None at this time.

State Health Retiree Plan Updates


We have previously reported that all Medicare eligible retirees under the SEHBP (teachers) who are enrolled in traditional Medicare with either the NJ Direct 10 or NJ Direct 15 plans will be automatically enrolled into new Aetna Medicare Advantage plans.  It has come to our attention that additionally, any retired SHBP (police, fireman, etc.)  employees who had been enrolled in the Horizon Medicare Advantage NJ Direct 10 or 15 will also be moved to new Aetna Medicare Advantage plans.

SEHBP Plan Updates


Additional details have become available regarding changes to the School Employee Health Benefits Program (SEHBP).  First, the changes previously described were approved by the School Employee Health Benefits Commission and are hence, official.  Both the new plan option and the retiree changes will be effective as of January 1, 2019.

Aetna New Pre-Auth Process & Pre-Auth Denials


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.

SEHBP Plan Reforms


Yesterday, following an agreement between Gov. Murphy and the New Jersey Education Association, the School Employee Health Benefits Program’s (SEHBP) Plan Design Committee passed several resolutions enacting reforms to reduce costs under the plan.  The SEHBP covers all employees of K-12 schools and community colleges that opt into the state program.

Updated Disclosure Form


As previously reported, the Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act requires a disclosure form to be signed by patients beginning August 29, 2018.  We have updated our interim sample form (to be replaced by official form once released by the Board of Chiropractic Examiners) to include sections for both in and out of network providers/patients.

Medicare: MACRA Update!


The Government Accountability Office (GAO) released a report on July 31 which was, in essence, following up on several directives issued to the Centers for Medicare & Medicaid Services (CMS) in the 2015 MACRA law (Medicare Access and CHIP Reauthorization Act). 

United Healthcare Policy: Headaches and TMJ


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. 

New OON Law Disclosure Form!


As you are aware, on June 1, 2018, Governor Murphy signed into law the Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act.  The main components of the bill were designed to protect patients from unexpected out-of-network bills for providers operating at in-network hospitals or other healthcare facilities.  There are however several new disclosure requirements that apply to all out-of-network providers, including chiropractic physicians.  

Horizon 98943 Update


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. 

Appellate Division Ruling in SHBP Case


The ANJC today received the Appellate Division's decision in the State Health Benefit Plan $35 cap on out-of-network chiropractic reimbursement appeal. 

Horizon 98943 Issue Update


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.”

Horizon 98943 & 97014 Denials


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 (Medicaid) to Stop Reimbursing 98943


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.

Medicare Audit Request


Audits of all kinds have been expanding in both frequency and depth.  The ANJC is seeking to understand what is being sought in these audits and how doctors can best pass them.  We are currently focusing on the wide variety of Medicare audits. 

Medicare Advantage - Clover Audit Letter


Many ANJC members have received letters from Clover, a Medicare Advantage insurance carrier, stating that files had been audited, overpayments were issued to the doctor and will be recouped.

SHBP Horizon NJDirect Medicare Advantage Plan 98943 Issue


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. 

2018 Medicare Fee Schedule Info


The Medicare Part B deductible for 2018 will be $183. There is no change from 2017. The 2018 Medicare fee schedule has been released. The base fee schedule for chiropractic services through Medicare has gone up approximately 1% each for the allowed chiropractic procedures (98940-98942).

What Will Happen to Obamacare?


While no legislation to repeal or amend Obamacare has become law, we do have a bill passed by the U.S. House of Representatives and a draft of a bill from the U.S. Senate. Here we examine some of the major themes from the most recent offerings of the two chambers of Congress.

CMS Updated ABN Forms


by Matt Minnella, ANJC Director of Insurance and Regulatory Affairs

New ABN Form Mandatory June 21st!


CMS has released an updated Advanced Beneficiary Notice of Non-coverage (ABN) form (Form CMS-R-131). There are no substantive changes to the form or its usage. However, the updated form has added language informing beneficiaries of their rights to CMS nondiscrimination practices and how to request the ABN in an alternative format if needed. The new form also includes the updated expiration date of the form which is 03/2020.

PIP Uniform Appeal Update!


As previously advised, as of April 17th 2017 the New Jersey Department of Banking and Insurance (DOBI) mandates a uniform appeal process using specific forms for pre- and post-service appeals created and provided by the NJ DOBI. Shortly after implementation, it came to our attention that nearly all carriers made changes to their Decision Point Review (DPR) plans following this change. Certain changes found are clearly detrimental to medical providers treating PIP patients and most importantly, to the patients themselves.

SHBP Appellate Court Oral Arguments Heard 5-9-2017


On Tuesday, May 09, 2017, the ANJC’s General Counsel Jeffrey Randolph engaged in oral arguments with a Deputy Attorney General of the New Jersey Attorney General’s Office before the NJ Appellate Court in the ANJC vs. the State Health Benefits Commission et al. case.

New PIP Uniform Appeal Forms and Process - Webinar


As previously advised, the NJDOBI is instituting a uniform appeals process for PIP claims. This new uniform appeal process will be in effect as of April 17, 2017. Jeffrey Randolph Esq., General Counsel to the ANJC, has created a webinar explaining the changes and new process.

Aetna 97140 Update


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.

New PIP Uniform Appeal Forms and Process Takes Effect April 17, 2017


On Oct. 17, 2016, the New Jersey Department of Banking and Insurance (DOBI) published in the N.J. Register amendments to the PIP regulations implementing a new, mandatory appeal process for PIP claims to take effect April 17th.

PIP Update


by Matt Minnella, ANJC Director of Insurance & Regulatory Affairs

2017 Medicare Fee Schedule Info


The Medicare Part B deductible for 2017 will be $183. This is up from $166 in 2016.

Medicare 2017 Quality Payment Program 12-2-16


There are significant changes coming to the Medicare system of reimbursement beginning in 2017. This comes in the form of what is called the Quality Payment Program.

Optum Per-Visit Fee Schedule


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.

SHBP & SEHBP Update 10-12-16


Since our last update on the State Health Benefits Plan we have obtained the resolutions passed by the SHBP Plan Design Committee at their 8/29/16 meeting via OPRA request. Three of the seven resolutions have possible bearing on ANJC members.

SHBP Conference Call 5-18-2016


If you missed our Statewide Conference call regarding the State Health Benefits Program on Wednesday May 18th, 2016 it is now available

New PIP APTP Form - 4/15/16


A new Attending Provider Treatment Plan form for PIP pre-certifications will be mandatory beginning on April 15th, 2016.

SHBP Conference Call 3-30-2016


If you missed our Statewide Conference call regarding the State Health Benefits Program on Wednesday March 30th, 2016 it is now available

SHBP Conference Call 1-21-2016


If you missed our Statewide Conference call regarding the State Health Benefits Program on Thursday, January 21st, 2016 it is now available

2015 and Older News & Updates


If you missed our Statewide Conference call regarding the State Health Benefits Program on Thursday, January 21st, 2016 it is now available