We strive to make information readily available to your office. We understand that your office is affected by any changes to the contracts that you hold through Mercy Managed Care. In efforts to keep you updated, this section is designed to update you on contract information including: new contracts, contract terminations, rate updates, TPA changes, and miscellaneous other news.

Please be aware that not all rate changes or contract updates below will necessarily pertain to everyone. We are also not able to publish specific rate information online as that data is confidential. Please see the additional resources below that are available to you to confirm specific contract participation.

• Mercy Network LLC providers: If you are participating with Mercy via a contract with Mercy Network LLC (this would include providers in Southwest Missouri,  Northwest Arkansas, Oklahoma and select providers in St. Louis), please reference your online matrix for specific contract participation.
• Mercy PHO providers: If you are contracted with Mercy via the Mercy PHO (this would include the majority of providers in the St. Louis region), please reference your PHO contract and enrollment packet for a listing of the contracts you hold through Mercy.
• Mercy employed/integrated providers in the St. Louis region: Please continue to reference the Managed Care hub on Baggot Street, and the Sharepoint site as your reference for contract participation.
• All other Mercy employed/integrated providers: Please continue to use the Managed Care hub on Baggot Street as your reference for contract participation.

Provider Changes
As a contracted provider, it is important to notify us immediately of changes to your practice such as: a new provider joining the practice, changes in billing information, provider leaving the practice, or adding a new clinic location.  Notification may help avoid claim denials.  Please submit changes by fax 417-820-3821 or email. Please include a W-9 Form if the change involves a new billing address or tax identification number.

HealthChoice Network News November 2022

In this issue

• Certification penalties
• HealthChoice advanced claim review implementation
• Update to dental code D0350
• HealthChoice code review vendor change
• New HealthChoice ID card for medical, dental and pharmacy
• Department of Corrections billing update
• VARIS update
• Copays for primary care and specialists
• HealthChoice Electronic Funds Transfer
• Certification portal update
• Contact information

Anthem Provider Newsletter – Missouri December 2022

This month’s featured articles:

Administrative:

• CAA: Timely updates help keep our provider directories current
• Attention lab providers: COVID-19 update regarding reimbursement
• Clinical practice and preventive health guidelines available on anthem.com
• Member assessment of PCP after-hours messaging in 2022
• Important information about utilization management
• Members’ rights and responsibilities
• Member’s assessment of behavioral healthcare after-hours messaging in 2022
• Coordination of care
• Case management program
• IngenioRx will become CarelonRx on January 1, 2023

Policy Updates:

• Reminder – updated AIM Musculoskeletal program effective January 1, 2023 – site of care reviews

Pharmacy:

• Pharmacy information available on the provider website
• Specialty pharmacy updates – December 2022

Medical Policy & Clinical Guidelines:

• AIM Specialty Health Cardiology Clinical Appropriateness Guidelines CPT Code List update
• AIM Specialty Health Genetic Testing Clinical Appropriateness Guidelines CPT Code List update
• Medical Policies and Clinical Guidelines updates – December 2022
• Reimbursement policy update: Multiple Surgery – Facility
• Reimbursement policy update: Bundled Services and Supplies – Professional
• Reimbursement policy update: Treatment Rooms with Office Evaluation and Management Services – Facility

Medicare:

• Keep up with Medicare News – December 2022
• 2023 Medicare Advantage service area and benefit updates
• Personal home helper benefit ending

Cigna – Reimbursement Policy Update – Outpatient Facility Frequency Limits

We routinely review our coverage, reimbursement, and administrative
policies for potential updates. In that review, we take into consideration
one or more of the following: Evidence-based medicine, professional
society recommendations, Centers for Medicare & Medicaid Services
(CMS) guidance, industry standards, and our other existing policies.

As a result of a recent review, we will update the way we process
outpatient facility claims that are subject to medically unlikeiy edits
(MUE), or frequency limits. We will administratively deny reimbursement
for the portion of a claim that is above the MUE limit set by CMS.
Denials will include administrative appeal rights.

This update is effective for dates of service on or after February 18,
2023. We will update the Code Editing Policy and Guidelines to reflect
this change.

Please click on the above link to view the complete announcement.

Effective December 31, 2022, the direct agreement between Mercy and Commerce Bank will terminate. However, members will still have access to Mercy providers at their tier 1 benefit level through standard UHC and BCBS/Anthem plans.

Please make sure that you request to see new identification cards when employees of this group present for care.

List Effective January, 2023

Wellcare and Wellcare by Allwell require prior authorization (PA) as a condition of payment for many services. This Notice contains information regarding such prior authorization requirements and is applicable to all Medicare products offered by Wellcare and Wellcare by Allwell.

Wellcare and Wellcare by Allwell are committed to delivering cost effective quality care to our members. This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice. Prior authorization is a process initiated by the physician in which we verify the medical necessity of a treatment in advance using independent objective medical criteria and/or in network utilization, where applicable.

It is the ordering/prescribing provider’s responsibility to determine which specific codes require prior authorization. 

Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered. NON-PAR PROVIDERS & FACILITIES REQUIRE AUTHORIZATION FOR ALL HMO SERVICES EXCEPT WHERE INDICATED.

For complete CPT/HCPCS code listing, please see Online Prior Authorization Tool on our website at: https://www.wellcare.com/en/Missouri/Providers/Bulletins and  https://www.homestatehealth.com/providers/allwell-provider-materials.html

Cigna – Digital ID Cards

Cigna has shared the following information regarding their increased use of digital ID cards.

Starting in 2022 you will be seeing more members with Digital ID Cards.  You might have received an email with the same information.  To ensure all correct team/contacts received the information I am sending it out again.

Cigna continues to leverage the power of technology and data to accelerate its transition to fully adopt digital-only ID cards* by 2024. This approach to digital ID cards is the next step in our journey to offer more digital-first solutions for our customers and providers.

What this means to you
Digital ID cards are not new for Cigna or the industry overall. Over the past several years, you may have noticed patients starting to present their ID cards to you in a digital format – typically on their phone from the myCigna^® app or from the myCigna.com^® website. This experience for you and your front-office staff should not change.

However, you may start to see more patients who have a digital-only ID card beginning in 2023. As they do today, your patients will have the option to:

Importantly, please note the digital ID card will look the same as the physical ID card does today and will contain the same benefit information.

If the member does not have access to a smart phone or computer.  Your office staff can always look up the digital card on CignaforHCP.com.  You are able to search by the members first and last name with their Date of Birth.

Effective 12/31/2022 SumnerOne, Inc will be terming their direct contract with Mercy. We have been advised that they will be moving to the UnitedHealthcare Core Network effective January 1, 2023.

****Keep in mind that the Mercy North Central region-which includes the Springfield, Joplin and Rolla area-is out of network with the UHC Core plan.******

Beginning January 1st, 2023 UnitedHealthcare will be offering a new Individual Exchange plan in the North Central and East markets. Our Mercy providers will be enrolled.

They have provided a link to the Individual Exchange plan which I have added below as well as link to the Quick Reference Guide.  The Reference Guide provides a wide range of information including a sample ID card, where to find eligibility and benefit information, as well as claim submission information.  You will also find several links on the Plan Page.

Please review and ensure your staff is aware.

UHC Individual Exchange Plan Page

Quick Reference Guide

HSH Clinical and Payment Policy Updates 111422

Home State Health has announced that they will be implementing the following clinical and payment policy updates.  Please click on the link above to view the complete announcement.

• Biopsychosocial Treatment of Obesity
• Pulmonary Function Testing

Please review the announcement from Health Blue Medicaid regarding several interactive sessions they’re hosting related to the Follow-Up After Hospitalization (FUH) Collaboration initiative.  This is primarily geared towards Behavioral Health providers and additional details and registration information can be found on the attachment.

Attached is an invitation for upcoming interactive Munch and Learn sessions that Healthy Blue MO will be hosting to educate behavioral health providers about the MHD Follow-Up After Hospitalization (FUH) Collaboration initiative.  Should you would like to participate please follow the directions on the flyer by sending a email to the mailbox indicated but be sure to put this in the subject line: FUH Initiative Virtual Provider Munch & Learn to insure that you register for the correct series.

Please share this invite with any and all associates within your organization that would benefit from these sessions including leadership, providers, behavioral health clinical staff, discharge coordinators, etc.

HEALTHY BLUE SPONSORED BH PROVIDER MUNCH LEARN