b'CODING Update ComplianceLEGAL NUTRITIONCouncilANJC Leadership LEGAL EASE NUTRITION REHAB Council Executive Directors Update LEGAL Q&A CHIROASSISTBy Jeffrey RandolphANJC Legal Counsel Q I attempted to appeal through themust initiate the first level appealagreement, the carrier is requesting DOBI appeal process an insurerswithin 12 months of a denial bycopies of the patient records as an Legislative Update calling the State Health Benefitauthorized representative of the denial of chiropractic services and it was rejected on the basis that INSURANCE Update INSURANCE Update it was a self-funded plan. Is thisPlan to receive instructions on howpatient. N.J.A.C. 13:44E-2.2(e), to submit written appeal. You willwhich governs chiropractic record correct? be notified of second level appealTECHNIQUE Councilkeeping in New Jersey, only requires rights if denied at first level. If stilla chiropractor to provide copies A That is correct. If you are dealingdissatisfied, your patient (not you)within 30 days of a receipt of a with a self-funded plan, this meanscan file an external appeal to thewritten request from a patient or that the carrier processing the claimState Health Benefits Commission.their authorized representative. only acts as a plan administratorOnce it reaches this level ofAccordingly, if you are non-par, you for a self-insured employer andappeal you are not permittedhave up to 30 days to provide the MedicareQ&AMedicare Update does not pay the actual claims.to act on behalf of your patientcopies to the carrier. Self-funded plans are not regulatedin further proceedings, only theOUR HEALTHby the New Jersey Departmentpatient has standing to do so. If of Banking and Insurance; ratherstill dissatisfied, your patient canJeffrey Randolph, Esq. (the author they are regulated by the U.S.request that the case be reviewedof Legal Ease and Legal Q&A) is an Department of Labor and theby an Administrative Law Judgeindependent person of the ANJC federal ERISA law. However, thiswithin 45 days of SHBC denial. Alland his views are not authorized, does not permit the carrier tofurther appeals are to the Appellatesponsored, or otherwise approved by impose its own reimbursementDivision of the New Jersey Superiorthe ANJC. The information provided policy when reimbursing self-fundedCourt.is for general guidance on matters of plan claims. The carrier should beinterest only and may not take into following the policy language ofQ I received a request for copiesaccount particular facts relevant to your the self-funded plan, not their own.of my patient records related toindividual situation. The application You should request a copy of thea post-payment audit by a majorand impact of laws and health care self-funded plans summary planmedical insurance carrier. Theycan vary widely based on the specific description (SPD), which must betold me they would fax me a listfacts involved. Given the changing provided under ERISA, to determineof patients and I would have 24nature of laws, rules and regulations, what the actual self-funded policyhours to provide them all of thethere may be omissions or inaccuracies states regarding chiropracticcopies. Am I required to providein information contained in these benefits. If there is no basis for thethese copies in such a short timematerials. Accordingly, the information denial, you should appeal the denialframe? you receive is provided with the as an adverse claim determinationunderstanding that the author and pursuant to the appeal processThe threshold question is whether detailed in the SPD. A you participate with the carrier orthe ANJC are not herein engaged in not. If you participate, you must firstrendering legal, accounting, tax, health Q I attempted to appeal through thereview your participating providercare or other professional advice and DOBI appeal process an insuranceagreement to see if there is aservices nor are they providing specific carriers denial of chiropracticresponse deadline for providing fileadvice with regard to your practice, services and it was rejectedcopies following a request from thethe treatment of any specific illness, on the basis that it was a Statecarrier. If there is such a provisiondisease, deformity or condition, or Health Benefits plan covering aand it requires a 24 hour turnaround,any other matter that affects trade, state employee. Is this correct? it is most likely enforceable as youcommerce, or legal rights of others. have contractually agreed to it byAs such, this article should not be A This is correct. Similar to self-fundedsigning the agreement. On theused as a substitute for consultation plans addressed in the previousother hand, if you do not participatewith professional accounting, tax, question, State Health Benefits Planswith the carrier, there is nolegal, health care, or other competent such as NJPLUS and NJDIRECTcontractual agreement wherein youadvisers. Before making any decision or have their own appeal processmust provide copies of recordstaking any action, you should consult an separate and apart from the DOBIwithin a certain time frame. In theappropriately trained professional. appeal process. In general, youabsence of a participating provider www.njchiropractors.com I 7'