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).)

CA launch of its EHR incentive program delayed until April 1, 2011.

New California Pre-Existing Condition Insurance Plan utilizing Blue Shield Network

CMS Delays Ordering/Referring Deadline on PECOS

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 mpm@medpromanagement.com.

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.