bulletin summer 2011

3047 Avenue U, Brooklyn NY 11229 Phone: 888-WCHEXPERTS Phone: 888-WCHEXPERTS www.wchsb.com

WCH Service Bureau, Inc Is the proud member of the

following professional

WCH Bulletin June 2011 VOLUME 2 ISSUE 3

WELCOME TO OUR SUMMER EDITION!

Dear Readers, We would like for you to enjoy this issue of WCH bulletin, its mainly focuses on the credentialing ser-vices that WCH offers to healthcare providers and suppliers. In addition, we are providing you with most recent updates currently taking place in the insurance industry. WCH wishes you and your family to have a won-derful summer. We are looking forward hearing your adventure stories.


INSIDE THIS ISSUE:

Provider enrollment by WCH.................................................................................................................................3 Our credentialing process.......................................................................................................................................4 Medicare proposes a 50% cut for some imaging fees in 2012............................................................................5-6 Medpac recommended that...................................................................................................................................7 The accompanying chart outlines coding and policy changes.............................................................................8-9 California blue shield pledges $180 million in rebates.........................................................................................10 California hmo rates raised an average of 11% per year from 2000 to 2010.......................................................10 Medicare identified six billing characteristics that may indicate fraud in outpatient therapy services..............11 010 electronic prescribing (erx) incentive program ...........................................................................................12 Revalidation of provider enrollment information................................................................................................13 Reporting of recoupment for overpayment on the remittance advice (ra) with patient control number..........13 Compliance alert.............................................................................................................................................14-15 Medicaid: radiology prior approval......................................................................................................................16 Valueoptions to administer emblem behavioral health services to hip and ghi hmo members..........................17 New radiology claims processor...........................................................................................................................18 Frequently asked by physical therapist clients.....................................................................................................19 Contact information..............................................................................................................................................20


PROVIDER ENROLLMENT by WCH For more than ten years, WCH Service Bureau, Inc. proudly serves a thousand of providers

in New York, New Jersey, Pennsylvania, California, Delaware, Florida and many other

states, providing each client with best credentialing, personal attention, re-credentialing,

chart auditing and billing services.

Our company provides services to fit all your practice’s needs, and we can find any solu-

tions that will satisfy your practice. The quality of our services are designed to increase

your practice revenue and ensure that

the accuracy of your medical data to be

parallel to the guidelines and require-

ments of the healthcare industry.

We know and understand the creden-

tialing process rules and regulations of

different insurance organizations and

their unique provider credentialing re-

quirements. Moreover, also know that

insurance weak points; which allows us

to navigate the provider credentialing

process to achieve positive results.

Contact us today for your credentialing needs.

WCH specializes in enrollment of:

Independent Diagnostic Testing Facility (IDTF)

Durable Medical Supply (DME)

Pharmacies

Multi-Specialty Groups

Laboratories

Solo Groups and Physician Groups

Civil Surgeons

Individual contracts (all specialties)

Transportation Companies

Early Intervention Agency (EIA)

Home Health Agency(HHA)

Sleep Centers

WCH BULLETIN VOLUME 2 ISSUE 3


Our Credentialing Process

From years of experience WCH understands the importance of accurate credentialing process and contract negotiating that will guide your practice to success. The credentialing process at WCH is simple for every type of healthcare provider.

Step 1: WCH - meets with Clients and discusses what credentialing services are needed.

Step 2: WCH - Signs the credentialing agreement, and sends it along with the credentialing information form and the invoice to the client.

Step 3: WCH - Verify panel availability. Request contracts. This process can take approximately 2-3 weeks

Step 4: WCH - Meets with the client to sign the insurance contracts/applications.

Step 5: WCH - Completes, mails the contracts/applications to insurance companies and reports to cli-ents Step 6: WCH - Conducts weekly phone calls to request status updates from the respective insurance companies, and submit additional information if required. Update providers and weekly notes

Step 7: WCH - Upon contract approval, contact providers and update them on the effective date, pro-vider ID. Case is closed

Step 8: Providers can begin billing for services. WCH billing team is ready for the client


Please visit our new sites for more information about credentialing services:

http://credentialingsite.com/

http://insuranceenrollment.net/


Medicare proposes a 50% cut for some imaging

fees in 2012

Service 2011 payment 2012 payment Change

New office visit $102.95 $73.57 -$29.38

Established office visit $68.97 $49.13 -$19.84

Chest x-ray $23.78 $16.53 -$7.25

Mammogram $110.76 $77.64 -$33.12

Intracoronary stent insertion $873.19 $588.30 -$284.89

Total knee arthroplasty $1,539.47 $1,081.71 -$457.76

CMS already reduces what it pays for the technical component when multiple scans are provided

to the same patient on the same day. Now they are proposing to extend the reduction to the profes-

sional component. So a physician who interprets more than one MRI or CT scan taken of the same

patient during the same visit, for instance, would see a 50% reduction in pay for interpreting the

second and any subsequent scans.

The CMS says that money saved by reducing rates for overvalued services helps boost pay for pri-

mary care and other services that it considers undervalued.

Not every specialty that provides imaging services would be affected equally. The services that

CMS plans to cut are not commonly provided by cardiologists, said Brian Whitman, associate di-

rector of regulatory affairs for the American College of Cardiology. However, diagnostic services

offered by cardiologists, also could see payment reductions when the technical component of a test

is billed at the same time as another service.

The AMA has disagreed with that approach and suggested the policy would compromise care.

Doctors must e-prescribe at least 10 times in the first 6 months of 2012 to avoid a penalty in 2013.

A 29.5% Medicare pay cut for physicians is scheduled for January 2012 unless Congress prevents

the reduction.

In the proposed fee schedule it would apply a similar approach used this year to implement Medi-

care e-prescribing penalties in future years, meaning doctors must e-prescribe in 2012 to avoid a

1.5% penalty in 2013.

What this cut would look like



Specialty Projected 2012 spending (in millions)

Change

Allergy/immunology $194 1%

Anesthesiology $1,847 2%

Cardiology $6,778 -1%

Colon and rectal surgery $146 1%

Critical care $252 0%

Emergency medicine $2,658 -1%

Family practice $5,640 1%

Gastroenterology $1,837 0%

General practice $656 1%

Geriatrics $200 1%

Internal medicine $10,737 1%

Multispecialty clinic/other $84 0%

Neurology $1,520 2%

Nuclear medicine $53 -3%

Obstetrics-gynecology $678 0%

Ophthalmology $5,316 2%

Orthopedic surgery $3,572 1%

Pathology $1,122 -1%

Pediatrics $68 1%

Physical medicine $928 2%

Psychiatry $1,134 0%

Pulmonary disease $1,758 0%

Radiology $4,722 -4%

Physicians who earn bonuses for e-prescribing this year would not be subject to the

2013 penalty. Doctors who earn bonuses for e-prescribing in 2012 also would not be pe-

nalized in 2014, when the pay cut rises to 2%.

How specialties would fare

The impact of cuts on Medicare payment that CMS is proposing to implement for 2012

varies depending on the specialty.

Source: Centers for Medicare & Medicaid Services (www.ofr.gov/OFRUpload/OFRData/2011


http://www.ofr.gov/OFRUpload/OFRData/2011-16972_PI.pdf


Specialty Projected 2012 spending (in millions)

Change

Allergy/immunology $194 1%

Anesthesiology $1,847 2%

Cardiology $6,778 -1%

Colon and rectal surgery $146 1%

Critical care $252 0%

Emergency medicine $2,658 -1%

Family practice $5,640 1%

Gastroenterology $1,837 0%

General practice $656 1%

Geriatrics $200 1%

Internal medicine $10,737 1%

Multispecialty clinic/other $84 0%

Neurology $1,520 2%

Nuclear medicine $53 -3%

Obstetrics-gynecology $678 0%

Ophthalmology $5,316 2%

Orthopedic surgery $3,572 1%

Pathology $1,122 -1%

Pediatrics $68 1%

Physical medicine $928 2%

Psychiatry $1,134 0%

Pulmonary disease $1,758 0%

Radiology $4,722 -4%

The Medicare Payment Advisory Commission in its June report to Congress recommended tighter re-views of spending on diagnostic imaging, among

other advice.

MedPAC recommended that:

Congress reduces the professional component for multiple diagnostic imaging services when interpreted by the same physician for the same patient session. Congress reduces the physician work component of diagnostic imaging services ordered and performed by the same physician. Congress establishes a prior authorization program for very frequent users of ad-vanced diagnostic imaging services. The Health and Human Services secretary accelerate ongoing efforts to bundle certain physician Medicare payments. Congress provides Medicare funding to physicians, hospitals and other health pro-fessionals so they can contract directly with quality improvement organizations.

Source: "June 2011 Report to the Congress: Medicare and the Health Care Delivery System," Medicare Pay-

ment Advisory Commission, June (www.medpac.gov/documents/jun11_entirereport.pdf)

http://www.ama-assn.org/amednews/2011/06/27/gvl10627.htm


http://www.medpac.gov/documents/jun11_entirereport.pdf

http://www.ama-assn.org/amednews/2011/06/27/gvl10627.htm


Aetna regularly adjusts its clinical, payment and coding policy positions as part of our ongoing pol-

icy review processes. In developing the policies, Aetna may consult with external professional organi-

zations, medical societies and the independent Physician Advisory Board, which provides advice to us

on issues of importance to physicians.

The accompanying chart outlines coding and policy changes:


Procedure Implementation date Implementation date

Laboratory and diagnostic interpretation

Reminder Aetna allows payment for the diagnostic interpretation of one lab or diagnostic test performed per date of service (DOS) across providers.

Precertification will not override incidental procedure denial

New effective date: 9/12/2011

Precertifications will not override related services that are considered incidental. The effective date of this policy changed from 9/1/2011 to 9/12/2011.

Multiple procedure reductions for therapy procedures

11/14/2011 Effective for dates of service on or after November 14, 2011, multiple procedure reductions will be applied to certain therapy procedures. The procedure with the highest practice expense RVU will be allowed at 100 percent. The practice expense portion of each additional therapy service performed by the same provider group on the same date of service will be allowed at 80 percent. The Therapies – Modalities per Date of Service payment policy still applies.

Per day limits 12/1/2011 Per day limits will apply to the following codes effective 12/1/2011: 97802 and 97803 Medical nutrition therapy 4 units per date of service (2 units per site, per side (LT, RT)) for: L2755 Addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepeg composite, per segment



Page 8


Laboratory and diagnostic interpretation

Reminder Aetna allows payment for the diagnostic interpretation of one lab or diagnostic test performed per date of service (DOS) across providers.

Precertification will not override incidental procedure denial

New effective date: 9/12/2011

Precertifications will not override related services that are considered incidental. The effective date of this policy changed from 9/1/2011 to 9/12/2011.

Multiple procedure reductions for therapy procedures

11/14/2011 Effective for dates of service on or after November 14, 2011, multiple procedure reductions will be applied to certain therapy procedures. The procedure with the highest practice expense RVU will be allowed at 100 percent. The practice expense portion of each additional therapy service performed by the same provider group on the same date of service will be allowed at 80 percent. The Therapies – Modalities per Date of Service payment policy still applies.

Per day limits 12/1/2011 Per day limits will apply to the following codes effective 12/1/2011: 97802 and 97803 Medical nutrition therapy 4 units per date of service (2 units per site, per side (LT, RT)) for: L2755 Addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepeg composite, per segment


Per day limits 12/1/2011 L5618 – L5626 Addition to lower extremity, test socket L5673 and L5679 Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for/for use with locking mechanism 12 units per date of service for: 80101 Drug screen, qualitative; single drug class method (e.g., immunoassay, enzyme assay), each drug class 20 units per date of service for: +97598 Debridement, open wound, including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; each additional 20 sq. cm, or part thereof

Source: http://www.aetna.com/newsletters/provider/OfficeLinks/2011/September/clinical-coding-changes.html


California Blue Shield

pledges $180 million in rebates

The money will go to customer credits, public health and ACOs. The insurer will limit annual income,

but doesn't guarantee it won't raise rates again.

Blue Shield of California has pledged that the nonprofit health plan will limit its net income to 2%

of revenue.

The company's pledge takes effect for its 2010 income. It will credit $167 million of its 2010 in-

come to current customers, $25 to $160 – for individual subscribers, $130 to $415 for a family of

four. Employers who pay for workers' coverage will be credited between $110 and $130 per em-

ployee.

Blue Shield Chief Executive Officer Bruce Bodaken announced the company's decision on June

7th.

However the 2% promise holds only as long as "the company's board of directors determines that

Blue Shield remains financially solvent..." The company said it might have to raise rates in the fu-

ture.

California HMO rates raised an average of

11% per year from 2000 to 2010.

Bodaken talked about the health reform. He said reform will expand access, but won't be enough

to make sure everyone is covered.

In the past decade, California HMO rates raised an average of 11% per year. Even if they reduce

that trend to 8%, premiums will double by 2020. That means a comprehensive benefit package will

cost nearly $40,000 for a family of four while wages in California are on track to rise by just 50%

to an average of $75,000 in 2020. The simple fact is that unless premiums track wage increases, the

number of uninsured will snowball, undermining the coverage gains made by health reform.

By EMILY BERRY, amednews staff. Posted June 20, 2011.

http://www.ama-assn.org/amednews/2011/06/20/bisb0620.htm


http://www.ama-assn.org/amednews/site/bio.htm#berry

http://www.ama-assn.org/amednews/2011/06/20/bisb0620.htm


Medicare identified six billing characteristics that may indicate fraud in outpatient therapy services

These characteristics were:

1 - Average number of outpatient therapy services per beneficiary that providers indicated would exceed an

annual cap. According to therapy fraud experts within the PSCs, the KX modifier is often overused and/or

used inappropriately. Medicare calculated the average number of services per beneficiary that had the

KX modifier.

2 - Percentage of outpatient therapy beneficiaries whose providers indicated that an annual cap would be

exceeded on the beneficiaries’ first date of service in 2009. Providers should use the KX modifier only when

providing services that are expected to exceed an annual cap. This is unlikely to occur on the beneficiary’s

first date of service in a new calendar year. We identified beneficiaries whose providers billed Medicare

using the KX modifier on the beneficiaries’ first date of service in calendar year 2009.

3 - Average Medicare payment per beneficiary who received outpatient therapy from multiple providers.

This characteristic raises concerns about stolen Medicare identification numbers or “professional beneficiar-

ies” who exchange their identification numbers for kickbacks from providers. We identified beneficiaries

who received outpatient therapy from more than one provider in 2009 and calculated the average re-

imbursement per beneficiary in 2009.

4 - Percentage of outpatient therapy beneficiaries whose providers were paid for services provided through-

out the year. Therapy services are appropriate for improving the beneficiary’s functioning level, but not for

maintaining an existing level of functioning. We identified beneficiaries who received outpatient therapy

during all four quarters of 2009.

5 - Percentage of outpatient therapy beneficiaries whose providers were paid for services that exceeded

one of the annual caps. We identified beneficiaries who received either a combination of PT and SLP ser-

vices or OT services, excluding those provided in hospitals, for which Medicare allowed more than $1,840.

6 - Percentage of outpatient therapy beneficiaries whose providers were paid for more than 8 hours of outpa-

tient therapy provided in a single day. According to PSC representatives, providing more than 8 hours of

therapy to a beneficiary in a single day is usually medically unnecessary and/or infeasible because of the

characteristics of the Medicare population and the nature of services provided. We identified HCPCS codes

for which the unit of service represents a specific amount of time (typically, 15 minutes) spent in direct con-

tact with the beneficiary on any single calendar day. We then determined how many of these services a bene-

ficiary received on the same day.



2010 Electronic Prescribing (eRx) Incentive Program

Incentive Payment

The CMS is pleased to announce that incentive payments for the 2010 Medicare Electronic Prescribing

(eRx) Incentive Program has begun for eligible professionals who met the criteria for successful report-

ing.

Distribution of 2010 payments Medicare Electronic Prescribing (eRx) Incentive is scheduled to be

completed by August 31, 2011.

Effective January 2010, CMS revised the manner in which incentive payment information is communi-

cated to eligible professionals. CMS has instructed Medicare contractors to use a new indicator of LE to

indicate incentive payments instead of LS. LE will appear on the electronic remit.

To further clarify the type of incentive payment

issued: PQRI or eRx incentive, CMS created a 4

-digit code which indicates the type of incentive

and reporting year. For the 2010 eRx incentive

payments, the 4-digit code is RX10.

Additionally, the paper remittance advice will read, “This is an eRx incentive payment.” The year will

not be included in the paper remittance.

June 20, 2011

The following CMS resource is available to help eligible professionals understand the 2010 eRx Incen-

tive Payments: http://www.cms.gov/ERxIncentive/Downloads/

Guide_Understanding_2010_eRx_Incentive_Payment_06-20-2011.pdf


http://www.cms.gov/ERxIncentive/Downloads/Guide_Understanding_2010_eRx_Incentive_Payment_06-20-2011.pdf

http://www.cms.gov/ERxIncentive/Downloads/Guide_Understanding_2010_eRx_Incentive_Payment_06-20-2011.pdf


Revalidation of Provider Enrollment Information (For all providers and suppliers who enrolled in Medicare prior to March 25, 2011)

All providers and suppliers enrolled with Medicare prior to March 25, 2011, must revalidate their

enrollment information after receiving notification from their Medicare Administrative Contractors

(MAC). When you receive notification from your MAC to revalidate, you must:

update your enrollment through Internet-based PECOS or complete the CMS-855;

sign the certification statement on the application;

and if applicable, pay your fee thru pay.gov.

Also, please be sure to mail your supporting documents and certification statement to your MAC.

http://www.cms.gov/MLNMattersArticles/downloads/SE1126.pdf

http://www.palmettogba.com/palmetto/providers.nsf/ls/J1B~8KJH6L5080?opendocu

Reporting of Recoupment for Overpayment on

the Remittance Advice (RA) with Patient Control

Number

The Centers for Medicare & Medicaid Services (CMS) generates remittance advices that include

enough information to providers so that manual intervention is not needed on a regular basis.

It has been brought to the attention of CMS that providing the Patient Control Number as received

on the original claim rather than the Health Insurance Claim (HIC) number would:

∙ Enhance provider ability to automate payment posting, and

∙ Reduce the need for additional communication (phone calls, etc.) that would reduce the costs for

providers as well as Medicare.

The ERA will continue to report the HIC number if the Patient Control Number is not available.

This would appear in positions 20-39 of PLB 03-2. A demand letter is also sent to the provider when

the Accounts Receivable (A/R) is created. This document contains a claim control number for track-

ing purposes that is also reported in positions 1-19 of PLB 03-2 on the ERA.

http://www.cms.gov/MLNMattersArticles/Downloads/MM7499.pdf


http://www.cms.gov/MLNMattersArticles/downloads/SE1126.pdf

http://www.palmettogba.com/palmetto/providers.nsf/ls/J1B~8KJH6L5080?opendocu

http://www.cms.gov/MLNMattersArticles/Downloads/MM7499.pdf


Compliance Alert

COMPLIANCE PROGRAM REQUIREMENT FOR NEW MEDICAID

PROVIDERS May 5, 2011

New York Social Services Law §363-d subsection 3 and 18 NYCRR §521.3(b) require applicants as

providers in the Medicaid program to have a compliance program and to certify that they have an

effective compliance program, if required. The purpose of Compliance Alert 2011-05 is to provide

guidance to providers who are applying for participation status in New York State’s medical assistance

(Medicaid) program on this requirement. This Compliance Alert will address the Medicaid providers

who are required to have and to certify that they effective compliance programs because Medicaid is a

substantial portion of business operations.

Statutory/Regulation Authority:

Persons or entities who are subject to the provisions of New York State Public Health Law articles

28 or 36 (generally hospitals, nursing homes, clinics, home care agencies, etc.) and New York State

Mental Hygiene Law articles 16 and 31 (Office of Mental Health, Office of Persons with Developmen-

tal Disabilities and Office of Alcohol and Substance Abuse Services facilities, etc.) are required by So-

cial Services Law §363-d subsection 4 and 18 NYCRR §521.1 to adopt and implement effective compli-

ance programs. In addition to the above providers, 18 NYCRR §521.1(c) requires providers for which

Medicaid is or should be reasonably expected to be a “substantial portion of business operations” to

adopt and implement effective compliance programs. For most providers, if the Medicaid provider

orders at least $500,000 in Medicaid services during a 12-month period, or claims and/or is paid at least

$500,000 in Medicaid services during a 12-month period, that provider is determined to have Medicaid

as a substantial portion of business operations. This requires the Medicaid provider to have a compli-

anceprogram and to annually certify that it is effective.

Social Services Law §363-d subsec. 3 requires:

Upon enrollment in the medical assistance program, a provider shall certify to the

department that the provider satisfactorily meets the requirements of this section [363-d].

18 NYCRR §521.3(b) requires:

Upon applying for enrollment in the Medical Assistance program, … a required provider

shall certify to the department, using a form provided by the Office of the Medicaid

Inspector General on its Web site, that a compliance program meeting the requirements

of this Part [521] is in place.

NYS Department of Health Medicaid Application - Required Documentation to be Submitted,

requires providers to:

SUBMIT THE OFFICE OF MEDICAID INSPECTOR GENERAL (OMIG) PROVIDER

COMPLIANCE CONFIRMATION (IF APPLICABLE). …



Bureau of Compliance Review of New Medicaid Providers

For providers who must have a compliance program and annually certify that their compliance pro-

gram is effective, solely because Medicaid is a substantial portion of business operations,1 the certifica-

tion should be based upon the existence of a compliance program that meets the eight elements set out

in Social Services Law §363-d subsec. 2 and 18 NYCRR §521.3(c).

1. The Bureau of Compliance will review the Medicaid provider applicant to determine if he/she/it

will claim, order or be paid $500,000 for Medicaid services during a 12-month period. If the

Medicaid provider applicant’s Medicaid business is not a “substantial portion of business

operations,” the applying provider need not certify as part of the Department of Health’s

application process that he/she/it has a compliance program.

The Medicaid provider applicant should be advised that he/she/it will be expected to certify that

he/she/it has an effective compliance program when the Medicaid provider applicant’s business

is a “substantial portion of business operations” as defined in 18 NYCRR §521.2(b).

The Medicaid provider applicant is expected to take reasonable notice of the facts and

circumstances surrounding the services that he/she/it will be providing when making the

assessment of whether Medicaid shall be a “substantial portion of business operations.”

2. If option “1” above does not apply and the applying provider has a Medicaid patient base such

that the applying provider’s Medicaid business is a “substantial portion of business operations”

as defined in 18 NYCRR §521.2(b), the applying provider must certify as part of the Department

of Health’s application process that he/she/it has a compliance program.

The applying provider is expected to take reasonable notice of the facts and circumstances

surrounding the services that he/she/it will be providing when making the assessment of whether

Medicaid shall be a “substantial portion of business operations.” This shall include, but not be

limited to, the following:

a. If the applying provider is purchasing an existing Medicaid provider location, whether

the Medicaid business at that location at the date of purchase meets the definition of a

“substantial portion of business operations” as defined in 18 NYCRR §521.2(b).

b. If the applying provider has an existing Medicaid patient base that, when combined with

1 If the Medicaid provider applicant is subject to Public Health Law Articles 28 or 36, or Articles 16 or

31 of the Mental Hygiene Law, the Medicaid provider applicant must certify that he/she/it has an effec-

tive compliance program as part of the Department of Health application process regardless of the dollar

amount claimed, order or paid by Medicaid during a 12-month period. The new location or new ser-

vices, will move the total Medicaid business by the applying provider to become a “substantial portion

of business operations” as defined in 18 NYCRR §521.2(b).

c. If the applying provider is purchasing an existing Medicaid provider or Medicaid

provider location where Medicaid is a “substantial portion of business operations” as

defined in 18 NYCRR §521.2(b), does the selling Medicaid provider have a compliance

program that meets the requirements of Social Services Law §363-d subsec



2 and 18 NYCRR §521.3(c) such that during a transition, as part of the sale, the selling Medicaid

provider’s compliance program can be incorporated into the applying Medicaid provider’s operation until

such time as the applying Medicaid provider can update, revise or replace the existing compliance pro-

gram?

d. The applying Medicaid provider’s current or prior NYS Medicaid compliance history for

programs. Medicaid provider applicants with any questions can contact OMIG’s Bureau of Compliance

at [email protected].

Issued: 05/05/2011

Medicaid: RADIOLOGY PRIOR APPROVAL

For Ordering Providers

If you are ordering a CT, CTA, MRI,

MRA, Cardiac Nuclear, or PET procedure,

you or your office staff are required to obtain

an approval number through the RadConsult

program.

If you also provide in-office radiology imaging, you are asked to confirm that RadConsult has proc-

essed and approved the procedure request before scheduling an appointment. This will ensure payment of

the claims you submit for services. Using a secure login, you will have the ability to access RadConsult

Online or call the RadConsult contact center to check the status of procedure requests. Beneficiaries who

are eligible for both Medicaid and Medicare (dual eligible) or beneficiaries who are enrolled in a man-

aged care plan are not included.

For Radiology Providers

If you are performing a CT, CTA, MRI, MRA, Cardiac Nuclear, or PET procedure, you must verify that

an approval has been obtained before performing these diagnostic imaging services for New York Medi-

caid FFS. Approvals will be required for claims payment. Failure to obtain an approval number may de-

lay or prevent payment of a claim.

Additional information is available at

http://www.emedny.org/ProviderManuals/Radiology/index.html


http://www.emedny.org/ProviderManuals/Radiology/index.html


ValueOptions to Administer Emblem Behav-ioral Health Services to HIP and GHI HMO

Members

This fall, ValueOptions® will become the benefit administrator for inpatient and outpatient be-

havioral health services for most EmblemHealth, GHI HMO and HIP members.

ValueOptions will be responsible for the following:

credentialing

claims processing and payment

utilization management, case management, appeals,

And all other provider service issues related to behavioral health treatment. You will receive

additional information and instructions shortly.

Applications for Electronic Record Subsidies End This Week

The New York City Department of Health is giving away the last of its subsidized Electronic

Health Record (EHR) licenses to primary care providers with at least 10 percent of their patients

enrolled in Medicaid. In addition to subsidized EHR implementation, practices will be given sup-

port to achieve CMS Meaningful Use designation and additional earnings potential of up to

$63,750. Act quickly; the deadline to apply is June 3, 2011.

CPT-4 Codes for Tobacco Cessation Counseling EmblemHealth reimburses for tobacco cessation counseling based on current CMS guidelines. In addition, studies

show that a follow-up visit within one week of the patient's quit date can double the effectiveness of any intervention.

Please schedule these critical office visits and use the following CPT-4 codes for your services:

99406 Smoking and tobacco-use cessation counseling visit, intermediate, greater than three minutes up to 10 minutes.

99407 Smoking and tobacco-use cessation counseling visit, intensive, greater than 10 minutes.


http://msg1svc.net/cgpqv/360021/54/1246431/5862/0/S/0/0/gvcw.html


Emblem Health Improving Religio-Cultural Competence in Patient Care

Available through October 4, 2011, this 60-minute audio-visual course explains how cultural

practices and religious beliefs can affect patient decision-making and treatment options. The course

offers one AMA PRA Category 1 Credit™ to physicians.

E-Prescribing by EmblemHealth Available Now!

EmblemHealth provider Web site has an electronic prescribing service that allows you to send

prescriptions directly to a pharmacy from your point of care. Your prescriptions are delivered in

real time, accurately and legibly.

New Radiology Claims Processor Beginning July 1, 2011CIGNA has entered into an expanded

relationship with MedSolutions, Inc. (MSI), who will now provide

exclusive radiology benefit and network management services for

CIGNA.

Health care professionals who are affected by this change will

receive a letter explaining this new relationship.

As an exclusive provider of radiology benefit and network man-

agement services, MedSolutions, Inc. (MSI) will be responsible

for processing appeals related to any of their utilization manage-

ment decisions.

After the market transition to MSI, appeals should be submitted

to:

MedSolutions,

730 Cool Springs Boulevard, Suite 800,

Franklin, Tennessee 37067

If a committee or external review is offered due to state regulations or account requirements, the

initial denial letter will provide instructions for submitting the appeal to CIGNA

MedSolutions will provide the following services on behalf of CIGNA:

Radiology facility credentialing

A utilization program featuring Predictive Radiology Intelligence

Network management services

Reimbursement of low-technology radiology services provided within the MedSolutions net-

work

Nuclear cardiology imaging management

http://www.cigna.com/customer_care/healthcare_professional/newsletters/

JulyNetworkNews/06_MedSolutionsUtil_0711.html


http://www.cigna.com/customer_care/healthcare_professional/newsletters/JulyNetworkNews/06_MedSolutionsUtil_0711.html

http://www.cigna.com/customer_care/healthcare_professional/newsletters/JulyNetworkNews/06_MedSolutionsUtil_0711.html


Frequently Asked by Physical Therapist Clients: How long must I maintain patient records? All patient Records must be kept for six years. Records for children must be kept until the

child is 22, even if that means keeping the records for more than six years.

Can I accept a referral from a physician assistant for physical therapy treatment?

A physician assistant may perform services when under the supervision of a physician. Medi-

cal services which may be performed by a physician assistant include a referral to a physical

therapist for treatment. In making such referral, the physician assistant is acting as the agent

of the physician.

Answer to both questions are obtained from New York State Physical Therapy Board:

www.op.nysed.gov


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