The NYSCA Insurance Committee (The NIC) has been in constant contact with UMR regarding NYCE PPO claim processing issues since the first week of March, providing detailed examples and offering solutions to assist in resolving claim payment delays. We received and relayed your concerns (and examples) to UMR, including denials for appropriately billed services submitted to the same patients prior to the rollout of the new program.
The NIC understands your frustration with the ongoing nature of these denials, and your relayed inability to understand the denial rationale in the EOB. We would like to share some positive news and updates.
Claim Payment Updates
UMR agreed with our concerns and suggestions, and implemented changes to their payment systems. We anticipate this will align with that utilized by EmblemHealth (and UnitedHealthcare in the upstate market). This week , the NIC received confirmation from NYSCA members that payment has started, including services dating back to January.
We remain in communication with UMR to ensure that this will include corrected claims and inquiries filed by providers - including corrected claim denials which were requiring appeals. Improperly submitted claims remain the responsibility of the rendering provider (e.g., use of ICD-9 diagnosis codes, incorrect member IDs, lack of use of standardized billing requirements, etc.).
E/M Denials
The NIC continues to express your concerns regarding the systemic denial of properly billed E/M services rendered with CMT on the same date of service. As noted in our July News From The NIC, it appears UMR is routinely requiring documentation to support medical necessity of a separately identifiable E/M service, which has not been required by EmblemHealth or UnitedHealthcare on every such visit. The NIC will keep you appraised as we learn more from UMR and NYSCA members.
NYSCA Members: To share your current experiences with the NYCE PPO program (success or challenges, including recoupment concerns), please contact the NYSCA Insurance Committee. Members can also utilize our new contact form located at the bottom of the Commercial Insurance Page of our website.
Thank you for sharing your examples - and Feedback.
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Work like this is made possible through the involvement and support of NYSCA members. From addressing insurance and reimbursement challenges to advocating for the profession and keeping doctors informed about issues that affect their practices, NYSCA works every day to represent New York chiropractors.
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