None at this time.
Aetna - Triad
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.
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.
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.
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.
United - Optum
Originally taking effect on June 1, 2018, United amended their policy on manipulative therapy (including chiropractic and osteopathic manipulation) to consider the treatment “unproven and/or not medically necessary for treating . . . headaches.” Immediately, the ANJC reached out to United/Optum to contest the policy. The ANJC also signed on to a letter from the ACA to United contesting the policy change along with 40 other chiropractic associations.
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
On behalf of the Chimicles & Tikellis law firm: Chimicles & Tikellis LLP is investigating whether Cigna is overcharging insureds being treated by physical and occupational therapists (PT/OT) in ASH’s network.