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Trilogy's Claims Administrative Handbook

Updated Topics

The Handbook is updated quarterly and all topics in the Handbook are reviewed annually to be sure the information provided is relevant, accurate, and current. Below are examples of some of the topics updated during 2015.
Legislative Topics
Medical Plan Overview - updated with information on the ACA final ruling related to SBCs.
HIPAA - Updated with information on final regulations amending HIPAA rules relating to excepted benefits.  
COBRA - information on the requirement of employers to provide "Information Reporting Of Minimum Essential Coverage" to enable employees to substantiate to the IRS that they were enrolled in minimum essential coverage was added. Updated information on the premium subsidy credit was added.
Mental Health Parity Act - information regarding the proposed rule to apply certain provisions of the Act to requirements for Medicaid managed care organizations, Medicaid alternative benefit plans and the Children's Health Insurance Program was added.
Medicare - 2016 premiums, deductible, copayments and therapy caps were updated. Information on the Merit-Based Incentive Payment System was added. A complete MSN message list was added.
Affordable Care Act Overview - New information on the Cadillac Tax and premium subsidies was added. Updated with information on the ACA market reform final regulations issued on 11/18/15.
Affordable Care Act and Lifetime/Annual Limits - updated with information on HHS' final rule on benefit and payment parameters for 2016 including provisions related to cost-sharing.
Affordable Care Act and Preventive Care - Updated with information on final rules relating to accommodations for eligible religious non-profit organizations. Information added on cost sharing for anesthesia services performed in conjunction with a preventive colonoscopy.
Affordable Care Act and Patient Protections - Updated with information on the ACA market reform final regulations issued on 11/18/15.
Regulation of Insured and Self-Insured Health Insurance - Updated with information on the California and New York "Surprise Bills Laws".
State Assessments on Health Related Claims - Updated with current assessment information by state.
Domestic Partner/Same-Sex Married Couples - Information on the effect of the 6/26/15 U.S. Supreme Court decision legalizing same-sex marriage was added.
Americans With Disabilities Act of 1990/Effect on Health Plans - Updated with information on how Title I of the ADA applies to employee wellness programs.
Eligibility Overview - Updated with clarification on the use of non-financial incentives and wellness program regulations under ACA.
Third Party Reimbursement - Updated with information on CIGNA Corp. v. Amara, where the Supreme Court affirmed that a plan cannot enforce recovery provisions that are stated in the SPD and not in the master plan document. Also updated with information on Montanile v. Board of Trustees of the National Elevator Industry Benefit Plan, where the Supreme Court ruled that a plan fiduciary cannot recover from a participant's general assets.
Evidence of Insurability - Updated with information on the ACA market reform final regulations relating to rescissions.
Flexible Benefits Administration - Maximum HSA contribution amounts and HDHP minimum deductible and out of pocket limits for 2016 were updated.
Procedural Topics
Coding & Billing - updated with information the latest release of the CPT-4 and CDT-2016. Information on the transition to ICD-10 as of was added.
Eligibility Overview - Updated with the proposed regulations that describe ADA requirements for compliant employer wellness programs. Also updated with ACA market reform final regulations relating to coverage of dependent children to age 26.
Occupational, Physical and Speech Therapy - updated with Medicare outpatient therapy caps for 2016.
Privacy and Confidentiality - Information on Phase 2 audits under the HIPAA/HITECH audit program was added.
Workers' Compensation - Information added on the distinction between a workers' compensation injury and an occupational disease.
Product Liability - Updated with information on medical products and drugs that have resulted in lawsuits.
Prescription Drug Overview - Information on the FDA's position relating to the importing of prescription medication from Canada for personal use was added.
Pharmacy Benefit Manager Audits - Information on the benefits of performing a PBM audit was added.
Prescription Drug Claim Processing Issues - Information on specialty drugs and biosimilar drugs was added.
STD - Other Disability Income Sources - Disability benefits by state were updated.
STD Benefit Taxation - The Social Security taxable wage base was updated.
Dental Plan Overview - New information on how to measure frequency limitations was added. Information on pre-determination of benefits and overbilling was added.
Experimental and Investigational - New information on Medicare coverage guidelines for Investigational Device Exemptions was added.
Medical Topics
AIDS - The Antiretroviral Medication Classification Table and list of investigational medications was updated.
Acupuncture - updated with additional conditions for which acupuncture is considered investigational.
Allergy Testing and Treatment - additional tests were added that are not considered medically necessary.
Attention Deficit Hyperactivity Disorder - Additional covered services were added.
Autistic Spectrum and Learning Disorders - State specific autism mandate information was added.
Biofeedback - updated with additional conditions for which biofeedback is considered investigational.
Botulinum Toxin Injections - updated with additional conditions for which this treatment is considered medically necessary.
Cardiac Rehabilitation - Covered conditions were updated.
Chemotherapy and Radiation Therapy - Updated with additional medically necessary conditions and treatments.
Chiropractic Treatment - The list of non covered services was updated.Endometrial Ablation - Updated with additional surgical procedures which are considered eligible.
Chronic Fatigue Syndrome - Updated with additional investigational treatments.
Complementary and Alternative Medicine - Updated with additional investigational treatments.
Dental Conditions - Updated with information on when monitored anesthesia care may be considered medically necessary for dental and oromaxillofacial surgery.
Gender Reassignment - Updated with diagnostic criteria from the DSM5.
Genetic Testing - Updated with additional conditions for which genetic testing is considered medically necessary.  Also updated with additional investigational indications and services.
Growth Hormone - updated with additional conditions for which growth hormones are considered investigational.
Hyperhidrosis - updated with additional experimental treatments.
Impotence/Erectile Dysfunction - Updated with additional investigational services.
Infertility - Updated with additional investigational services.
Liver Transplants - Updated with additional experimental medications.
Behavioral Health Overview - Updated definition of partial hospitalization and residential treatment was added.
Obesity - Updated with information that a routine cholecystectomy is typically considered medically necessary when performed in conjunction with bariatric surgery.
Prosthetic Devices - Updated with additional covered devices. Also updated with additional investigational devices.
Psoriasis Treatment - Updated with additional FDA-approved treatments.
Spinal Surgery/Procedures - updated with additional procedures and devices which are considered medically necessary.
Obstructive Sleep Apnea - updated with additional experimental treatments.
TMJ - updated with additional investigational diagnostic tests and treatments.
Vaccines/Immunizations - updated with current information on the CDC’s Recommended Immunizations Schedules.
Operational Topics
Appeals Processing - Updated with information on the ACA market reform final regulations issued 11/18/15.
Reinsurance - Information added related to the deduction of Rx program rebates from aggregate excess loss reimbursement.
Privacy and Confidentiality - Updated with information on the final rule amending the HIPAA Privacy Rule to strengthen the current background check system in order to prevent individuals prohibited by law from possessing or receiving firearms.
Surgery Overview - Updated information on search limits in the FAIR Health database was added.
Surgery Payment Guidelines - The Medicare National Physician Fee Schedule Relative Value File information was updated.
Listings and Directories
Medicare Claim Offices - listing updated with the current Medicare intermediary, carrier, durable medical equipment contractor and regional home health intermediary for each state.
CMS Regional Offices - listing updated with current contact information for the ten CMS regional offices.
Postal Inspector Locations - updated with current contact information.
State Dental Board Directory - updated with current contact information.
State Insurance Department Directory - updated with current contact information.
State Licensing Agencies For Nursing Homes - listing updated with current contact information.
State Medical Associations - listing updated with current contact information.
Acronyms - listing was updated.
Internet Sites - listing was updated.
Regional Organ Procurement Organizations - updated with current contact information.


Handbook Info
Handbook Demo Download
Updated Topics
License Agreement

“The Trilogy Claims Administrative Handbook is the best resource for accurate, fair and consistent claim operating procedures. The Handbook is organized in a user friendly manner and is updated quarterly so that the information is always current. This Handbook is an absolute “must have” for administrators and carriers throughout the industry.”
Vice President of Claims Administration