UNITED HEALTH CARE MULTIPLE PROCEDURE REDUCTION ERROR

on . Posted in Commercial Insurances

It has been recently discovered that United HealthCare is having a system wide issue in relationship to processing both therapy and modality charges.

From the information we gathered, all therapy claims billed with multiple units are being processed incorrectly by their computer system. The system is separating all charges with multiple units and breaking them down to individual line items.  At that point, the system is then breaking payment down based on the number of CPT codes, resulting in an incorrect multiple procedure reduction.

UHC does not have much information, they just became aware of the issue and do not expect it to be rectified until September or October 2013.

 For reference, the denial codes or Y1 and Y2.

(Y1)- This service line submitted with a single date of service and multiple units, or multiple dates of service and multiple units. Will be recoded to separate the dates and/or units.

(Y2)- For processing purposes this service line has been recoded (1) with an individual date of services. (2) with an individual unit, and/or (3) without a modifier.

Should a practice receive this denial, our staff has been instructed to call UHC and have the claim reprocessed.  UHC has already developed a “Claims Project Team” to handle the intake and reprocessing of these errors.

Please contact the office should you have any questions or concerns.

Horizon BCBS Recredentialing Responsibilities

on . Posted in Commercial Insurances

Compliance with Horizon Blue Cross Blue Shield of New Jersey's recredentialing standards is an ongoing contractual responsibility of all participating physicians and other health care professionals. Participating physicians and other health care professionals are also under a continuing contractual obligation to correct any previously provided credentialing information that is, or becomes, inaccurate.

As required by New Jersey state guidelines and accreditation bodies, all practitioners must be recredentialed every 36 months. Physicians and other health care professionals who fail to update or provide necessary information in a timely manner may have their PPO and/or managed care agreements terminated.

Horizon BCBSNJ works with Medversant®, a leader in technology solutions for the management of health care provider information, to help it carry out its recredentialing process. The following is a high-level overview of our recredentialing process.

  • Nine months prior to your recredentialing due date, Medversant will begin the recredentialing process by searching for current information on the Council for Affordable Quality Healthcare® (CAQH) online Universal Provider Datasource® (UPD). If your information is up-to-date on the UPD, the recredentialing process will continue.
  • If information is either not on the UPD or not current on the UPD, Medversant will contact you to request that updated and/or missing information is made available.
  • If Medversant doesn't receive a response, Horizon BCBSNJ will send you two letters:
    - The initial letter will be mailed 90 days before the recredentialing cycle ends.
    - The final letter will be sent 60 days before the recredentialing cycle ends.
  • If Medversant has not received a response, you will be terminated from Horizon BCBSNJ networks at the end of the month prior to your recredentialing due date.

If you have questions about recredentialing, including questions about your recredentialing status, submission instructions or general process inquiries, please call 1-800-508-5799 and, when prompted, select the option for Questions Regarding Credentialing, and then select the option for Horizon Provider.

Medversant representatives are available Monday through Friday, between 7 a.m. and 10 p.m., Eastern Time.

June 6, 2013 Recredentailing Responsibilities

Cigna single appeal reviews only, effective 07/01/2013

on . Posted in Commercial Insurances

Historically, for certain business units and types of appeals, Cigna has offered second-level appeals to health care professionals who were not satisfied with the resolution of a first-level review. Please be aware that beginning July 1, 2013, Cigna will no longer offer second-level appeals. All appeals will follow a thorough single appeal review process and will be completed within 60 days. This change establishes a consistent approach for health care professionals across Cigna’s network.

 

As a reminder, all appeals should be initiated in writing within 180 calendar days of the date of the initial payment or denial decision. If the appeal relates to a payment that we adjusted, the appeal should be initiated within 180 calendar days of the date of the last payment adjustment.

 

Patients are still entitled to second level appeals per ERISA guidelines, so remember to include an assignment of benefits when completing a second level appeal on behalf of the patient.

 

Health care professionals should submit all appeal requests on a “Request for Provider Payment Review Form,” which can also be found on the Cigna for Health Care Professionals website at (CignaforHCP.com > Resources > Forms Center > Medical Forms). This form will help Cigna understand the circumstances around your appeal request in order to conduct that thorough review.

 

For additional information on how to submit an appeal, please review the Claim Adjustment & Appeals Guidelines on the Cigna for Health Care Professionals website (CignaforHCP.com >Resources > Clinical Reimbursement Policies and Payment Policies > Claims Appeals Policies and Procedures > Appeal Policy and Procedures).

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Welcome to Precision Billing & Consulting Services, LLC, a full service billing and consulting agency serving the entire nation.

Precision Billing & Consulting Services, LLC, allows you to save money while eliminating the headaches and worries of staying compliant with insurance regulations.

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Thursday, September 17, 2015

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