Coding Corner: CPT reporting for preventive medicine services

June 24, 2016
Area(s) of Interest: Payor Contracting Practice Management 

On July 1, 2016, a new law will take effect that requires plans to ensure that their physician directories are accurate and up-to-date. The law (SB 137) includes multiple components aimed at providing patients with more accurate and complete information to identify which providers are in their payors' networks.

The California Medical Association (CMA) has published a new On-Call document to help physicians comply with the new law, which requires physicians to do their part in keeping their directory information up-to-date. Specifically, the law requires providers to notify payors within five business days if they are no longer accepting new patients or, alternatively, if they were previously not accepting new patients and are now open to new patients.

Additionally, physicians are required under the new law to respond to plan and insurer notifications regarding the accuracy of their provider directory information, either by confirming the information is correct or by updating demographic information as appropriate. Failure to do so may result in a delay in payment and removal from the provider directory. Additionally, a payor may terminate a contract with a provider for a pattern or repeated failure to update the required information in the directories.

It will be imperative that staff responsible for phones, email and faxes are aware of the requirements and are prepared for payor inquiries. It is also important that practices respond in a timely manner and are accurate in the responses given.

To help physicians understand their obligations under this new law, CMA has published On-Call document #7163, "Provider Directories." CMA On-Call documents are available free to members in CMA's online Health Law Library. Nonmembers can purchase On-Call documents for $2 per page.

CMA also recently hosted a webinar, “Ensure Your Practice is Ready and Won’t Be Penalized Under the New Provider Directory Accuracy Law,” which gives an overview of the new law and a pilot program launched by America’s Health Insurance Plan. The pilot was designed to ensure physician directories are more accurate and that payors are compliant with SB 137 requirements, while reducing the administrative burden for practices. This webinar is now available on-demand in CMA's online resource library and is free to CMA members ($99 for nonmembers).

Contact: CMA's Center for Legal Affairs, (800) 786-4262 or legalinfo@cmadocs.org.


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