Law Office of Jeffrey Randolph, LLC A.N.J.C. General Counsel

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Law Office of Jeffrey Randolph, LLCA.N.J.C.
General Counsel

• Horizon BCBS of NJ
• Administrative Action
• January 2010
• (Part 2)

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What Plans?

• Managed Care Applies to Horizon HMO, Horizon
  POS Horizon Direct Access.
• PPO / Traditional Horizon PPO, Horizon
  Traditional / Indemnity products.
• Not SHBP separate appeal process to SHBC.
• Self-Funded Not covered governed by ERISA.

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Appeal Your Denials Covered Plans

• !! Make sure you are following the right appeal
  route !!
• Medical Necessity Denial DOBI appeal
• Non-Med. Necessity Denial DOBI appeal
• SHBP Non-DOBI appeal
• ERISA Non-DOBI appeal
• NOTE Jumping Routes may occur!

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Which Route Do I Take?

• MOST IMPORTANT DECISION WHICH APPEAL
  ROUTE?
• 1) Medical Necessity Denials Three Step
  Internal /External Appeal Route to IURO (HCAPPA).
• 2) Non-Medical Necessity Denials Two Step
  Appeal Route to Major Medical Arbitration
  (PICPA). This is the most likely route for
  denials based upon global bundling / scope of
  practice.
• 3) Non-DOBI appeal route varies by plan.

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Medical Necessity Denials

• What qualifies as a Medical Necessity Denial?
• Not Medically Necessary all care denied.
• Not Medically Necessary less care authorized
  that you requested.
• Experimental / Investigational in nature (ie. MUA)

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Non-Medical Necessity Denials

• What Qualifies as a Non-Medical Necessity Denial?
• Global bundling
• Service outside scope of practice.
• Contractual issues (i.e. preauthorization
  failure).
• Post-Payment reviews.
• UCR issues.

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Three Level Medical Necessity AppealIndependent
Health Claims Appeal Program (IHCAP)

• 1) Level One Internal Appeal with carriers
  medical director or other reviewing provider.
  (could be nurse).
• 2) Level Two Internal Appeal with insurer
  review panel including like specialty provider
  (D.C.).
• 3) Level Three External Appeal to Independent
  Utilization Review Organization (IURO).

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Documentation to Submit to DOBI for Medical
Necessity External Review

• DOBI External Appeal form
• http//www.state.nj.us/dobi/chap352/352ihcapform.d
  oc
• Signed Authorization Assignments of Rights form
• http//www.state.nj.us/dobi/chap352/352consentform
  .doc
• Written copies of Stage I II appeal decisions
• Evidence of coverage issued by insurer
• Fee 25 payable to DOBI
• Clinical Records
• Treatment guidelines

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Two Level Non-Medical Necessity AppealProgram
for Independent Claims Payment Arbitration Act
(PICPA)

• 1) Level One Internal Appeal with Insurer
  Review Department.
• Use DOBI Form 352 www.state.nj.us/dobi/chap352/3
  52application.doc
• Mail to Horizon BCBS of NJ
• Appeals Department
• PO Box 10129
• Newark, NJ 07101
• 2) Level Two File Major Medical Arbitration
  with Maximus, Inc.

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Maximus Arbitration (PICPA)

• Set up account file arbitration on line at
  https//njpicpa.maximus.com
• 90 days to file from receipt of internal appeal
  denial.
• Must be at least 1,000 in issue.
• 50 preliminary review fee (non-refundable) and
  130 arbitration fee (refundable) per 1000 in
  issue.
• Mail fees to MAXIMUS, Inc., Attn New Jersey
  PICPA, 50 Square Drive, Suite 210, Victor, New
  York 14564.
• Address questions to Maximus via email at
  njpicpa_at_maximus.com or by phone at [phone].
  
• Review prior decisions at www.state.nj.us/dobi/ch
  ap352/selectarb.html

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Maximus Arbitration What to Submit.

• All information related to your internal claims
  appeal, including a copy of the Internal Appeal
  Form, and the insurer's decision, if any.
• All relevant medical records and billing records
  (i.e. HCFA 1500s).
• All relevant correspondence between the health
  care provider and insurer.
• A copy of the 10/7/09 DOBI Order.

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Maximus Arbitration What Happens Then?

• Reviews will be based solely on the submitted
  documentation. There is no arbitration hearing.
• MAXIMUS will forward the written results of the
  Arbitration to the provider, insurer, and DOBI
  within 30 calendar days following receipt of the
  documentation necessary for making a decision.
• Decisions are binding and non-appealable in most
  circumstances.
• Can get 12 interest on improperly denied claims.

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Conclusion

• 1) ANJC Legal looking into retrospective
  reimbursement and is contemplating legal action.
  More information to follow.
• 2)You MUST file at least one internal appeal if
  Horizon continues to deny payment for EM
  modalities to preserve your rights.
• 3) Participating Providers may be locked into the
  Maximus arbitration process. Non-Par providers
  have more options. Consult ANJC counsel if you
  have questions.

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Conclusion

• Questions and Answers?
• Law Office of Jeffrey Randolph, LLC
• T 973-831-4080
• F 973-831-4082
• Email jrandolph_at_jrlaw.net