Aetna and Cigna are making changes to their procedures on July 1 that will affect your practice.
Aetna will make changes to the National Precertification List. The insurer will add Actimmune, Zaltrap, and Xeljanz to the list of drugs needing precertification, and remove oral hepatitis C medications Incivek and Victrelis.
Cigna will stop offering second-level claims denial appeals to physicians unhappy with the way their initial appeal turned out. All appeals will follow a single appeal review process and be completed within 60 days. For more information, log on to the Cigna Network Newsletter, April 2013; scroll down to page 5 and look for the headline "Single appeal reviews." Practices should use the "Request for Provider Payment Review Form" and review the Claim Adjustment and Appeals Guidelines. Both are on the Cigna website.
In Texas, the new Cigna policy applies only to self-funded ERISA plans. Those plans will have only one level of appeal within Cigna. They will have the Independent Review Organization (IRO) level of appeal, which is external and required under the Patient Protection and Affordable Care Act. Due to state regulations, Cigna must continue to offer two levels of appeal for administrative appeals, and two levels of appeal for medical necessity appeals, for all other plans.
These are just ust two of the important dates and deadlines will occur in coming months. TMA's Deadline for Doctors will help you avoid hassles. The TMA Council on Practice Management Services developed the calendar to keep you abreast of upcoming state and federal regulations and key health policy issues that impact you and your practice. It is filled with the TMA information resources, tools, and educational programs you need stay in compliance.
For more information, contact the TMA Knowledge Center at (800) 880-7955 or by email.
Action, June 14, 2013