The World Trade Center (WTC) Health Program Nationwide Provider Network (NPN) is a limited federal health benefit program, which provides medical monitoring (surveillance) and treatment for WTC-related conditions to enrolled 9/11 responders and survivors. For a health condition to be covered for treatment, it first must be certified by the WTC Health Program. In addition, influenza vaccination and breast, cervical, colorectal, and lung cancer screening in accordance with United States Preventive Service Taskforce (USPSTF) guidelines are covered.
Certified WTC-related health conditions are illnesses or health conditions on the applicable List of WTC-Related Health Conditions for which exposure to airborne toxins, any other hazard, or any other adverse condition resulting from the September 11, 2001, terrorist attacks is substantially likely to be a significant factor in aggravating, contributing to, or causing the illness or health condition. The condition also must meet other Program policies and criteria, such as latency. This determination is based on an examination by a Program-affiliated medical professional with experience in treating or diagnosing these WTC-related health conditions.
Reimbursement for healthcare services is federally mandated in accordance with the Federal Employees’ Compensation Act (FECA) Fee Schedule or the Medicare Physician Fee Schedule where FECA rates are not established. The WTC Health Program does not follow the Outpatient Prospective Payment System. Claims are submitted to the NPN for payment. WTC Health Program members should never be billed directly for any services or balances, including co-payments, coinsurance, or deductibles.
Billing will vary depending on whether the Program member is enrolled as a Survivor or a Responder. Responders and Survivors with a certified WTC-related health condition (known as Certified-Eligible Survivors) receive an NPN member ID card that includes important billing information.
Survivors will have an “S” in their member number (e.g., 911Sxxxxx). The member will also know if they are classified as a Survivor or a Responder.
• Always bill primary health insurance first for Survivors.
• Once the primary insurance is billed, balance bill any remaining amount, including any cost-share imposed by the primary insurance for the Survivor member, such as a co-payment or coinsurance, to WTC Health Program NPN (MCA-Sedgwick). The primary insurance explanation of benefits (EOB), if applicable, must be included.
Responders do not have an “S” in their member number (e.g., 911xxxxxx), where member numbers for Responders will be all numeric (starting with ‘911’). For Responder members, bill the WTC Health Program NPN the full amount, in accordance with the FECA fee schedule or the Medicare Physician Fee Schedule where FECA rates are not established.
• Please note that primary insurance is not billed for Responders.
For both Responder and Survivor members with established workers’ compensation claims, the provider is not responsible for billing workers’ compensation for WTC Health Program benefits.
Providers can bill the WTC Health Program NPN (MCA-Sedgwick) in any of the following ways:
• E-Bill Payor ID: LV371 (Office Ally and Data Dimensions)
• Mail Room: PO Box 8021, Dublin, OH 43016
• E-Fax: (866) 728-7860 / (614) 408-2836
• Provider Portal: sedgwickwtc.com/providers
The WTC Health Program requires all providers to be paid electronically. To expedite the payment of claims for NPN members, please submit the required electronic funds transfer (EFT) information as soon as possible, before submitting a medical bill. EFT information can be submitted through the NPN Provider Portal.
Managed Care Advisors, a Sedgwick company, is contracted to provide Nationwide Provider Network services for the WTC Health Program. The WTC Health Program is administered by the National Institute for Occupational Safety and Health, part of the Centers for Disease Control and Prevention in the U.S. Department of Health and Human Services. Sedgwick privacy policy.