Insurance News and Updates

Email Campaign to Fight Horizon/ASH Partnership


Easily email your local representatives in Trenton plus other key lawmakers to encourage them to ask DOBI not to approve a partnership between Horizon BCBS and ASH!

Horizon-ASH Conference Call Recording & Information


You may have or will soon be receiving a letter from Horizon announcing that they have entered into an agreement with American Specialty Health Networks (ASH).  ASH will be providing network management services for Horizon beginning January 1, 2020.

New PIP & Workers Comp Electronic Billing Laws


New Jersey has passed state laws mandating that bills for Personal Injury Protection (PIP) claims and Workers' Compensation claims must be billed electronically.  

Legislative Update: NJ Minimum Wage Increased July 1st


The minimum wage for employers with six or more employees in New Jersey has been raised to $10.00 per hour as of July 1, 2019.  The rate will rise $1.00 to $11.00 per hour on January 1, 2020 and then an additional $1.00 each year until reaching $15.00 in 2024. 

Correction: United to Require GP Modifier as of Sept. 1, 2019


United Healthcare has delayed the requirement to append the GP modifier to any codes that are deemed "Always Therapy" codes, according to CMS, until September 1, 2019. 

2019 Award Nominations


Nominations Now Open for ANJC Lifetime Achievement Award and Chiropractor of the Year!

United to Require GP Modifier as of July 1, 2019


Beginning July 1, 2019 United Healthcare will require the GP modifier to be appended to any codes that are deemed "Always Therapy" codes according to CMS. 

CIGNA-ASHN Class Action Information


Postcards regarding the $11.75 million settlement of the CIGNA-ASHN class action lawsuit have begun reaching class members.  As such, the ANJC wants to provide what you need to know.

How to File A Complaint with NJ Dept of Banking & Insurance (DOBI)


In response to more members seeking recourse for a wide variety of issues with insurance carriers and their programs, we have put together a brief webinar.  The webinar walks you through where to find and how to file a complaint to the New Jersey Department of Banking and Insurance, otherwise known as DOBI.

Supreme Court Decision & Regulatory Amendments Concerning NJ No-Fault (PIP) Insurance Claims


On March 26, 2019, the New Jersey Supreme Court held in a split decision that auto accident victims who chose the limited $15,000 coverage for no-fault (PIP) benefits in their auto insurance policy cannot recover medical expenses exceeding that amount in their personal injury case from the third party that caused the accident.

Diagnosis Code Denials


We have been hearing from membership that claims are being rejected for invalid diagnosis codes.  The doctors double check and the codes are in fact current, valid ICD-10 codes.  In all cases I have seen so far, the issue has been that the doctor reported two or more ICD-10 codes that are considered mutually exclusive to each other.

Optum Leases Network to Zelis


Optum has agreed to lease its network to Zelis (formerly Stratose). Zelis is a “health care savings company” which is also sometimes known as a silent PPO company. What this means is that if you are in-network with Optum but out of network with a number of companies Zelis works with, then you will be paid at the Optum contracted rates rather than the out of network rate for the carrier under contract with Zelis.

Aetna-NIA-SHBP Updates, Appeal, External Review & DOBI Complaints Webinar Recording!


Recording of webinar presented on Monday Feb. 25, 2019.

Aetna-NIA-SHBP SEHBP Updates


Review of the latest updates regarding Aetna, NIA and the SHBP/SEHBP Medicare Advantage Plans.

Aetna NIA Pre-Auth Documents


As of January 1st pre-authorization is required for in-network doctors on fully funded Aetna plans.  This process is handled on Aetna's behalf by a company called NIA.  There were a series of webinars presented by NIA on this new process throughout the month of December.  If you did not watch one of these webinars a recording is available on their website  You would need to be registered with NIA and logged in to view the webinar. 

SHBP-SEHBP Aetna Medicare Advantage Claim and Contact Info


As you know, approximately 175,000 retired state workers and school employees have been moved to Aetna Medicare Advantage plans that will be effective Jan. 1, 2019.  Aetna had sent letters to providers with a breakdown of the claim and contact information for these plans.  In case you missed or did not receive the letter, the information is below.

Aetna NIA Pre-Auth Soft Launch


As previously reported, Aetna will be implementing a new pre-authorization program being managed by National Imaging Associates (NIA) beginning January 1st.  The process will be required for in-network providers on fully funded policies only.  For claims submitted on or after January 1st pre-authorization will be required in order for payment to be issued. 

Aetna Erroneous Pre-Auth Denials


On Oct. 2, 2018, we advised that many members had received denials from Aetna for lack of pre-authorization of care.  We immediately approached Aetna regarding this as the new pre-authorization program is not set to begin here in New Jersey until Jan. 1, 2019

Aetna Pre-Authorization Webinars


As previously reported, Aetna’s contract with Triad/eviCore is expiring on Dec. 31, 2018.  A vendor called National Imaging Associates (NIA) will be managing a new pre-authorization program immediately following the Triad contract expiration, starting Jan. 1, 2019. 

2019 Medicare Fee Schedule


The 2019 Medicare fee schedule and deductible have been released. 

Update: Revised SHBP/SEHBP Aetna Medicare Advantage Plans Now Posted


As a follow up to our earlier email regarding the revisions to Aetna’s SHBP/SEHBP Medicare Advantage plans please be advised that the Summary of Benefits and Coverage documents for these plans have been updated and re-posted to the NJ Division of Pension and Benefits website. 

Aetna Revises SHBP/SEHBP Medicare Advantage Plans


Late Friday we were notified by Aetna of revised plan designs for the SHBP/SEHBP Medicare Advantage plans for 2019.

SHBP/SEHBP Changes Webinar


The ANJC webinar on the major changes to the State Health and School Employee Health Benefits Program recorded on Tuesday, October 30 is now available. 

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.

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.  

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.

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