Empire Blue Cross Blue Shield Prior Authorization: What Providers Need to Know
- Jamie P
- Aug 12
- 7 min read
For healthcare providers, navigating insurance requirements can be one of the most time-consuming parts of patient care. When it comes to Empire Blue Cross Blue Shield (Empire BCBS), prior authorization (PA) is a critical step for certain treatments, procedures, and medications. While these requirements help manage costs and ensure appropriate care, they can also lead to delays if handled incorrectly.
In this article, we’ll cover what providers need to know about Empire BCBS prior authorization, including the request process, common pitfalls, handling denials, and strategies to improve approval rates — so you can help patients access care without unnecessary delays.
What Is Prior Authorization and Why It Matters
Defining Prior Authorization
Prior authorization is when a health insurance plan requires pre-approval for certain medical services, treatments, or prescriptions before agreeing to cover them. Without prior authorization, the insurer may deny payment, leaving patients with large out-of-pocket bills.
Balancing Cost Control and Patient Care
Insurers like Empire BCBS use PA to ensure that the treatment is medically necessary and cost-effective. While this safeguards resources, it can add administrative work for providers and cause frustration for patients if the process is slow.
Common Services Requiring Prior Authorization with Empire BCBS
Advanced imaging (MRI, CT scans, PET scans)
Certain elective surgeries
Specialty medications, including injectables
Out-of-network services
High-cost durable medical equipment
Overview of Empire Blue Cross Blue Shield’s Prior Authorization Policy
Which Treatments and Medications Require PA
Empire BCBS maintains a list of services requiring PA, updated regularly on its provider portal. This includes both medical and pharmacy prior authorizations.
Differences Between Medical and Pharmacy PA
Medical PA: Required for procedures, hospital admissions, equipment.
Pharmacy PA: Required for high-cost or specialty drugs, often through a separate pharmacy benefits manager (PBM).
Policy Updates and Resources
Empire BCBS posts updates on its provider site, and providers should check these at least quarterly to stay current.
The Empire BCBS Prior Authorization Request Process
Getting the Correct Request Form
Forms vary depending on the service or drug requested. Always use the most current version from the Empire BCBS provider portal.
Required Patient and Provider Information
Patient demographics and insurance ID
Provider NPI and contact details
Diagnosis codes (ICD-10)
Clinical Documentation and Supporting Evidence
This can include chart notes, imaging results, lab reports, and treatment history.
Submission Methods
Provider Portal (fastest and preferred)
Fax (for services not available in the portal)
Mail (least efficient)
Avoiding Common Prior Authorization Pitfalls with Empire BCBS
Incomplete Forms or Missing Fields
Even one missing detail can cause a denial or delay.
Not Meeting Medical Necessity Criteria
Empire BCBS reviews requests against its medical policy criteria. If documentation doesn’t meet these, denial is likely.
Step Therapy Requirements
For certain medications, patients may need to try lower-cost options first. Documentation of these trials is required.
Prior Authorization Expiration Dates
Approved PAs often have a validity window. If the service is not performed within this period, you may need to resubmit.
Coordinating Between Patients, Providers, and Empire BCBS for Faster Outcomes
Even when a prior authorization request is complete and accurate, delays can still happen if there’s a breakdown in communication between the key parties — the patient, the provider’s care team, and Empire Blue Cross Blue Shield. Streamlining coordination can significantly reduce turnaround times and improve approval rates.
Setting Patient Expectations Early
From the moment you prescribe a service or medication that requires PA, explain to the patient:
The reason prior authorization is necessary
The expected processing time for Empire BCBS
What they might need to provide (e.g., consent forms, medical records) Educated patients tend to respond more quickly to insurer or provider requests, which keeps the process moving.
Clear Roles Within the Care Team
Every team member should know exactly what part they play:
Clinicians supply detailed chart notes and medical justification.
Administrative staff fill out the PA form and submit it.
PA coordinators track progress and follow up with Empire BCBS.
Using a shared PA tracker (spreadsheet, EMR dashboard, or project management tool) ensures everyone can see the latest status and next steps in real time.
Related: What Is Delegation?
Maintaining Contact with Empire BCBS
Proactive outreach can prevent weeks of delay:
Call Empire BCBS within 48–72 hours of submission to confirm receipt
Ask if additional documentation is needed before they review
Log all communication for accountability and future reference
Collaborating Across Providers
If the PA requires records from multiple specialists, request them immediately rather than waiting for Empire BCBS to ask. A simple checklist can ensure all necessary documents are attached before submission.
The Payoff of Good Coordination
A coordinated approach not only reduces administrative headaches but also means patients can start their treatments or procedures sooner. For providers, it translates into more predictable scheduling, better patient satisfaction, and fewer last-minute cancellations due to pending approvals.
How Empire BCBS Handles Urgent and Standard Requests
Urgent vs. Routine Requests
Urgent: Decisions typically within 72 hours.
Routine: Decisions typically within 14 calendar days.
Escalation Procedures
If timelines are not met, providers can request an expedited review or contact provider services for assistance.
Empire BCBS Prior Authorization Denials – Causes and Solutions
Common Denial Reasons
Insufficient documentation
Incorrect or missing diagnosis codes
Service not covered by the plan
Failure to meet step therapy
Solutions
Ensure full documentation before submission
Double-check codes against the most recent policy
Confirm coverage before scheduling services
Appealing a Denial with Empire Blue Cross Blue Shield
Understanding the Denial Letter
Empire BCBS will list the reason for denial and the steps to appeal.
Gathering Supplemental Evidence
Include any missing documentation, specialist opinions, or new test results.
Timelines for Filing Appeals
Typically 60–180 days from the denial date, depending on the plan.
Tips for Writing a Strong Appeal Letter
Address each denial reason directly, reference policy language, and include clinical justification.
Preventing Future Empire BCBS PA Denials
Review Past Denials
Identify patterns — such as recurring missing documents — and address them in your process.
Maintain Updated Policy References
Store current insurer criteria in a shared digital location for staff access.
Use a Final Review Checklist
Verify all fields, ICD-10 codes, and supporting evidence before submission.
Tracking and Improving Prior Authorization Performance
Monitoring Approval Rates and Timelines
Keep internal metrics to identify problem areas and monitor improvements over time.
Identifying Recurring Denial Reasons
Target training and process updates where denials occur most.
Using Data to Improve Submission Accuracy
Data trends can help prioritize staff training and automation investments.
Leveraging Technology for Empire BCBS Prior Authorizations
EMR Integration
Submit directly from patient records to avoid manual data entry errors.
Document Management Systems
Organize supporting evidence for easy access during submission.
OCR and AI Tools
Use tools that can pre-check forms for completeness and predict denial risk.
Explore: Healthcare Virtual Assistants
Outsourcing Prior Authorization to Specialists
How Outsourcing Can Speed Up the Process
Specialist PA services know exactly what insurers look for, which reduces delays.
What to Look For in a PA Service Provider
Experience with Empire BCBS policies, strong follow-up processes, and secure data handling.
Combining In-House and Outsourced Solutions
Keep urgent or simple PAs in-house and outsource complex or high-volume cases.
Explore: Why Hire a Virtual Assistant?
Leveraging Technology to Streamline Empire BCBS Prior Authorizations
Prior authorization management is often seen as a paperwork-heavy burden, but with the right technology, providers can turn it into a faster, more predictable process — especially when working with insurers like Empire Blue Cross Blue Shield.
EMR-Integrated PA Submission Tools
Modern electronic medical record (EMR) systems can:
Auto-fill patient and provider details into Empire BCBS’s PA forms
Flag missing fields before submission
Allow direct electronic submission to Empire BCBS portals
This reduces manual data entry errors and saves valuable staff time.
OCR Scanning for Supporting Documents
Optical Character Recognition (OCR) can scan and categorize supporting documents such as lab results, imaging reports, and physician notes. This allows you to upload all relevant evidence into the PA submission quickly and in the correct format.
AI-Powered Completeness Checks
Some PA software uses artificial intelligence to identify gaps in your request and recommend additional documentation before it’s sent to Empire BCBS. This can reduce the risk of a denial for “insufficient information.”
Automated Status Tracking and Alerts
Instead of manually checking the Empire BCBS portal, automated systems can:
Pull status updates daily
Send alerts if a request is stuck in review
Notify staff when a decision has been made
How Virtual Assistants Fit In
Healthcare-focused virtual assistants (VAs) can manage the tech side of PAs, including:
Uploading documents to the Empire BCBS portal
Monitoring for insurer requests
Preparing appeal packets if needed
Maintaining performance dashboards for turnaround time and approval rates
Related: Healthcare Virtual Assistants
From Bottleneck to Workflow
By combining the right software tools with trained staff or VAs, prior authorization can shift from a frustrating bottleneck to a streamlined part of your daily workflow. The result? Faster Empire BCBS decisions, improved patient satisfaction, and reduced administrative costs.
Best Practices for Managing Empire BCBS Prior Authorizations in Your Practice
Create a Standard Operating Procedure
Document each step of the PA process for consistency.
Continuous Staff Training
Hold quarterly updates to review policy changes and denial trends.
Maintain Insurer Relationship Contacts
Direct contacts can expedite issue resolution.
Educate Patients
Let patients know upfront if their treatment requires PA and explain possible timelines.
Final Thoughts
Empire Blue Cross Blue Shield prior authorization can be complex, but with accurate documentation, clear communication, and the right tools, providers can reduce delays and improve patient satisfaction. Proactive management not only benefits patients but also streamlines workflows and improves practice efficiency.
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