Health Ins Carriers & MCO's
Aetna - Triad
In June of this year, the ANJC filed a complaint with DOBI against Aetna for a number of processing issues. ANJC Leadership met with DOBI Commissioner Marlene Caride and her team in follow up to our complaint in July. Attendees included Dr. Jordan Kovacs, board president; Amy Boright Porchetta, executive director; Dr. Michael Goione, insurance consultant; Jeff Randolph, general counsel; Jon Bombardieri, government affairs counsel; and Matt Minnella, director of insurance and regulatory affairs.
Recording of webinar presented on Monday Feb. 25, 2019.
Review of the latest updates regarding Aetna, NIA and the SHBP/SEHBP Medicare Advantage Plans.
As of January 1st pre-authorization is required for in-network doctors on fully funded Aetna plans. This process is handled on Aetna's behalf by a company called NIA. There were a series of webinars presented by NIA on this new process throughout the month of December. If you did not watch one of these webinars a recording is available on their website www.radmd.com. You would need to be registered with NIA and logged in to view the webinar.
As previously reported, Aetna will be implementing a new pre-authorization program being managed by National Imaging Associates (NIA) beginning January 1st. The process will be required for in-network providers on fully funded policies only. For claims submitted on or after January 1st pre-authorization will be required in order for payment to be issued.
On Oct. 2, 2018, we advised that many members had received denials from Aetna for lack of pre-authorization of care. We immediately approached Aetna regarding this as the new pre-authorization program is not set to begin here in New Jersey until Jan. 1, 2019
As previously reported, Aetna’s contract with Triad/eviCore is expiring on Dec. 31, 2018. A vendor called National Imaging Associates (NIA) will be managing a new pre-authorization program immediately following the Triad contract expiration, starting Jan. 1, 2019.
Many members have received a letter from Aetna regarding a new pre-authorization process coming January 1, 2019. Aetna’s contract with Triad/eviCore is expiring on December 31, 2018. A vendor called National Imaging Associates (NIA) will be managing this new pre-authorization program immediately following the Triad contract expiration. The process will apply to all physical medicine procedure codes regardless of what type of provider performs them whether it be a DC, PT or MD. The pre-authorization program will be applied to in-network providers on fully funded plans only.
by Matt Minnella, ANJC Director of Insurance & Regulatory Affairs
Following the ANJC’s successful settlement of our law suit against Aetna for inappropriately denying 97140 codes when billed with CMT, we are still pursuing the fulfillment of Aetna’s obligations under the agreement.
Many members have reported receiving a letter, phone call or both from Inovalon on behalf of Horizon. Inovalon is a company that has performed what are called Risk Adjustment Reviews for various carriers over the years.
As of Sept. 1, 2019, Horizon NJ Health, Horizons’ Medicaid subsidiary, is no longer accepting faxed pre-authorization requests. There is an online process that must be utilized to request care.
Easily email your local representatives in Trenton plus other key lawmakers to encourage them to ask DOBI not to approve a partnership between Horizon BCBS and ASH!
You may have or will soon be receiving a letter from Horizon announcing that they have entered into an agreement with American Specialty Health Networks (ASH). ASH will be providing network management services for Horizon beginning January 1, 2020.
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.”
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, 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.
United - Optum
As previously reported, United Healthcare had planned to require the GP modifier to be added to all "therapy codes" as of September 1, 2019. Per the United Healthcare September news bulletin, this policy will be "delayed to give care providers more time to adjust to changes in the submission of 'Always Therapy' procedure codes to include the CMS required therapy modifiers."
United Healthcare has delayed the requirement to append the GP modifier to any codes that are deemed "Always Therapy" codes, according to CMS, until September 1, 2019.
Nominations Now Open for ANJC Lifetime Achievement Award and Chiropractor of the Year!
Beginning July 1, 2019 United Healthcare will require the GP modifier to be appended to any codes that are deemed "Always Therapy" codes according to CMS.
Optum has agreed to lease its network to Zelis (formerly Stratose). Zelis is a “health care savings company” which is also sometimes known as a silent PPO company. What this means is that if you are in-network with Optum but out of network with a number of companies Zelis works with, then you will be paid at the Optum contracted rates rather than the out of network rate for the carrier under contract with Zelis.
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.
Cigna - ASHN
Postcards regarding the $11.75 million settlement of the CIGNA-ASHN class action lawsuit have begun reaching class members. As such, the ANJC wants to provide what you need to know.