b'INSURANCE Update Inovalon, Medicare & Medicaid Pre-Auth By Matt MinnellaANJC Director of Insurance & Regulatory AffairsHorizon Inovalon Letters/Record Requests: Many members have reported receiving a letter, phone call or both from AreaCodeParNon-ParLimiting Charge Inovalon on behalf of Horizon. Inovalon is a company that0198940$31.86$30.27$34.81has performed what are called Risk Adjustment Reviews for 01*98940$24.99$23.74$27.30various carriers over the years. There are several companies that have done these reviews for insurance carriers including0198941$45.60$43.31$49.81 Ciox, ArroHealth, Episource and others. Horizon has conrmed01*98941$38.29$36.38$41.84 that these requests are for Risk Adjustment Reviews.0198942$59.22$56.26$64.70 Risk Adjustment Reviews essentially are gathering of informa- 01*98942$51.92$49.32$56.72 tion on a carriers patient population health to report to the9998940$30.92$29.37$33.78government, which can affect reimbursement levels of govern-99*98940$24.39$23.17$26.65ment sponsored programs such as Medicare Advantage and Medicaid managed care. The carriers are required by law to9998941$44.30$42.09 $48.40 perform these reviews. 99*98941$37.36$35.49$40.81 Since these reviews have been required by law following the9998942$57.61$54.73$62.94 enactment of PPACA (Obamacare), we have not seen any99*98942$50.67$48.14$55.36 negative outcome for a provider stemming from a Risk Adjust-ment Review. Also, if you are in-network you are obligated per* Represents all services in any facility other than ofce.Area 01 = Sussex, Warren, Passaic, Bergen, Morris, Essex, Hudson, Union, your contract to comply with the records request.Middlesex, Somerset, Hunterdon CountiesWe have heard that many of these letters insist that youArea 99 = All other Countiesrespond with the records within seven days. These companiesLIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BYoften write very short time frames to create a sense of urgencyNON-PARTICIPATING PROVIDERS.to make sure the letter isnt put aside and lost in the shufe. I believe the most recent Horizon participating provider agreement allows 20 days to comply with records requests,Horizon NJ Health had done training webinars prior to the so you should have at least that long. If you contact them andchange to explain the process. Please see the Power Point provide the records in a reasonable amount of time (under thepresentation on the new process used in the webinars via 20 days) this will likely not be an issue. Horizon NJ Healths website here: www.horizonnjhealth.\x02\x03\x04\x05\x06\x07\x08\x06\x05\x0b\x0c\x0e\x08\x05\x0f\x0e\x06\x05\x10\x11\x12\x13\x14\x12\x12\x05\x15\x16\x17\x18\x03\x03\x0e\x17\x18\x08\x03\x19\x07\x0c\x0e\x17\x10\x11\x12\x13\x17If we become aware of any other function or outcome of these\x15\x1a\x0c\x08\x1b\x1a\x0brecord requests, we will advise membership immediatelyHorizon NJ Health reps have been providing additional Medicare 2020 Fee Schedule Released: The 2020 Medicaretraining to providers on this change, including on-site visits to Part B fee schedule and deductible have been released. Theprovider ofces. You can nd the Horizon NJ Health provider standard premium will be $144.60 a month. This is what arelations rep for your county under Professional Contracting Medicare beneciary pays per month. The deductible will beand Servicing Staff here: www.horizonnjhealth.com/$198.00 a year. This is an increase from $185 last year. The\x02\x03\x1c\x08\x0c\x02\x08\x14\x06\x05\x1a\x19\x03\x1d\x07\x19\x14\x02\x03\x1c\x08\x0c\x02\x08\x06\x1bcoinsurance will remain 20 percent, as always. Below is a chart of the Medicare fee schedule for chiropractic codes in theThe links to both of these resources can also be found ontwo regions of New Jersey as well as the same codes whenwww.anjc.info under Insurance > News and Updates > New rendered in a setting other than an ofce (such as in the homeHorizon Medicaid Pre-Auth Process or Insurance > Health or in an assisted living facility). The majority of the amountsInsurance Carriers & MCOs > BCBS > New Horizon Medicaid have changed slightly from last year with some going up andPre-Auth Process. some going down. Most have changed by only a few cents. None have changed more than a dollar. Horizon NJ Health (Medicaid) New Pre-authorization Process: As of Sept. 1, 2019, Horizon NJ Health, Horizons Medicaid subsidiary, is no longer accepting faxed pre-au-thorization requests. There is an online process that must be utilized to request care. 18 I Winter 2020 www.anjc.info'