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Empire Open Network Physician Written MRI Order Form 2007
Get Empire Open Network Physician Written MRI Order Form 2007-2024
Hone *Date of Birth *Work Phone: *SSN Cell Phone: *Physician s Name (Please Print) Billing Information: Health MVA/NF Physician s Phone: PreCert/Authorization: Physician s Fax: Insurance Company: W/Comp Other Policy#: Requested MRI/MRA Procedure Brain Knee Cerviceal Ankle Thoracic Foot Lumbal Wrist Prostate Elbow Abdomen Shoulder Pelvis Thigh Orbits Lt. Rt. Other Scan Type: Diagnosis: ICD-9 Dx Codes , Requesting Appointme nt Date: Lt. Lt. Lt. Lt. Lt. Lt. Lt. Rt. Rt. Rt. Rt.
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Nf FAQ
Medical/Surgical Program The Empire Plan is designed to provide enrollees with comprehensive medical care coverage. Using participating providers helps keep the cost to you and The Empire Plan at a reasonable level. UnitedHealthcare is the program administrator for this coverage.
UnitedHealthcare administers The Empire Plan's medical portion, and its Empire Plan Network was specifically developed to serve the needs of The Empire Plan.
When a doctor, hospital or other provider accepts your health insurance plan we say they're in network. We also call them participating providers. When you go to a doctor or provider who doesn't take your plan, we say they're out of network.
They have not agreed to a contract with your insurance company and may charge higher rates for the same services. However, this doesn't mean your insurance company will pay these higher rates. If your insurance company provides out-of-network coverage, it may only pay the amount it would for an in-network service.
Your SEHP medical coverage will be through insurance carriers under contract with NYSHIP: Empire Blue Cross Blue Shield (for hospital benefits), UnitedHealthcare Insurance Company of New York (medical/surgical), GHI/ValueOptions (mental health and substance abuse) and CIGNA/Express Scripts (prescription drugs).
What is The Empire Plan? A. The Empire Plan is NYSHIP's unique health insurance plan designed exclusively for New York State's public employees and employers. The Empire Plan pays for covered hospital services, physicians' bills, prescription drugs and other covered medical expenses.
About the Program The Empire Plan is the primary health insurance plan for NYSHIP, covering 1.1 million members. Civil Service contracts with UnitedHealthcare Insurance Company of New York (United) to administer the Empire Plan's medical/surgical benefits.
Single $35 copayment for all covered services provided during the visit by a participating laboratory. $80 copayment for MRI, MRA, CT Scan, PET Scan and Nuclear Medicine test.
Empireopennetwork Related content
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Oct 1, 2007 — When the provider(s) administering and/or interpreting the MRI is an...
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