Important Extended Healthcare Adjudication Changes – Effective April 2016
Over the past year, GroupSource has completed an extensive review of our adjudication practices, with respect to
how we assess and determine
ermine eligibility for the following benefits:
•
•
•
ASSIGNMENT OF BENEFITS
COMPRESSION STOCKINGS
ORTHOTICS & ORTHOPEDIC SHOES
Please read the information below to learn how these changes will impact your plan members.
Assignment of Benefits
Our review has found that many claims are being submitted for items that have not yet been dispensed to the plan
member. This occurrence is significant enough to warrant a change in our claims submission procedures.
Please note that GroupSource will no longer aaccept
ccept assignment of benefits for medical services & supplies,
paramedical visits and vision services. This change will allow us to better validate claim eligibility, and thus improve
the management of your benefits program
program, which in turn has a positive affect on your costs.
NOTE: We will continue to pay claims directly to pharmacies and dental offices. Services related to urgent care, such
as hospital and ambulance claims, may also be assigned directly to the provider.
Compression Stockings
Industry trends show
ow a significant increase in claims for compression stockings. In many instances, the fees
submitted for these claims are much higher than the deemed reasonable and customary amount (e.g. markups can
be as high as 400%). Please note that the following criteria will apply when we validate eligibility for compression
stocking claims:
1.
2.
3.
4.
The minimum required compression factor must be met
met.
Physician referrals must indicate the medical diagnosis or condition, the recommended pressure gradient,
and recommended length.
A detailed paid-in-full
full receipt, including a breakdown of charges, date stockings were received, as well as
provider name and address, must be provided when a claim is submitted.
Amounts payable, including
ding surcharges, will be limited to the reasonable and customary charge.
Orthotics and Orthopedic Shoes
Industry trends show a significant increase in claims for orthotics & orthopedic shoes.
Orthotics are corrective devices worn inside a shoe to support and align foot function. Custom-made
Custom
orthopedic
shoes are typically used to treat a congenital deformity, traumatic injury or a disease affecting the feet.
To be eligible for coverage under your plan, orthotics and orthopedic shoes must be custom made of raw materials
and crafted using a cast of the insured person’s foot. If permanent custom modifications are made to shoes
manufactured and branded as orthopedic, they are also eligible for coverage.
Please bee sure to include the following information when submitting a claim for orthotics or orthopedic shoes:
1.
2.
3.
4.
Referrals from an eligible provider that also includes the medical diagnosis of the condition.
condition
A gait
it analysis/biomechanical evaluation
evaluation.
A detailed
etailed lab invoice indicating that the orthotics or orthopedic shoes are custom made.
made
A detailed paid-in-full receipt, which includes a breakdown of charges, the date the item was received, as
well as the provider name and address
address.
If you have any questions regarding this change, please do not hesitate to contact your GroupSource representative.
representative