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State Compliance

Maintaining State Compliance

Prime Health Services maintains a Compliance Department to ensure that Prime Health and Prime Health’s clients remain in compliance with each state’s ever-changing laws, rules, regulations, and court decisions. Most state legislatures meet from January through May each year, which is when decisions are made regarding existing law and new or proposed laws. Some states (e.g., Texas) have legislatures that meet only every other year, so these states have very powerful commissioners who can more quickly and easily change state regulations.

One of the primary goals of our Compliance Department is to keep our company and clients well informed of the decisions made by these state legislatures and commissioners. Another role of our Compliance Department is to handle state certifications and filings. Some states have adopted legislation that governs provider networks and or managed care organizations (MCO) in an effort to control their workers’ compensation costs.

Each state’s network and MCO regulations are different, which is why Prime Health’s state offerings and certifications vary state-to-state as well. Similarly, many of the states that require network or MCO certifications also require frequent updates or filings to their state regulatory departments. Such filings may be annual, bi-annual, or even quarterly, and our Compliance Department works hard to keep us well informed and compliant under the strict timeframes.

Our continuous evaluation of the regulations that govern these state certifications and filings allows our company and clients to offer the most up-to-date and progressive services and products to our customers. Prime Health works hard to remain in compliance with the various requirements of our local, state, and federal governments and court systems, which is why our Compliance Department is a good resource for our company and clients.

Notices and Updates

Based on the disclosures required of group health plans and health insurance issuers in the No Surprises Act, Prime Health will provide the in-network providers’ negotiated rates.

Providing these deliverables allows transparency within tasks being asked of our clients and our clients’ clients.

At Prime Health, our provider contracts are evergreen and we can track when a provider (NPI) status is disabled or a contract (TIN) is termed. We also track dates on contracts and discounts when they are added/changed.

Prime Health uses commercially reasonable efforts to maintain accurate provider directories, which are regularly updated and verified at least every 90 days. Prime Health will respond, within one business day, to individuals who inquire about the network status of a provider or facility.

To aid in this initiative, with the use of technology, Prime Health is working with industry leaders in the provider data collection and verification space.

Beginning July 1, 2022, health care providers will need to:

• Submit the CMS-1500 form. Electronic submission through an XML submission partner is strongly encouraged, though not required. When mandatory submission of the CMS-1500 form begins, use of current medical billing/reports including Doctor’s Initial Report (Form C-4) and Doctor’s Progress Report (Form C-4.2) will be discontinued.

• Prominently report the injured worker’s temporary impairment percentage, work status and the causal relationship of the injury at the top of the CMS-1500 form medical narrative.

Between now and July 1, 2022 health care providers are urged to review their processes to understand how these changes will affect them. The Board will continue to post periodic updates to the website based on feedback and questions received from stakeholders.

More information can be found at http://www.wcb.ny.gov/CMS-1500/

We provide our clients with a wealth of information and the tools they need to successfully navigate the complex web of compliance regulations and certifications. For a preview of some of that support, you can request access to our State Resources.

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Request State Resources? Click here!