b'ComplianceLEGAL NUTRITIONCouncilANJC Leadership ANJC Leadership LEGAL EASE NUTRITION REHAB Council Executive Directors UPDATE LEGAL Q&A CHIROASSISTINSURANCE Update INSURANCE Update Legislative UpdateBy Matt MinnellaANJC Director of Insurance & Regulatory Affairs TECHNIQUE CouncilSpring Insurance UpdateAetna-NIA Issues:There has beenthe NIA system, indicating they need4. Parent code denials:The NIA much confusion and several instances ofMedicareQ&Asystem is supposed to approve pre-auth, and this was confirmed by misinformation given by Aetna and NIANIA and Aetna call centers. This was,providers for units of a particular billableOUR HEALTHthrough the rollout of the new pre-au- for the most part, incorrect. The SHBP/ group of codes. These billable groups thorization process administered by NIA. SEHBP Aetna Medicare Advantageare represented by one of the codes Aetna and NIA put together a letter plan members are in the NIA systemin each group. For example, 98940 to address some of the outstandingbecause they will require pre-authrepresents the manipulation billable concerns. You can find this letter on thefor care rendered by a PT or OT,group. This group includes all manip-ANJC website, www.anjc.info, underbut not chiropractic care with oneulation codes including 98940, 98941, Insurance > News & Updates >exception. A small percentage of SHBP/ 98942 and 98943. If you are approved Aetna-NIA SHBP-SEHBP UpdatesSEHBP retirees are on Aetna Medicarefor 10 units of 98940 in this scenario, posted on Jan. 30 or under Insurance >Advantage HMO plans, which they wereyou should be able to bill any of the Health Insurance Carriers & MCOs >on prior to the mass migration of themanipulation codes for that patient up Aetna.retirees to the Aetna Medicare Advan- to 10 times during the defined time tage plans for this year. Among SHBP/ period. We have been seeing many Aetna and NIA had advised that to checkSEHBP retiree plans, only these HMOexamples where providers are approved if a patient needed pre-authorization orplans will require pre-auth and coverfor these 10 units of 98940, bill a not the doctor should enter the patientsonly spinal manipulation. The patients98941 (as should be allowed under the information into the NIA site www. with these plans should have ID cardssystem), and are denied. The denials RadMD.com. If the patient showed in theirmarked as HMOs.state that the code billed is not what system it meant that Aetna had loadedThere is another group of SHBP/SEHBPwas approved! We have alerted NIA and them there and that patient neededpatients who may require pre-auth.Aetna of this issue. They say they are pre-auth. If they were not in the system,Townships and school districts can chooseworking on a correction. then they would not need pre-auth.to either use the state-run health plan or5. E/M-CMT-Extra-spinal Denials:Several issues arose. Lets review: to set up their own plan for their activeWe have received many reports of 1. Denials for Lack of Pre-Auth: employees. Some townships and schoolAetna denying CMT codes when billed When the system went live, theredistricts have opted to set up their ownwith any evaluation and management were patients who were not loadedplan with Aetna. Some of these are fully(E/M) codes even when the E/M code into NIAs system by Aetna that did infunded plans and hence will requirewas appended with the -25 modifier. fact need pre-auth. Therefore, manypre-authorization. Aetna notes that the IDSimilarly we have seen CMT codes doctors checked the system, saw thatcards for these plans would not show thedenied when billed on the same date the patient did not need pre-auth,SHBP or SEHBP insignia.of services as extra-spinal manipulation. proceeded with care and eventually3. Triad:Many members have reportedWe brought this to Aetnas attention, received denials for lack of pre-auth. Thereceiving EOBs from Aetna with noand originally they advised that they letter encourages doctors to re-checkpayment stating that the claims werefollow NCCI claim edits and the denials their patients to make sure they havesent to Triad for processing. Somewere correct. There are no NCCI edits not been added to the NIA system sincehave even received letters from Triadnor any other coding rules or guidelines the initial rollout. For denials receivedconfirming that the claims were receivedthat would dictate these types of under this scenario, they advise doctorsand would be processed soon! Letdenials. Eventually, Aetna acknowledged to contact the dedicated Providerus re-confirm: Triads contract witherror in these claim denials. At the time Relations Managers: Aetna ended Dec. 31, 2018, and noof printing we are awaiting a time frame Charmaine Everett New Jersey chiropractic claims shouldfor corrected payments to be issued. Email: cseverett@magellanhealth.com be handled by Triad. I alerted AetnaData iSight-NJ DOBI Meeting:Phone: 800-450-7281 x32615 to this issue. Aetna advised that thisFor over a year, members have been Justin Clifford was a mistake and the issue had beenseeing significant reductions on their Email: jclifford@magellanhealth.com corrected as of Tuesday, Jan. 29. Aetnaout-of-network claims to carriers such states all claims sent to Triad had beenas CIGNA, United and Aetna from a 2. SHBP/SEHBP Plans Requiringpaid by Aetna as of Feb. 8. If you havethird-party repricing company called Pre-Auth:For the first several weeks2019 claims that have not yet been paidData iSight. This company is lowering of the year, members reported thatbecause they were sent to Triad errone- the allowed amounts on claims for SHBP/SEHBP patients were showing inously, contact me at matt@anjc.info.out-of-network providers and creating 12 I Spring2019 www.anjc.info'