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Claims priced by Data Isight and how to file appeals with State Commissioner of NJ

B

Biller2023

Networker
Messages
89
Location
Trenton, NJ
We are an out of network provider and many claims of Aetna are priced by a company called Data Isight. Data Isight processes claims with a lesser allowed amount and when we ask them to reprice the claim, they say that the claim is ineligible for negotiations. We then contact Aetna to tell them that we do not accept Data Isight's rates and Aetna says that we should only contact Data Isight as the claim was priced by them. How do we make the insurance reprice the claim as this is going back and forth?

We have also filed appeals with Aetna regarding these claims and the appeals were closed stating we have reached final level of appeal and the agents have asked us to contact the State Commissioner of NJ if we wish to do next level of appeal.

How do we contact the State commissioner of NJ. Is there a specific number or a website to file appeals with them? Aetna does not have any of this information.
 
Biller2023 said:
We are an out of network provider and many claims of Aetna are priced by a company called Data Isight. Data Isight processes claims with a lesser allowed amount and when we ask them to reprice the claim, they say that the claim is ineligible for negotiations. We then contact Aetna to tell them that we do not accept Data Isight's rates and Aetna says that we should only contact Data Isight as the claim was priced by them. How do we make the insurance reprice the claim as this is going back and forth?

We have also filed appeals with Aetna regarding these claims and the appeals were closed stating we have reached final level of appeal and the agents have asked us to contact the State Commissioner of NJ if we wish to do next level of appeal.

How do we contact the State commissioner of NJ. Is there a specific number or a website to file appeals with them? Aetna does not have any of this information.
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Can you clarify what you mean by “lesser allowed amount”? I want to make sure I’m understanding what you believe is incorrect about the pricing.

You mentioned that you are an out-of-network provider. Are these commercial Aetna claims, or are these Medicare/Medicaid claims where the reimbursement is supposed to be based on a specific Medicare/Medicaid fee schedule?

Also, what type of services are these claims for?

Are they for emergency or other services subject to the No Surprises Act?

Or is the patient voluntarily going out of network?
 
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