New CMS Audit Suspension Policy Effective 10/1/2015

September 29, 2015

CMS recently sent out an announcement about a new audit policy that they’re implementing for their eligibility transactions. This only affects transactions being sent through their EDI system not transactions being sent through DDE. The short version of the policy is as follows:

1. Beginning 10/1, CMS will start randomly auditing transactions in search of instances where the same NPI and HICN are sent multiple times in one day.

2. If they identfy instances where the same beneficiary is being sent excessively by the same provider, they’re going to suspend that NPI from using their eligibility system (HETS).

3. The NPI will remain suspended until a written corrective active plan is submitted to and accepted by CMS.

You should have received some version of this notification from your eligibility vendor but in case you haven’t I’ll link you to the original notice. Please take this very seriously. If you have any automated processes that will repeatedly send the same member, please consider reviewing this process.



Register Now for the CMS National Provider ICD-10 Call

August 24, 2015

CMS will be holding a call to discuss coding tips and updates on the status of ICD 10 this Thursday at 2:30 ET. Sorry for the short notice. See the announcement below.

Thursday, August 27; 2:30-4pm ET

To Register: Visit MLN Connects Event Registration. Space may be limited, register early.

Don’t miss the August 27 MLN Connects Call — five weeks before ICD-10 implementation on October 1, 2015. CMS Acting Administrator Andy Slavitt will be opening the call with a national implementation update. Then, Sue Bowman from the American Health Information Management Association (AHIMA) and Nelly Leon-Chisen from the American Hospital Association (AHA) will be joining us with coding guidance and tips, along with updates from CMS.


  • National implementation update, CMS Acting Administrator Andy Slavitt
  • Coding guidance, AHA and AHIMA
  • How to get answers to coding questions
  • Claims that span the implementation date
  • Results from acknowledgement and end-to-end testing weeks
  • Provider resources

Target Audience: Medical coders, physicians, physician office staff, nurses and other non-physician practitioners, provider billing staff, health records staff, vendors, educators, system maintainers, laboratories, skilled nursing facilities, home health agencies, and all Medicare providers.

UHC ICD-10 Edits

August 7, 2015

I’m getting inundated with ICD updates from the payers and clearinghouses now that 10/1 is getting near. I thought I would share some of these from time to time.


 Date:  8/6/2015

ICD-10 Code Edits Applied By UnitedHealthcare

Oct. 1, 2015 is the compliance date for the transition to ICD-10 coding to replace ICD-9. These codes are used by physicians and health care professionals to record and identify diagnoses and procedures for claims payments. ICD-10 affects diagnosis and inpatient procedure coding only. It does not affect current procedural terminology (CPT) coding for outpatient procedures.

ICD-10 edits currently in place are shown in the grid below, subject to change prior to Oct 1. Please refer to the Enhanced Claim Edits section of for the complete list of edits applied by UnitedHealthcare.

optum screen shot

Based on ANSI X12 TR3 compliance regulations, WEDI SNIP Types indicated are enhanced at a pre-adjudication level during HIPAA validation. This enables UnitedHealthcare claim submitters to identify and correct rejected information prior to the claim’s acceptance into our adjudication system for processing.


We encourage providers to check claim submission reports on a regular basis and in a timely manner. They can view tracking your electronic claims to learn more about electronic reports and rejections. The UnitedHealthcare ICD-10 website contains many tools and resources to assist submitters with the transition to ICD-10. Our newest is the Physician ICD-10 Coding Practice Tool that allows providers to practice selecting ICD-10 codes for various clinical scenarios across 35 medical specialties.

If you have any questions, please contact Electronic Data Interchange (EDI) Support:


UnitedHealthcare Commercial UnitedHealthcare Medicare SolutionsUnitedHealthcare West EDI transaction support form  or 800-842-1109
UnitedHealthcare Community Plan EDI transaction support form or or 800-210-8315
UnitedHealthcare Oxford or 800-599-4334


*Exceptions:  Harvard Pilgrim (04271), Medica HealthCare Plans (78857), Preferred Care Partners (65088), The Alliance (88461) and TRICARE West (99726)


Thank you,


Centene to Buy Health Net in $6.3 Billion Health-Care Deal

July 8, 2015

I’m not sure how I missed this one. More acquisition news.


Centene Corp. agreed to buy Health Net Inc. for about $6.3 billion in cash and stock, creating a combination of two smaller U.S. health insurers ahead of an expected round of mergers among the industry’s giants.

Health Net investors will get 0.622 shares of Centene and $28.25 in cash for each share they hold, the companies said in a statement on Thursday. The implied price of $78.57 a share is 21 percent more than Health Net’s closing stock price Wednesday.

The deal gives Centene the biggest market share among private administrators of Medicaid, the federally funded health program for the poor — a bet that the U.S. government will keep playing a larger role in health care. The transaction would give Centene a bigger presence in the California Medicaid program, which is the largest in the U.S. with more than 12 million individuals, and provides an entry into the Medicare market.

The transaction makes sense, said Peter Costa, an analyst at Wells Fargo & Co. “Centene is the largest Medicaid managed-care company, but has only minor market share in California, where Health Net has been rapidly growing,” he said.

Health insurers in the U.S. are looking at mergers to cut costs and keep profits expanding after enjoying an influx of new business from the Patient Protection and Affordable Care Act, which brought previously uninsured people into the market for the first time. At the same time, the law put pressure on profit margins by imposing new fees and mandating companies spend at least 80 percent to 85 percent of premiums on medical claims.

Merger Madness

Aetna Inc. is said to be nearing an acquisition of Humana Inc., Bloomberg reported last week. And on June 20, Anthem Inc. went public with a bid for Cigna Corp. UnitedHealth Group Inc., the largest U.S. health insurer, could also make a bid for Aetna.

It’s also possible UnitedHealth could jump in with a competing offer for Health Net, said Ana Gupte, an analyst at Leerink Partners LLC.

Centene will assume about $500 million in debt as part of its transaction with Health Net, which the companies expect to close in early 2016. The buyer plans to fund the purchase using its existing cash and debt financing, with Wells Fargo & Co. providing $2.7 billion in financing commitments, the companies said.

The combined company would have more than 10 million members and an estimated $37 billion in pro forma premium and service revenues for 2015, and the acquisition would boost earnings by about 10 percent in the first year, according to the statement.

Stock Moves

Health Net rose 11 percent to $72.13 at 11:38 a.m. in New York. Centene dropped 6.1 percent to $75.95.

Centene Chief Executive Officer Michael Neidorff said he’s not concerned about the market’s reaction.

“This is a very quiet market day, we all know that,” he said in a telephone interview. “As people understand the benefits of this transaction, it will take care of itself.”

Neidorff, who’s also Centene’s chairman, will be chairman, president and CEO of the combined company, which will be based in St. Louis.

Health Net CEO Jay Gellert will help with the transition, the companies said. If Gellert departs after the deal closes, he could be eligible for a golden parachute worth $38 million at the implied offer price, according to a Bloomberg analysis of the company’s most recent proxy filing.

Allen & Co. and Evercore Partners Inc. were the financial advisers to Centene on the transaction, with Skadden, Arps, Slate, Meagher & Flom LLP offering legal counsel. JPMorgan Chase & Co. is Health Net’s financial adviser with Morgan, Lewis & Bockius LLP serving as legal counsel.


Aetna agrees to buy Humana for $37 Billion

July 6, 2015

More acquisition news. Aetna is buying Humana for $37 Billion. It will probably take a year or so before we see any major changes as far as contracts, billing, insurance cards etc. What do you think of this deal? Will it make your life easier or more complicated?

Anthem Offers to Buy Cigna for $54 Billion Dollars

June 20, 2015

Update 6/22 Cigna rejects Anthem offer but the deal isn’t dead.

6/20 I have to admit I didn’t see this coming. I thought Anthem was going to buy Humana.

Anthem offers to buy Cigna in $54 billion deal – Modern Healthcare


By Bob Herman  | June 20, 2015

Health insurer Anthem has publicly proposed acquiring competitor Cigna Corp. for $184 per share in a deal valued at $53.8 billion.Anthem’s play to take over Cigna marks the official first step in what observers saw as inevitable consolidation in the health insurance industry. But the transaction is far from a done deal because regulatory approvals and a battle over the CEO chair remain significant hurdles.Anthem’s deal is nonbinding and needs approval from Cigna’s board of directors and shareholders. The two insurers have been in negotiations since August 2014, and this represents the fourth offer since then. Anthem hopes to complete a deal by the end of the month.

Under the latest proposal, Anthem would pay $184 per share in cash and stock, or about $47.4 billion. Cash would represent 68.6% of the deal, and Anthem’s shares would make up the rest. Including debt, the deal would be worth $53.8 billion, Anthem said. Cigna shares closed Friday at $155.30.

“This combination is the absolute best strategy for both organizations to maximize the potential and lead the transformation of the healthcare industry,” Anthem CEO Joseph Swedish said in a statement.

However, Cigna CEO David Cordani has demanded he become CEO of the newly merged company. Anthem has offered for Swedish to stay in his CEO role and make Cordani president and chief operating officer, which Cordani has rebuffed. Swedish hinted that he would step down from his CEO role after two years after the merger, but there would be no guarantee Cordani would take over.

“We were stunned that the Cigna board continues to insist on a guaranteed CEO position for Mr. Cordani over choosing to allow its stockholders to realize the significant premium being offered,” Swedish wrote in a letter dated Saturday. “We therefore are now reaffirming our June 18 proposal for a combination of our companies, which we believe your stockholders will find more compelling.”

Further, Anthem would have to get antitrust approval from the Justice Department and licensure approval from the Blue Cross and Blue Shield Association. Anthem said it was “confident” it would get the OK from the Blues.

If Anthem and Cigna combined, the new company would have expected revenue of $115 billion this year, still a little smaller than UnitedHealth Group. But the giant would also have 53 million covered members, far surpassing UnitedHealth, and would be a leader in the fully insured and self-insured employer markets.

Anthem hired investment bank UBS as its financial adviser.

Coventry Healthcare USA Becomes Aetna Better Health of Missouri

June 16, 2015

On June 29th, Coventry Healthcare USA will change it’s name to Aetna Better Health of Missouri. There are a few significant changes to note:

  1. Medical management criteria will change from Mckesson’s Interqual Criteria to Hearst Corporation’s MCG guidelines.
  2. The portal will no longer be updated with information for this membership.
  3. The payer ID and claim submission address will change.

I’ve attached the recently published quick reference guide and provider notice regarding this change. If you’re using an eligibility vendor to get the data, make sure that they will be ready to accommodate this change. Any transactions submitted to the old payer ID beginning 8/1/2015 will be rejected. Also any authorization transactions (278) submitted to either the old payer ID or the new payer ID between 6/23/2015 and 6/28/2015 will receive an error message. The payer is advising that you hold these until 6/29.

Aetna Better Health Quick Reference Guide

Aetna Better Health Missouri Announcement


Yikes. I’ve been hacked!!!! (FIXED)

May 12, 2015

Google recently notified me that the site has been hacked. Luckily the hackers didn’t completely hijack the site but I may need to take it down for a couple of days to do some clean up. I’ll try to give you some notice before taking everything offline.  Sorry everyone. I’ll keep you posted on the outcome.


Crisis averted. The fix was much easier than I thought and it only took a few minutes.


Prefix List Update, Anthem Breach, Cigna Purchases Qualcare

February 5, 2015

Prefix List Update

This weekend I’m planning to replace the existing prefix lists with a brand new list. There are still some changes that need to be made but I didn’t want to hold it up any longer. There are a few things to note about the new list:

1. The pages will be organized a little differently than the current pages. All the prefixes for a particular letter of the alphabet will be on one page. Hopefully this will make it easier to find what you need and it will make it easier for me to update.

2. There were hundreds of prefixes on the new list that are no longer assigned to a plan but were in the past. I’ve left those on the site for now. They’re labeled “unassigned” where the plan name should be. If you think leaving them on the list adds clutter let me know and I can remove them.


Aetna Eligibility Issues with Walmart Members

January 13, 2015

Please see the update below from Aetna regarding checking eligibility for Walmart members. Evidently you can only check eligibility for them electronically using the name and DOB.


We’d like to let you know that using certain search criteria, users are unable to get successful real-time eligibility and benefits responses for Walmart members.


Using certain search criteria, users attempting to get eligibility and benefits details for Walmart members are receiving an error code of “Subscriber/Insured Not Found” (AAA75).

— To receive a successful response, users can use the Name/date of birth search option.

— The following search criteria will not return a successful response, that is, using these search criteria will return an error:

– Walmart ID/date of birth
– Walmart ID/name
– Walmart ID/name/date of birth

We’re in the process of identifying the root cause of this issue. We’ll send additional information after we’ve determined how to correct this issue.