Claims-Assistance Program (CAP)

The Claims Assistance Program (CAP), available only to MSNJ members and their staff, intercedes with insurance carriers to assist on problem claims. CAP has successfully resolved hundreds of problem claims for members and has obtained hundreds of thousands of dollars for our members. CAP has helped members to receive interest on overdue claims; reverse denials of claims; reverse downcoding; and unbundle claims to be paid at the correct code.

If you are a physician member or a practice-manager member you are eligible for this service. However, CAP cannot be a substitute for an office’s billing manager. In addition, billing staff should exhaust the internal remedies of the insurance carrier before seeking the assistance of CAP. Once internal remedies have been exhausted, follow the CAP procedure outlined below. The program is easy to use, and every medical office from that of a sole practitioner to a large group should be able to comply with the process.

1. It is the policy of the Claims Assistance Program to require our members to execute a Business Associate Agreement (in compliance with HIPAA) before working on a claim or claim(s). [Sample business associate agreement.]
2. Address a cover letter to Lawrence Downs, that identifies the specific carrier, the total amount owed, and the specific details of your issue with the insurance company. You must state that you billed on a timely basis, did follow-up, and complied with all data requests from the payer. Claims that are older than one year from the date of service will not be accepted unless documented follow-up is attached.
3. Attach any and all correspondence with the carrier. This information should include:
   • A copy or computer printout of the original claim filed
   • Explanations of Benefits received from the carrier
   • Copies of appeal letters sent to the carrier
   • The carrier’s response to the appeals
   • Logs of all telephone correspondence with the carrier
   • Any additional information requested by the carrier (i.e. office notes)
4. If the information is less than 20 pages, fax it to 609.896.1347. If it is more than 20 pages, send the package by regular mail to Mr. Downs at MSNJ, 2 Princess Road, Lawrenceville, NJ 08648.
5. If you are having difficulties with more than one carrier, develop a separate set of materials and cover letter for each carrier.
6. Aetna claims must first be pursued through the Aetna internal appeal process before being referred to MSNJ.
7. Upon receipt of your information, MSNJ will log it into our system and refer it to a high level contact at the carrier for expedited review. You will receive evidence of that referral. If the matter is not settled within 30 days, we will again contact the insurance company. If the dispute is not resolved within 60 days, we will refer it to the proper official at the Department of Banking and Insurance.
8. You must continue your efforts to pursue payment under company specific appeals processes while we pursue your claims as well.

Please note: The Claims Assistance Program is available to physician members only. We cannot accept claims from billing institutions. Submissions must be sent in directly from the physician’s office, on company letterhead, and it must be signed by the physician.

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