; Revised0702/20131 CPT © is a registered trademark of the American Medical Association22013 Relative Value Guide, American Society of Anesthesiologists page xi3 Current Procedural Terminology, cpt ® 2013 Professional Edition, pg. xi4ClaimsXten is a registered trademark of McKesson Information Solutions LLC]Clear Claim Connection TM is a registered trademark of McKesson Information Solutions LLCUse of Reimbursement Policy:State and federal law, as well as contract language, including definitions and specific inclusions/exclusions, take precedence over ReimbursementPolicy and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that services arerendered must be used. Reimbursement Policy is constantly evolving and we reserve the right to review and update these policies periodically.© 2013 Empire BlueCross BlueShield No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by anymeans, electronic, mechanical, photocopying, or otherwise, without permission from Empire BlueCross BlueShield.NY 0027 Page 10 of [10]Empire HealthChoice HMO, Inc.,and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association,an association ofBlue Cross and Blue Shield Plans. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue ShieldAssociation.