None at this time.

Horizon 98943 Update


As previously reported, we have seen many denials of 98943 from Horizon. Horizon had advised that these denials are erroneous. The issue was related to a recent upload of new claim edits based on Medicare policy. Horizon has notified us that the edit issue has been corrected for claims going forward. 

Appellate Division Ruling in SHBP Case


The ANJC today received the Appellate Division's decision in the State Health Benefit Plan $35 cap on out-of-network chiropractic reimbursement appeal. 

Horizon 98943 Issue Update


As previously reported, we have seen many denials of 98943 from Horizon with the denial reason code: U702: “This service is not paid. This denial occurred because the procedure code has a status indicator of N, I, P, M, R or C. Refer to the Medicare Physician Fee Schedule to determine CMS Guidelines for reimbursement.”

Horizon 98943 & 97014 Denials


We have recently heard from many members that CPT codes 98943 and 97014 are being denied on various (but not all) Horizon plans. We have seen these denials with two different reason codes. 

Horizon NJ Health (Medicaid) to Stop Reimbursing 98943


Horizon NJ Health, Horizon’s Medicaid managed care subsidiary, has announced that it will no longer reimburse CPT code 98943, extra-spinal manipulation, as of April 1, 2018.

Medicare Audit Request


Audits of all kinds have been expanding in both frequency and depth.  The ANJC is seeking to understand what is being sought in these audits and how doctors can best pass them.  We are currently focusing on the wide variety of Medicare audits. 

Medicare Advantage - Clover Audit Letter


Many ANJC members have received letters from Clover, a Medicare Advantage insurance carrier, stating that files had been audited, overpayments were issued to the doctor and will be recouped.

SHBP Horizon NJDirect Medicare Advantage Plan 98943 Issue


It recently came to our attention that these plans had ceased paying for 98943, extra-spinal manipulation.  We immediately contacted Horizon, who soon after confirmed a system error was denying these codes on these plans.  Horizon reports that the issue has been fixed as of this Monday, Jan. 22, for claims going forward. 

2018 Medicare Fee Schedule Info


The Medicare Part B deductible for 2018 will be $183. There is no change from 2017. The 2018 Medicare fee schedule has been released. The base fee schedule for chiropractic services through Medicare has gone up approximately 1% each for the allowed chiropractic procedures (98940-98942).

ICD-10 Code Set Updates


Every year, ICD-10 updates occur on Oct. 1st. This year includes the following changes to ICD-10-CM: 363 new codes 142 deletions 226 code revisions

Obamacare - One More Repeal Attempt


After several attempts at repealing Obamacare the Republicans are making one last effort this year. This will likely be the last effort of the year because they can only use the budget reconciliation bill to pass the legislation until September 30th.

Horizon X-ray Denial Issue


Over the last few months the ANJC has received a number of complaints of X-ray denials for Horizon patients with an unusual reason code. The denials all had a common denial code of F107 which read that the code was denied because, “The modifier is missing or invalid for the reported procedure code.”

What Will Happen to Obamacare?


While no legislation to repeal or amend Obamacare has become law, we do have a bill passed by the U.S. House of Representatives and a draft of a bill from the U.S. Senate. Here we examine some of the major themes from the most recent offerings of the two chambers of Congress.

Horizon OMNIA Lawsuit Update!


As you are aware, the ANJC and an individual chiropractor previously filed suit against the Horizon OMNIA Plan alleging violation of a number of state statutes as well as the Section 2706 of the federal Patient Protection and Affordable Care Act (“PPACA” or “Obamacare”). The basis of the lawsuit was discrimination against chiropractors for placing a disparately high number of chiropractors in Tier 2 of the OMNIA Plan which has high patient cost sharing obligations compared to Tier 1 with lower patient cost sharing when compared to other similar providers such as physical and occupational therapists.

New ABN Form Mandatory June 21st!


CMS has released an updated Advanced Beneficiary Notice of Non-coverage (ABN) form (Form CMS-R-131). There are no substantive changes to the form or its usage. However, the updated form has added language informing beneficiaries of their rights to CMS nondiscrimination practices and how to request the ABN in an alternative format if needed. The new form also includes the updated expiration date of the form which is 03/2020.

PIP Uniform Appeal Update!


As previously advised, as of April 17th 2017 the New Jersey Department of Banking and Insurance (DOBI) mandates a uniform appeal process using specific forms for pre- and post-service appeals created and provided by the NJ DOBI. Shortly after implementation, it came to our attention that nearly all carriers made changes to their Decision Point Review (DPR) plans following this change. Certain changes found are clearly detrimental to medical providers treating PIP patients and most importantly, to the patients themselves.

Medicare 2017 Quality Payment Program 12-2-16


There are significant changes coming to the Medicare system of reimbursement beginning in 2017. This comes in the form of what is called the Quality Payment Program.

Optum Per-Visit Fee Schedule


Many of you have received a letter or letters from Optum over the last week or so describing a new “per-visit” fee schedule. Optum has been rolling out this new payment model state-by-state beginning in late 2015. The amount of the per-visit fee varies by state. The $68 NJ per-visit fee is the highest allowance we are aware of thus far.

SHBP & SEHBP Update 10-12-16


Since our last update on the State Health Benefits Plan we have obtained the resolutions passed by the SHBP Plan Design Committee at their 8/29/16 meeting via OPRA request. Three of the seven resolutions have possible bearing on ANJC members.

SHBP Conference Call 5-18-2016


If you missed our Statewide Conference call regarding the State Health Benefits Program on Wednesday May 18th, 2016 it is now available

New PIP APTP Form - 4/15/16


A new Attending Provider Treatment Plan form for PIP pre-certifications will be mandatory beginning on April 15th, 2016.

SHBP Conference Call 3-30-2016


If you missed our Statewide Conference call regarding the State Health Benefits Program on Wednesday March 30th, 2016 it is now available

SHBP Conference Call 1-21-2016


If you missed our Statewide Conference call regarding the State Health Benefits Program on Thursday, January 21st, 2016 it is now available

2015 and Older News & Updates


If you missed our Statewide Conference call regarding the State Health Benefits Program on Thursday, January 21st, 2016 it is now available