Insurance

News & Updates

10/15/14 Horizon M127 Denials

We have been keeping you updated on several erroneous claim denials by Horizon over the course of this year.  The M127 denial code which read, “This service is not paid. The member has used the 2 services for chiropractic manipulation allowed per day under their health benefit plan” has been corrected as of September 9^th, 2014.  Per Horizon, you should not have received any denials with this reason code since then.

We have just been advised that Horizon has completed the adjustment of the approximately 5,500 affected claims.  Payment adjustments for those doctors affected should be received this week.

9/30/14 Horizon Erroneous Denial Codes F115, M016, M127

We have been working with Horizon to resolve several erroneous denial code issues that have been affecting membership. 

F115 denials were the first, which note the services are denied due to an invalid or missing modifier when in fact there was no such missing or invalid modifier. 

It appears the F115 issue has been resolved as of early July.  Horizon has advised that any claims denied due to this reason code, that had not already been reprocessed at the doctors request, would be done so automatically by Horizon.  This process should be complete at this time. 

M016 is another denial code in question.  While Horizon advises there are 3 different scenarios in which this code denies a service, the most common message reads, “This service is not paid.  The amount for the service has been considered for payment on a previous claim line or by another carrier.”

Horizon advised that the M016 fix is currently being tested and expects implementation no later than 10/15/14.  Claims that had been denied in error related to this issue should be automatically reprocessed by Horizon within 45 days of the fix date. 

M127 has also been an errant denial code during the past few months.  The common language we found for this denial code reads, “The service is not paid.  The member has used the 2 services for chiropractic manipulation allowed per day under their health benefit.”

Horizon has advised that this was an error and NOT a change in reimbursement policy.  They also advise that the issue has been corrected as of mid-September, so you should not be receiving this denial on new claims at this point.  Approximately 5,500 claims were affected, according to Horizon, and they are preparing a bulk adjustment to issue the payment corrections.  I do not have an exact date on this yet but it should occur in the next 30-45 days. 

Please email Matt Minnella at matt@anjc.info if you:

1. Have not received corrected payments from Horizon for erroneous F115 denials.
2. Receive M016 denial AFTER 10/15/14.
3. Are still receiving M127 denials on newly processed claims.

Horizon Recoupment Reversal EOBs

 A few weeks ago we alerted you that Horizon had agreed to reverse their recoupment demands relating to codes appended with the -52 modifier.  In early February, Horizon began to issue EOBs showing the reversal of these demands.

The reversal EOBs are confusing.  Many members have reached out to us believing that Horizon had begun recouping the money.  Also, the EOBs show late interest payments issued on these recoupment reversals.  

If your recoupment demand issued in late December 2013 was related to the -52 modifier  Horizon did not take this money back.  We have reviewed examples of these EOBs and have clarified the situation with Horizon.

In order to clearly explain how these EOBs read and what they mean, we presented a webinar hosted by myself and ANJC billing consultant Lynette Contreni-Bernier on Thursday March 6^th.  We recorded the webinar and are providing it now to any of you who missed it.

Horizon Recoupment Reversal Webinar

Horizon Update and Conference Call Recording

On our Statewide Conference call last Wednesday, we advised that Horizon has agreed to reverse their recoupments related to a number of modifier policies, including the -52 modifier.  If you missed the webinar, the audio presentation is available through link below:

Horizon Recoupment Statewide Conference Call

Since our call, Horizon has formally announced its decision to reverse these recoupments.  The link to Horizon’s update and explanation is here:

Horizon Notice on Recoupment Reversal

We had advised that from our review, the vast majority of our members appear to have received these recoupment letters because of the -52 modifier being appended to many of the procedures they billed for.  However, the reason for the recoupment was not expressly described on any of the correspondence we have seen.  If there is any doubt as to why you have received a recoupment letter from Horizon we encourage you to still submit a claims appeal prior to the 45 day deadline to preserve your rights.
For more detail on this appeal process, please see post below.

Horizon Recoupments

The ANJC has received information from a number of members that have received letters from Horizon BCBS of NJ in late December of 2013 requesting reimbursement of monies they claim to have overpaid within 45 days of the date of their letter. 

Upon further research of the issue, the ANJC learned that Horizon has posted on its website that as of December 18, 2013, their internal audit revealed that Horizon had overpaid health care providers that submitted claims to Horizon based upon three errors alleged on Horizon’s part:  i) Horizon had applied the incorrect PPO fee schedule when paying managed care claims resulting in overpayment of the claims; ii) Horizon paid claims in excess of the policy maximum benefit allowance; and iii) Horizon had incorrectly paid claims without applying amendments it claims to have implemented to its reimbursement policy resulting in overpayment of the claims.

The ANJC has been looking into this issue and has reason to believe that the overpayment claims may not be accurate and encourages any member that has received such a reimbursement letter to exercise their right to appeal this overpayment under the New Jersey HCAPPA law. 

If you have received such a letter requesting reimbursement, you have the right to appeal this overpayment determination as Horizon has acknowledged in its advisory published on its website.  Please note that you must file the appeal within 45 days of the date of the overpayment letter.  Please be advised that, if you do not file a timely appeal, Horizon has indicated that it will offset future claim payments on these patient claims to recoup the funds as they are permitted to do under the HCAPPA law.  However, a timely appeal will postpone this offset until the entire appeal process is exhausted.

If you choose to file such an appeal, take the following simple steps:

1. Download the Healthcare Application to Appeal a Claims Determination;  
2. BCBSNJDOBIAppAppealClaimsDet.pdf  Section A:  Fill out Section A with your Practice Information;
3. Section B: Fill out Section B of the form.  If you have patient authorizations, attach to the form;
4. Section C: Fill out Section C of the form and check box “F” on the form. Make sure you attach a complete copy of the Overpayment Demand letter from Horizon and any supporting documents that came with it. 
5. Section D: Under “Reasons for Appeal,” indicate that you disagree with Horizon’s overpayment determination and submit that you believe you were properly paid.  The following is a non-exhaustive list of possible appeal points that could be raised based upon your particular circumstance. These are examples only and you must choose appeal points that apply to your particular situation:
   1. Horizon’s Failure to Provide Detail of Overpayment:  You may possibly argue that Horizon has failed to clearly delineate the basis of overpayment as required by the HCAPPA law which prevents you from providing more detail in your appeal and submit that Horizon must prove that it, in fact overpaid your claims. 
   2. Recoupment Past 18 Months:  If Horizon is asking for reimbursement based upon dates of service performed more than 18 months prior to their repayment demand letter, you can possibly argue that the HCAPPA law precludes recovery past 18 months and there is no fraud or improper pattern of billing which would allow them to exceed 18 months as the erroneous payments were Horizon’s own fault;
   3. Change In Reimbursement Policy for Participating Providers: If you are a participating provider and the basis for overpayment is a change in reimbursement policy, you may possibly argue that you received no notice of any change in reimbursement policy implemented by Horizon and should not be subject to its terms if, you, in fact, did not receive any such notice.
   4. Exceeding Maximum Benefit:  If the basis for overpayment is exceeding the patient’s maximum benefit allowance and you know you did not reach the patient’s maximum reimbursement limit, provide proof that the limit had not been exceeded. 
   5. Prior Authorization:  If you had received prior authorization for the services, you may possibly argue that the HCAPPA law does not permit recoupment of previously authorized services absent fraud on the part of the provider of services and there can be no finding of fraud as the overpayment was based upon Horizon’s own error.
   6. ERISA Plans:  If the plan is subject to the federal ERISA law (most self funded plans), you can possibly argue that Horizon has no claim to equitable restitution of the funds as it cannot prove that you maintained the monies paid on the claims subject to the recoupment in a segregated account as required by ERISA Section §1132 as well as failed to dispute the payment of the claim within 30 days of the receipt of the claim as required by ERISA regulation 29 C.F.R. § 2560.503-1.
6. Sign the form and send certified, registered or overnight mail (so you have proof of timely submission) to the address located on the top of the form:  Appeals Department, Horizon BCBS of NJ, PO Box 10129, Newark, NJ 07101.
7. You can submit the appeal form with a cover letter.  A sample cover letter can be accessed at:  BCBSNJappealCoverLetter.pdf

   We will be holding a statewide call or webinar on this topic in the coming weeks as more information becomes available.  If you have any questions in this regard, please contact Matt Minnella, the ANJC Insurance Director, at matt@anjc.info.