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.

Wellcare is beginning its collaboration with New Century Health (NCH) to implement a new prior authorization program.

New Century Health is a comprehensive oncology quality management (OQM) and cardiology management specialty company optimizing the application of evidence-based medicine for the delivery of adult ambulatory cancer care and cardiology care.

This prior authorization requirement applies to your Wellcare Medicare Advantage members ages 18 and older for the following lines of business: HMO, PPO, PPO-DSNP, DSNP, PFFs, and C-SNP.

Additional information and training sessions can be found by viewing the attachments.

Wellcare Medicare Advantage and New Century Health Cardiology Prior Auth Updates

Provider Notification_WellCare Cardio

FAQ_Cardiology_WellCare

PDW Provider Demographic Information

wellcare-wellcare by allwell – covid19 testing screening and treatment 051223

During the PHE, we followed guidance from the Centers for Medicaid & Medicare Services (CMS) and instituted temporary waivers for select services. This action ensured that critical care could be quickly delivered to our members during a time of heightened need. Beginning May 12, 2023, these temporary waivers will expire, and our members’ Medicare plan benefits will be reinstated.

Please review the attached link regarding the specific changes effective May 12, 2023.

Cigna – Reimbursement Policy Update – Procedure and Place of Service 081223

Cigna routinely reviews their coverage, reimbursement, and administrative
policies for potential updates.  As a result of a recent review, they implement the following medical coverage policy updates.

• We will administratively deny Current Procedural Terminology (CPT) or Healthcare  Common Procedure Coding System (HCPCS) codes when billed with an inappropriate place of service (POS).
• This update is effective for dates of service on or after August 12, 2023.

Please follow the link below to review additional information on these items:

• COVID-19 PHE ends
• Breast milk storage bag quantity update
• ePrescribing to military pharmacies
• Using CareAffiliate for referrals and pre-authorization requests
• Online Authorization change request form
• Autism Care Demonstration discharge summaries
• Class I recall for certain Philips Respironics DreamStation 1 CPAP machines
• Billing Guidance for Spravato
• Resources for Asthma management
• Mental Health Awareness Month resources

In Case You Missed It: May 2023 TRICARE West Region Updates (mkt2747.com)

Beginning June 05, 2023 prescriptions must be sent electronically to Scott Air Force Base Pharmacy for controlled substances, including Schedule II Medications.

Send Prescriptions to: DoD Scott ePhcy
NCPDP: 1471109
Zip Code: 62225
Phone: 618‐256‐7400 or 618‐256‐9355

Additional information can be found here:

Electronic Prescription Information

Please review the attachment regarding billing guidance for Spravato Nasal Spray.

Spravato Nasal Spray

Home State Health Plan is committed to continuously improving its overall payment integrity solutions to prevent overpayments due to waste or abuse. This is a notification that we will begin performing additional prepayment claim reviews on 8/1/2023 using Optum’s Comprehensive Payment Integrity (CPI) tool.  As a result of these prepayment claim reviews, providers may be asked for medical records and billing documents that support the charges billed.

Click on the following link for the complete announcement.

Home State – Optum’s Comprehensive Payment Integrity (CPI) Reviews

The June 2023 Medica Connections is now available for viewing.  Some of the items addressed are listed below:

• Yearly diagnosis code evaluation is scheduled to begin soon.  This will be for 2022 DOS and will be performed by Optum and CiOX
• Various Clinical and Policy guidelines will be updated effective 07/17/2023 and a link is available to view those on the attachment
• Effective 07/01/2023 changes to the commercial member drug formulary will take effect.  These can viewed on the 2023 Medica Commercial Drug List
• The drug management policies can be reviewed in their entirety by following the link on the attachment
• Claim Appeals, Adjustments and Record Submission is the upcoming training course.  Registration instruction can be found by following the link on the attachment.

June2023Conn – Final

HealthChoice Network News May 2023

In this issue

• Venipuncture
• Fee schedule history
• Direct data entry of claims with Availity
• Home Infusion Therapy reimbursement changes
• HCPCS and OP fee schedule corrections for April 1, 2023
• Dental X-rays
• HealthChoice contact information

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.

The following link announces changes to their prior authorization requirements effective July 1, 2023.

allwell medicare authorization changes 070123