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Med-Pro Management, Inc.

Medical Practice Management and Consulting


February 2011 

In This Issue
Patient Wait Time Regulation
Insurance Payor Updates
Patient Wait Time Regulation
Effective January 17, 2011, the Department of Managed Health Care (DMHC) finalized an important new regulation entitled "Timely Access to Non-Emergency Health Care Services" (28 C.C.R. Section 1300.67-2.2).  The regulation is aimed at improving timely access to primary care physicians and other specialists for health plan enrollees.

The "timely access" regulation requires DMHC-regulated health plans (HMOs, Blue Cross of California PPO, Blue Shield of California PPO, as well as their contracting medical groups and IPAs) to ensure that patients can see a provider within certain time frames and that plans have adequate provider networks to meet these requirements.

The key to ensuring patient access to medical care depends on adequate physician plan networks.  Hence, health plans, not physicians, are ultimately responsible for ensuring that patients can see a provider within the specified time frames and that plans have adequate provider networks to meet these requirements.

Care / Service

Access Standard

Urgent appointment

Within 48 hours

Urgent care appointment that requires authorization

Within 96 hours

Non-urgent appointment for primary care

Within 10 business days

Non-urgent appointment with specialist

Within 15 business days

Non-urgent appointment for ancillary services

Within 15 business days

Note: The applicable waiting time may be extended if the referring or treating provider has determined and noted in the relevant record that a linger waiting time will not have a detrimental impact on the health of the enrollee. (28 C.C.R. Section 1600.67.2.2(c)(5)G).)


"In the business world, everyone is paid in two coins: cash and experience.  Take the experience first; the cash will come later."

Harold Geneen                


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Insurance Payor Updates
Health Insurance
Aetna: Aetna recently notified contracting physicians that effective April 4, 2011, Aetna will no longer provide physicians with paper EOBs. 

Anthem Blue Cross: The insurer notified contracting physicians in a notice dated January 5, 2011, of a new and revised medical policies and clinical UM (Utilization Management) guidelines, which will be effective April 8, 2011.  For a complete list, please email your request to

Cigna: Cigna recently announced that effective February 22, 2011, would be revising its modifier -25 and modifier -59 policies.  Cigna has reduced the list of codes that these two modifiers would otherwise pay.

TriWest/Champus: A clerical error has been identified in the TriWest claims processing system causing underpayments for several vaccines.  The vaccines had been entered into the TriWest system as two-unit vaccines rather than 2 ml description of the vaccines, thus reducing the payment by 50%. According to TriWest, all these claims have been corrected automatically.
If you are interested to find out more about any of the topics mentioned, please do not hesitate to send us an email at or call us at (888) 549-1713.



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