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  • Hipaa Roi Form - Empire Blue Cross Blue Shield

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AUTHORIZATION TO RELEASE INFORMATION AND/OR DESIGNATION OF A REPRESENTATIVE Member Name: Empire Member Identification Number: Date of Birth: I hereby authorize the following person/entity to receive.

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Your Payer Name is Empire BlueCross BlueShield HealthPlus. Your Payer ID is 27514. Note: If you use a billing company or clearinghouse for your EDI transmissions, please work with them on which payer ID they want you to use.

Empire will consider reimbursement for the initial claim, when received and accepted within timely filing requirements, in compliance with federal, and/or state mandates. Empire follows the standard of: • 90 days for participating providers and facilities. 15 months for nonparticipating providers and facilities.

Use the Prior Authorization tool within Availity or. Call Provider Services at 1-800-450-8753 (TTY 711) After hours, verify member eligibility by calling the 24/7 NurseLine at 1-800-300-8181.

Empire Blue Cross Blue Shield: New York Health Insurance, Medicare & More.

You must first ask for a Plan Appeal and receive a Final Adverse Determination. You will have 120 calendar days from the date of the Final Adverse Determination to ask for a Fair Hearing.

Your Payer Name is Empire BlueCross BlueShield HealthPlus. Your Payer ID is 27514. Note: If you use a billing company or clearinghouse for your EDI transmissions, please work with them on which payer ID they want you to use.

Empire Plan Hospital Program: To obtain hospital claims or subrogation information contact: Empire BlueCross New York State Service Center P.O. Box 1407Church Street Station New York, NY 10008-1407.

Provider Services: Call the number on the back of the member's ID card or call 800-676-BLUE (2583) to speak to a Provider Service representative.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232