The Centers for Medicare & Medicaid Services (CMS) announced today that it will implement a contingency plan to accept noncompliant electronic transactions after the October 16, 2003 compliance deadline. This plan will ensure continued processing of claims from thousands of providers who will not be able to meet the deadline and otherwise would have had their Medicare claims rejected. 'Implementing this contingency plan moves us toward the dual goals of achieving HIPAA compliance while not disrupting providers' cash flow and operations, so that beneficiaries can continue to get the health care services they need,' said CMS Administrator Tom Scully. CMS made the decision to implement its contingency plan after reviewing statistics showing unacceptably low numbers of compliant claims being submitted. 'Medicare is able to process HIPAA-compliant transactions,' said Tom Grissom, director of CMS' Center for Medicare Management, 'but we need to work with our trading partners to increase the percentage of claims in production.' The contingency plan permits CMS to continue to accept and process claims in the electronic formats now in use, giving providers additional time to complete the testing process. CMS will regularly reassess the readiness of its trading partners to determine how long the contingency plan will remain in effect. The authority to implement a contingency plan was provided by guidance issued by HHS on July 24. CMS recognized that transactions often require the participation of two covered entities and that non-compliance by one covered entity may put the second covered entity in a difficult position. The guidance stated that covered entities that make a good faith effort to comply with HIPAA transactions and code set standards may implement contingencies to maintain operations and cash flow. CMS announced its contingency plan on September 11, but at that time had not made a decision on whether the plan would be implemented. Today's announcement means the CMS plan will be implemented on October 16, 2003. 'We encourage other plans to assess the readiness of their trading partners and implement contingency plans if appropriate,' Grissom said.

The NYSCA officers and downstate board members met with Oxford representative Drs. James Dillard and Bartley Bryt and Triad officers, Drs. Agostino Villani and Santo Sampini during the NYSCA convention in Rye Brook, NY on September 19, 2003. The purpose of the meeting was to discuss NYSCA member issues with Triad handling of care plans over the past nine months. Much of member complaints focused on onerous paper work (first visit submission of care plans with 30 day extensions); down coding; lack of supportive care approval (even though Triad reports approval of this type of care); difficulty in treating the chronic pain patient and the lack of clinical information on care plans on which treatment authorizations are based. An additional issue that was addressed and immediately clarified was the PCP referral. It was explained that once the patient has obtained the PCP referral, providing they remain in the same plan, the patient does not need a new referral after the initial even with lapses or discharge from care. As far as the remaining issues are concerned, Triad reports changes to the forms to be implemented in the new year. They recommend visiting their website to view the provider manual for proper filing of forms as well as being able to download care plans to be filled out on your desktop. Your NYSCA leaders plan to continue discussions with Oxford to assist them in understanding chiropractic in the managed care environment. We will keep communications open with Triad as long as our members have issues. Your responsibility is to communicate your problems with us. We are particularly interested in supportive care denials. NYSCA - working for you - with you.

As part of the Board’s ongoing effort to improve services, increase efficiency, and limit costs, a new centralized mailing address for all mail related to workers’ compensation claims has been established. This P.O. address is in close proximity to the Board’s mail scanning facility in Binghamton, NY. To help the Board improve our efficiency, effective September 8, 2003, all insurers, attorneys, licensed representatives and health care providers involved with claims being processed in New York City, Long Island, Westchester, Rockland, Putnam or Orange Counties must direct all claims related mail correspondence to the following centralized address. Failure to do so could result in unnecessary delays in processing of claims. New York State Workers’ Compensation Board PO Box 5205 Binghamton, NY 13902 All claim related mail for the remainder of the state should continue to be sent to the appropriate district office addresses. All non-claims related mail should be sent to the appropriate department or office.

Superintendent of Insurance Gregory V. Serio and State Health Commissioner Antonia C. Novello announced that thousands of New York State consumers are exercising their health insurance rights and are winning access to necessary care under the State's External Review Law, according to the latest External Review Report released today. "New Yorkers have been empowered by the External Review Law and are availing themselves of this important appeal mechanism when their essential health coverage is denied by the insurer," Serio said. "Since this Law became effective on July 1, 1999, more than 5,000 consumers have requested external appeals. With an average of 46% of external review cases overturned, this means that over 2,000 New Yorkers have access to health insurance care that would not otherwise have been made available to them. This year’s External Review Report illustrates that under Governor Pataki’s leadership consumers are educated on their health insurance rights and using this knowledge to ensure necessary coverage." "Thanks to Governor Pataki, New Yorkers enjoy the most comprehensive patient protections in America," State Health Commissioner Antonia C. Novello, M.D., M.P.H., Dr.P.H., said. "The success of the external review process demonstrates that patients in our State know their rights and are taking advantage of the opportunity for a prompt, independent and professional appeal when they believe an insurer has made an arbitrary decision. This Law better ensures that medical treatment decisions are made by doctors and their patients, and that New Yorkers receive the quality health care they need and deserve." The External Review Annual Report, released by the State Insurance and Health Departments, provides a comprehensive overview of New York's External Review Program and includes a description of external review results from the past year. The report also provides information about the external review programs of other states and compares the experience of other states to that of New York. Highlights from the report include: The Insurance Department has received 5,000 requests for external appeals, over 1,300 in 2002. Since July 1, 1999, 1,110 denials of coverage by health insurers have been overturned in whole, 267 denials have been overturned in part and an additional 722 denials have been voluntarily reversed by health plans before an external appeal agent rendered a determination. 183 expedited external appeal requests have been assigned to agents for review since July 1, 1999. An appeal must be expedited if the patient's physician attests that a delay in treatment would pose an imminent threat to the patient's health. Agents must render a decision on expedited appeals within three days. In 2002, 44% of medical necessity denials were overturned in whole or in part by external appeal agents while 50% of experimental or investigational treatment appeals were overturned. External appeal requests are submitted to the Insurance Department, which screens requests for eligibility and completeness and assigns the appeal to one of the state's three certified external review agents. The External Appeal Annual Report, applications to request an external appeal, and external appeal information are posted on the Insurance Department’s Web site at www.ins.state.ny.us. The Insurance Department’s external appeal hotline, 1-800-400-8882 assists New Yorkers in filing external appeal requests. The Insurance Department also has staff on-call seven days a week to handle expedited appeals.