CareCentrix recently announced plans, effective January 1, 2020, to deny PAP rental and resupply claims for delinquent policyholders. The change affects beneficiaries with Cigna and Blue Cross of Florida plans where CareCentrix processes DME claims. The company published the controversial notice on the heels of a recent meeting with AAHomecare about DME supplier complaints, including authorization and reconsideration inconsistencies.
The new policy suspends non-life sustaining services for all policyholders who:
Policyholders who are current on their cost shares or who have met their deductible are not affected.
Strangely, only PAP rental and resupply claims are affected or deemed non-life-sustaining. No other services are affected by the policy.
How does the deductible status affect suspension?
One of the three criteria for payment suspension requires an active, unmet deductible. Once the beneficiary meets their deductible, the company will resume paying for PAP rentals and resupply claims. Notwithstanding, we expect CareCentrix will require new authorizations anytime the policyholder resolves a suspended status.
How can suppliers find out which customers are affected?
Suppliers can query patient status individually or download a list of all suspended patients via the CareCentrix secure portal. We recommend suppliers first download the master spreadsheet with all suspended policyholders, then compare the list to active PAP rental and resupply customers in their billing software. From the patient tab in the portal, a comprehensive list of affected policyholders is available by clicking “Download Suspension List.”
Additionally, suppliers should receive a 60-day email notification from CareCentrix with details about payment suspensions before they take effect. CareCentrix will also send email notifications to suppliers with recent PAP activity when the suspended status changes.
Carecentrix will use email addresses linked to the portal for branches with recent claims activity for affected policyholders. Because the reimbursement policy takes effect on January 1, 2020, we expect the first notifications to arrive on or after November 1, 2019.
How will the policy impact claim processing?
If suppliers submit PAP claims while a customer is suspended, the claims will deny CO-256, service not payable per managed care contract. EOBs will also contain an A1 denial with N59 remark code which basically redirects suppliers back to the provider manual. Because A1 and N59 are nondescript denial codes, suppliers should watch for the CO-256 denials from Carecentrix to identify these claims.
What happens to claims before and after a suspension date?
Claims with service dates prior to a suspension date are not affected. Suppliers can continue sending supplies and billing rentals up to the suspension date. Likewise, claims with service dates after a suspension ends are eligible for payment. When the plan sends notification of reinstatement, however, suppliers must secure a new authorization to resume covered services.
Do suppliers have recourse for denied claims?
Not really. The plan allows suppliers to refuse service, even if an approved authorization is on file. Per the published policy and FAQ, however, suppliers are prohibited from collecting directly from customers for these services … so as far as CareCentrix is concerned, mamma’s gotta get paid first, right?
Later, if the customer ultimately resolves their past due balance, suppliers can appeal denied claims through the reconsideration process. CareCentrix will deny resubmitted claims as duplicates, and again the plan prohibits passing balances to customers while they are suspended.
Encourage customers to make arrangements with the plan. Customers should call 866-441-4169 to negotiate a resolution and resume PAP services. CareCentrix claims to offer customers an interest-free payment plan with terms up to 18 months, depending on the amount of outstanding balance.
Guys, just make sure this payer is worth it. The collection rate needs to be pretty fantastical to justify the hoops and the hassle. And if you need help evaluating performance, we will help.
SOURCE LINKS
https://ha2.edelivery-view.com/Public/CCX1000/Change%20Impacting%20Certain%20Cigna%20and%20FLBL%20Members%20-%201210(a)(e).pdf
The new policy suspends non-life sustaining services for all policyholders who:
- Have aged cost share balances payable to CareCentrix in excess of six months,
- Are in the deductible phase of coverage, and
- Failed to pay, or establish a payment plan with, CareCentrix.
Policyholders who are current on their cost shares or who have met their deductible are not affected.
Strangely, only PAP rental and resupply claims are affected or deemed non-life-sustaining. No other services are affected by the policy.
How does the deductible status affect suspension?
One of the three criteria for payment suspension requires an active, unmet deductible. Once the beneficiary meets their deductible, the company will resume paying for PAP rentals and resupply claims. Notwithstanding, we expect CareCentrix will require new authorizations anytime the policyholder resolves a suspended status.
How can suppliers find out which customers are affected?
Suppliers can query patient status individually or download a list of all suspended patients via the CareCentrix secure portal. We recommend suppliers first download the master spreadsheet with all suspended policyholders, then compare the list to active PAP rental and resupply customers in their billing software. From the patient tab in the portal, a comprehensive list of affected policyholders is available by clicking “Download Suspension List.”
Additionally, suppliers should receive a 60-day email notification from CareCentrix with details about payment suspensions before they take effect. CareCentrix will also send email notifications to suppliers with recent PAP activity when the suspended status changes.
Carecentrix will use email addresses linked to the portal for branches with recent claims activity for affected policyholders. Because the reimbursement policy takes effect on January 1, 2020, we expect the first notifications to arrive on or after November 1, 2019.
How will the policy impact claim processing?
If suppliers submit PAP claims while a customer is suspended, the claims will deny CO-256, service not payable per managed care contract. EOBs will also contain an A1 denial with N59 remark code which basically redirects suppliers back to the provider manual. Because A1 and N59 are nondescript denial codes, suppliers should watch for the CO-256 denials from Carecentrix to identify these claims.
What happens to claims before and after a suspension date?
Claims with service dates prior to a suspension date are not affected. Suppliers can continue sending supplies and billing rentals up to the suspension date. Likewise, claims with service dates after a suspension ends are eligible for payment. When the plan sends notification of reinstatement, however, suppliers must secure a new authorization to resume covered services.
Do suppliers have recourse for denied claims?
Not really. The plan allows suppliers to refuse service, even if an approved authorization is on file. Per the published policy and FAQ, however, suppliers are prohibited from collecting directly from customers for these services … so as far as CareCentrix is concerned, mamma’s gotta get paid first, right?
Later, if the customer ultimately resolves their past due balance, suppliers can appeal denied claims through the reconsideration process. CareCentrix will deny resubmitted claims as duplicates, and again the plan prohibits passing balances to customers while they are suspended.
Encourage customers to make arrangements with the plan. Customers should call 866-441-4169 to negotiate a resolution and resume PAP services. CareCentrix claims to offer customers an interest-free payment plan with terms up to 18 months, depending on the amount of outstanding balance.
Guys, just make sure this payer is worth it. The collection rate needs to be pretty fantastical to justify the hoops and the hassle. And if you need help evaluating performance, we will help.
SOURCE LINKS
https://ha2.edelivery-view.com/Public/CCX1000/Change%20Impacting%20Certain%20Cigna%20and%20FLBL%20Members%20-%201210(a)(e).pdf
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