Pediatric Council

What is the New York Chapter 2 and New York 3 Pediatric Council?

The Pediatric Council is a group of pediatricians from New York Chapters 2 and 3 that has been working behind the scenes for some time representing the pediatric practitioners in our area.  The Council has been meeting with insurance companies to make them aware of the coverage, payment and logistical issues confronting our membership and has been negotiating to resolve them.


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Chapter Liaisons

How can you help?

July2012 Update

Change in Medicaid billing for vaccine administration for 2013  
Urgent - Use modifier -25 for Vaccine Administration as of January 1, 2013

June 2012 Update

Aetna Denies HPV9 for Males

What has been accomplished?

To date, we have had meetings with Aetna, Empire Blue Cross, GHI-Emblem and United Health Care.  Meetings generally occur about three times per year with each company.  To date, our Council has been instrumental in the facilitating the following:

Who are our representatives on the Council?

Our District II Executive Director, George Dunkel, also attends and has been of great assistance in scheduling the meetings and preparing our agendas and conference calls.

How can you help?

Our task is complicated by the number of insurance companies doing business in the Downstate area; currently, there are twenty seven (27).  To address this situation we have devised the following strategy, but this strategy requires manpower and that is why we are soliciting your participation.  We would like to identify chapter members to act as a liaison with an individual insurance company and develop an ongoing working relationship with someone in the upper management in that company.  These liaisons would act as the Councilís contact with the company and would be invited to attend our meetings with them.  If an issue arises, the liaison would be the first to address it with his or her contact at the company.  Hopefully those contacts at the insurance companies would communicate through the liaison if they needed  a problem brought to the attention of the pediatric community.  We would like to have a liaison for each of the 27 companies which is why we need your participation.  If you are interested, and we hope you are, please e-mail Steve Goldstein at and we will discuss this opportunity with you.

We can do more, but we need your help.  If you do not feel comfortable being a liaison, we still need your input and to hear about your problems.  Please forward your concerns to us so we can add them to our agenda for future meetings with the insurance companies.  

************************************** PortalRequired Immunizations
(Developed in consultation with the Commissioner of Health)

The Advisory Committee on Immunization Practices (ACIP) develops and adopts recommendations for the routine administration of vaccines for children and adults and promulgates schedules regarding the appropriate periodicity, dosage, and contraindications applicable to the vaccines.  Pursuant to Circular Letter No. 13 (2006), covered necessary immunizations for dependent children to age 19 are those vaccines and immunizations recommended by the ACIP.  ACIP recommendations are posted to the ACIP website after they are adopted.  Later, they are published in the Morbidity and Mortality Weekly Report (MMWR).  Once a recommendation is adopted, the vaccine or immunization must be covered in accordance with Circular Letter No. 13 (2006) as of the date of adoption.  Insurers and health plans should monitor the ACIP and CDC websites regularly for the most current information on recommended vaccinations.   Reliance on information published in the MMWR, should only be utilized in the absence of posted recommendations on the ACIP or CDC Websites, but even in such cases, recommended vaccines must ultimately be covered back to the date of adoption by ACIP.

Provisional recommendations and the federal Vaccines for Children Program (VFC) resolutions are posted on the ACIP and VFC websites and indicate adoption by ACIP. Please see the links below for more information.

ACIP Recommendations and VFC Resolutions (new external link)


Practitioner and Ordered Ambulatory Providers:
       Change in Medicaid billing for vaccine administration for dates of service on and after January 1, 2013

HHS to partner with pediatricians as Medicaid payments increase
        by Kathleen Sebelius, Secretary, U.S. Department of Health and Human Services


Council Update, July 2012 (Posted 7/21/12)

      The Pediatric Council, a combined group from Chapters 2 and 3, continues to interact with insurers to advocate for child health care coverage and to address the concerns of our members.

Emblem Health (GHI and HIP) stopped paying for in-office hemoglobin testing and CBCís sometime in May.  Currently they will only pay for these tests when done by a hematologist or oncologist.  All other doctors must send the lab work out. This issue had been discussed in 2010 when it was proposed by HIP and we thought the issue had been resolved.  We have been in contact with them to reverse this policy and our appeal is pending.  This policy creates another layer of difficulty for the pediatric office and patients and will delay filing of WIC forms.  It seems to be contrary to the guidelines of Bright Futures and the concept of the Medical Home as well.  If this has affected you, please speak to your Emblem provider representative to register your dissatisfaction.  At our last meeting with Emblem they told me that I was the only doctor to complain about their policies.  I will keep you posted about the outcome of these negotiations.

The issue of payment for developmental testing by Fidelis is still active.  A new letter just went out to their Medical Director from the District Chair, making a strong case for reversal of the policy and requesting reconsideration of claims back to April 1, 2012.  The new autism law, scheduled to take effect November 1, mandates that insurers cover screening, diagnosis and therapy.

Straight Medicaid does not recognize code 96110 either.  We advocate for inclusion of this code as a payable service but budgetary constraints will not allow this.  The code is currently considered by Medicaid a part of the well visit fee.  Medicaid is considering how best to distribute the extra funds available for primary care under the Affordable Care Act.

Some thoughts for practitioners about how best to deal with insurers and utilize the Pediatric Council:

  1. Fill out a Hassle Factor Form and send it in.  The Councils get them and we can bring your problems to the insurers.  Issues are taken seriously and we are willing to advocate for the practitioner.  We canít add a problem to the agendas if we are not aware of it.

  2. Speak to your Provider Representatives when issues come up.  Let them know about your problem and ask them to get you an answer or direct you to someone higher up in the organization.

  3.  Ask parents and parent groups who are affected by your issue to discuss it with the insurer.  No company wants a roster of unhappy clients.

  4.  Join the Pediatric Council and help us advocate for Children and Pediatricians.

Respectfully submitted,

Steven J. Goldstein, M.D., F.A.A.P.
Chair, Pediatric Council District 2, Chapter 2


Council Update, June 2012 (Posted 6/4/12)

The Pediatric Council, a combined group from Chapters 2 and 3, continues to meet with insurers to advocate for child health care coverage and to address the concerns of our members.

The Pediatric Council is interested in hearing about your issues with insurers and recruiting members to join us. If you have problems you would like to discuss, would like to help us, or agenda items for our meetings, please contact me at .

Respectfully submitted,

Steven J. Goldstein, M.D., F.A.A.P.


Aetna Denies Payment for HPV9 for Males (Posted 6/4/15)

PPAAC has learned from our Aetna contact that Aetna will not be covering HPV9 for boys greater than 15 years of age and if submitted claims will not be paid for that age group.  This is despite the ACIP recommendation and the recent AAP News publication that we shared with them.  Aetna revisits these policies quarterly. This will stand at least until the fall.


CPT Code 96110 (Posted 1/2/12)
CMS will assign the RVU's for 96110 so that it can remain a covered service for pediatrics when used as developmental testing with a report using a standardized testing tool.

The American Medical Associationís CPT editorial panel recently revised the description of code 96110 to cover "developmental screening" rather than developmental testing, as it had been previously described. As Medicare does not pay for screening or preventive services unless such coverage is authorized under the Medicare statute, for Medicare purposes, CMS modified the active status of code 96110 and did not include associated value units in the 2012 Medicare Resource Based Relative Value Scale physician fee schedule (PFS).

This change resulted in many questions and potentially unintended consequences for other payers. We want to be clear that Medicaid and other private payers will be able to continue to use code 96110 even though it is a statutorily non-covered service under Medicare. In addition, many State Medicaid programs rely upon Medicare-published relative value units, including those associated with code 96110. At the request of Medicaid and concerned stakeholders, in the next few weeks Medicare will provide the relative value units for this code.

Revised payment files to reflect corrections and revisions to the physician update amount will be posted on the Physician Fee Schedule portion of the CMS website under the PFS Relative Value Files section, available here in the near future. In advance of these files, the payment rate for code 96110 will be based on 0.28 total Relative Value Units (0.27 practice expense and 0.01 malpractice).

CMS has also created a new code, G0451 (Developmental testing with interpretation and report, per standardized instrument form), and published associated relative value units, to ensure that physicians can continue to bill for the types of services encompassed under CPT 96110 when used for testing and not screening purposes.


Urgent Message for AAP Members who Provide and Bill for Vaccine Administration

On January 1, 2013 the Centers for Medicare and Medicaid Services (CMS) released the latest version of the National Correct Coding Initiative (NCCI) edits. The NCCI edits are code edits published by both Medicaid and Medicare to support correct coding and claims adjudication. Included in the new Medicaid and Medicare edits were edits on all evaluation and management (E/M) services that disallow patient with immunization administration codes without the proper modifier. The modifier indicator for all these edits is a "1," meaning that with proper modifier placement, the edit can be overridden.

While the Academy is urgently working with National Correct Coding Solutions - the CMS contractor for NCCI edits - to have the edits suspended on all preventive medicine service codes (99381-99385 and 99391-99395) with all immunization administration codes (90460 and 90461, 90471-90474). It should be noted that the edits are currently locked in and will continue to be in effect for Medicaid, Medicare, and private payers that implement CMS coding policies until such time that AAP advocacy efforts are successful. Over the past several days, the AAP has been in telephone contact with the highest levels of the CMS contractor responsible for the NCCI edits and has delivered a formal letter demanding retraction of these edits.

Therefore, effective immediately and for all claims submitted after January 1, 2013, AAP urges its members to append modifier 25 to the preventive medicine service code (99381-99395) when it is reported in conjunction with any immunization administration service (90460-90461; 90471-90474).

A modifier 25 should also be appended to other non-preventive medicine E/M services (eg, 99201-99215) when reported in conjunction with immunization administration -- but only when the E/M service is significant and separately identifiable.

We understand this is an administrative burden for you and your staff. The AAP is working diligently to unlock this change and will forward additional information on this issue as it becomes available.

Please contact the AAP Coding Hotline with any questions or issues:


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