Fill in a Valid Empire Referral Template

Filling out the Empire Referral form can be tricky, and mistakes can lead to delays in receiving care. One common mistake is omitting required fields. Certain information is mandatory for the referral to be accepted. If any of these essential fields are left blank, the form will be rejected, causing unnecessary delays.

Another frequent error involves entering incorrect patient information. This includes mistakes in the patient’s name, date of birth, or insurance details. Providing inaccurate data can create issues when processing the referral. It’s crucial to double-check all entries before submitting the form.

People often overlook the specific requirements for the referring physician's information as well. Missing or incorrect information in the provider's details, such as name, service address, or provider ID, may lead to the referral not being processed. All sections must be completed carefully.

Many individuals do not specify the service start and end dates. Referrals are only valid for 90 days unless otherwise noted. Failure to provide these dates can cause confusion about the duration and validity of the referral.

Another mistake is neglecting to include the reason for the referral. This section is important for the review process, and skipping this can lead to delays. Providing detailed remarks helps ensure the referral is processed smoothly.

Some people forget to sign and date the form. Without the physician's signature, the referral holds no validity. Always ensure this step is complete to avoid unnecessary complications.

Lastly, not checking for adherence to the limitations and exclusions stated in the policy can lead to unexpected issues. Understanding what services require pre-approval is essential. Failure to comply with these requirements could result in denials for care that might be needed.

The Empire Referral form is an essential document for obtaining referrals to participating providers under various health plans. When completing the referral process, there are additional forms and documents that may be necessary to ensure all requirements are met. Below is a list of these documents, along with a brief description of each.

• Patient Registration Form: This document gathers essential information about the patient, including contact details, insurance information, and medical history, necessary for the healthcare provider's records.
• Authorization Form: Required for certain procedures, this form verifies that an insurance provider will cover specific services. It typically includes details about the service, provider, and duration of coverage.
• Encounter Form: Used by healthcare providers to document patient visits. This form includes details about the services rendered and often serves as part of the billing process.
• Claim Form: This document is submitted to an insurance company to request payment for services rendered. It provides detailed information about the patient, provider, and services provided.
• Continuation of Care Form: This form is often used when a patient is transitioning from one provider to another. It ensures that ongoing treatments are documented and authorized by the appropriate parties.
• Specialist Referral Form: Similar to the Empire Referral form, this document specifically authorizes a referral to a specialist. It includes patient and provider information pertinent to the specialist visit.
• Medical Records Release Form: This document allows healthcare providers to share a patient’s medical records with other providers or entities. It is essential for ensuring continuity of care.

Each of these forms plays a critical role in the healthcare process. Having the appropriate documentation will help facilitate communication and ensure that services are covered under the patient's health plan. For successful navigation through the referral process, it is advisable to review the specific requirements related to each form.

• Prior Authorization Form: Similar to the Empire Referral form, this document also requires patient and provider information. It is used to obtain approval before specific medical services, ensuring they meet insurance criteria.
• Specialist Referral Form: Like the Empire Referral form, this document specifically details information about the referring physician and the specialist. It is typically used to guide patients to the appropriate care.
• Insurance Claim Form: Both forms require detailed identification of the patient and treatment information. However, an insurance claim form is submitted after services are rendered to seek reimbursement.
• Health Assessment Form: This form gathers patient health information similar to section one of the Empire Referral form. It can help in understanding patient needs and treatment history.
• Referral Tracking Form: Much like the Empire Referral form, it tracks referrals' progress and status, often including a unique tracking number for monitoring.
• Authorization for Release of Information Form: This document, like the Empire Referral form, may require signatures and is used to authorize the sharing of patient medical records for the purpose of referral.
• Patient Intake Form: It collects information about the patient which is similar to the information collected in the Empire Referral form's patient section, aimed at preparing the provider for the patient's visit.
• Continuity of Care Form: This document ensures that relevant health information is transferred between providers, similar to how the Empire Referral form facilitates communication between referring and specialty providers.
• Authorization to Treat Form: Both forms require consent from the patient or their representative. This authorization declares that the patient agrees to receive specific healthcare services.

When filling out the Empire Referral form, it is crucial to pay attention to detail. Here are nine important guidelines you should follow:

• Do ensure all required fields are filled out completely.
• Don’t attempt to leave mandatory fields blank; doing so will result in rejection of the referral.
• Do include accurate patient and provider information.
• Don’t use non-participating providers without prior approval from Empire Medical Management.
• Do specify the reason for the referral clearly.
• Don’t forget to sign and date the form where required.
• Do check that the service dates are correct and compliant with the 90-day validity period.
• Don’t select services that require separate approval without a prior discussion.
• Do verify the Empire provider ID or NPI numbers before submission.

Following these guidelines helps ensure smooth processing of your referral requests and minimizes delays.

• Misconception 1: The Empire Referral form can be submitted without filling all required fields.
• Misconception 2: Any medical service automatically gets approval with this form.
• Misconception 3: Referrals are valid indefinitely once submitted.
• Misconception 4: All healthcare providers are eligible for referrals through this form.
• Misconception 5: You don’t need to specify the number of visits on the referral.
• Misconception 6: The referring physician’s signature is optional.
• Misconception 7: Patients can see any specialist they want without a referral.
• Misconception 8: Faxing the referral form is unnecessary if it's submitted online.
• Misconception 9: The referral can be completed without checking authorization limits or exclusions.

These misconceptions can lead to confusion and delays in care. It’s best to understand the requirements and the purpose of the Empire Referral form to ensure smooth and efficient processing.

When utilizing the Empire Referral Form, consider the following key points for successful completion and submission:

• Required fields must be completed. If any required fields are missing, the referral will not be accepted.
• Provide accurate patient information. Include the patient ID number, last name, first name, middle initial, and date of birth.
• Include the policyholder's name alongside the patient’s details. This ensures correct association with insurance coverage.
• Ensure correct provider information. Fill in the referring physician's last name, first name, middle initial, service address, provider ID or NPI, and phone number.
• Specify the specialist's information in Section 3, including their last name, first name, middle initial, service address, provider ID or NPI, and phone number.
• State the reason for the referral clearly. Include relevant remarks and any limitations or exclusions if applicable.
• Authorization lasts for 90 days. The referral is valid starting from the service start date unless indicated otherwise.
• Check on any non-valid services. Referrals for non-participating providers, inpatient admissions, and emergency admissions are not accepted without prior approval.
• Familiarize yourself with the health plans requiring referrals. These include HMO, Child Health Plus, Healthy NY, and Direct Pay HMO.
• Fax the completed form to the designated number, which is 1-800-522-5793. Ensure the form is sent to the correct address for processing.