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.

Get ready for digital-only Medicaid reconsideration and appeal submissions

Beginning Feb. 1, 2024, claim reconsiderations and medical pre- and post-service appeal submissions must be submitted electronically for UnitedHealthcare Community Plans (Medicaid) in the following states:

• Michigan
• Missouri
• New Jersey
• North Carolina
• Tennessee
• Washington
• Wisconsin

The first link will direct you to the general announcement while the second link contains more detailed informaiton.

Medicaid Digital-Only Submissions

Feb. 1: Reconsideration and appeal submissions going digital-only | UHCprovider.com

The January edition of the Medica Connections is now available for review by opening the attached file.

Jan2024Conn – Final

The following topics are covered in this edition.

General News

• Be aware of possible benefit changes for you Medica patients as there will be updates 01/01/2024. Please verify benefits.

Clinical News

• Medical Policies and clinical guidelines to be updated effective 02/19/2023. The full list of updates can be viewed by following the link on the attachment. You can also call 1-800-458-5512 option 1, option 8, ext 2-2355 to request printed copies.

Pharmacy News

• Medica to add new UM policies for 4 new medical pharmacy drugs effective 03/01/2024-Aphexda, Loqtorzi, Omvoh and Pombiliti.

Network News

• No updates to affect our region

Administrative News

• Provider administrative training webinar for January:  Navigating Provider Resources.  This is scheduled for January 18^th 12:00pm – 1pm CST.  The registration link and additional information can be found on the attachment.

HealthChoice News Update 122223

Featured Articles:

• Modifier 25
• Billing for DOC inmates
• Observation stays
• Submitting partial hospitalization and intensive outpatient program certification requests

Please follow the link below for more information related to the change to UHC for FedEx employees that choose that Option.

Reminder FedEx Employees may access UHC

Cigna – Reimbursement Policy Update – Revenue codes 270-279 billed without a procedure code UPDATE

We recently sent a letter informing you about a reimbursement policy update that would administratively deny revenue codes 249-259 and 637 when billed without a procedure code. We have reevaluated this reimbursement policy change, which affects its implementation.

What this means to you
• The previously communicated update to the Revenue Code Billing Requirements (R41)
reimbursement policy is no longer effective for claims submitted. with revenue codes 249-259 and 637 without a procedure code.
• Claims you may have submitted for dates of service on or after September 17, 2023 that were denied as a result of this policy update will be automatically reprocessed. You do not need to take any action.

If we decide to proceed with this policy update, we will communicate _a new imp!ementation date and additional details. at a later time.

As a First Health provider, you are considered an in-network provider for Curative members.

Curative, a health plan administrator with $0 deductible, $0 copay, and $0 out-of-pocket costs for all in-network care, is now accessing the First Health Network*. Curative has recently expanded its services to include employer groups that will access the network, and our goal is to ensure that there is no question about your network participation and no disruption in care.

Please make sure that your scheduling and front office staff know about your First Health participation so that Curative members can access your services with their in-network benefit. If you have any questions about your network status, please call First Health at 1-800-226-5116, First Choice of the Midwest at 1-888-246-9949, and Cofinity at 1-800-831-1166.

Please ensure that you are reviewing the health plan ID card and submitting claims as indicated on the ID card.

To confirm patient eligibility, please visit https: /curative.corn/eligibility. For electronic billing, please use payer ID: CURTV.

For more information, please visit the First Hea!F1 Network provider page at https:// curatlve. com/first health- network.

Questions about Curative’s plan? Reach out to or call provider support at 855-414-1083.  To learn more about Curative, please visit https:/curative.corn.

*Every Curative member qualifies for the $0 deductible, $0 copay for in-network care, and preferred prescriptions by completing a Baseline Visit within 120 days of the plan effective date. See https:/curatlve.corn to learn more.

Arkansas BCBS – Providers News December 2023

This month’s featured articles:

Arkansas Blue Cross and Blue Shield

• Coverage Policy Manual Updates
• DispatchHealth
• Electronic Data Interchange (EDI) Unique Submitter Identification Number No Longer Required for Claims Submission
• Medical Pharmacy Coverage changes
• Medical Records Review Process Improvements
• New Prior Authorization for GLP1 Receptor Agonist Drug Class
• Overpayments: Payer-Identified Overpayments now Available on Availity Essentials Portal
• Paper Claim Reduction
• Please Hold Claims Incurred During the Credentialing Process
• Please Use Availity During Open Enrollment
• Prior Authorization (PA) Intake Methods Changing
• Provider enrollment and re-credentialing
• Medical specialty medications prior authorization update
• Quality of Care (QOC) Complaints
• Metallic Formulary changes effective January 1, 2024
• Standard formulary changes effective January 1, 2024
• Value formulary changes effective January 1, 2024
• USAble MCO and Workers’ Compensation
• Zero-dollar CPT codes

Federal Employee Program

• 2024 FEP Benefit Changes
• Plan-specific updates
• HEDIS Improvement Coding Guide for Practitioners and Coders Prenatal and Postpartum Care Measures
• FEP Reminders

Medicare Advantage

• CMS Requirement for Provider Certification on National Plan and Provider Enumeration System (NPPES)
• CMS Part D Guidance
• HIPAA and HITECH Reminders
• Medicare Advantage Pharmacy Update
• Medicare Part B Step Therapy
• Paper Remittance Advice Changes: Arkansas Blue Medicare
• Reminder on Billing Qualified Medicare Beneficiaries
• Requirements for Medicare Outpatient Observation Notice

Blue & You Fitness Challenge

• 21st Annual Blue & You Fitness Challenge

EFFECTIVE JANUARY 1, 2024

We are pleased to announce that, effective January 1, 2024, Express Scripts® will begin processing pharmacy claims for our plan members.

Express Scripts is a pharmacy benefit management (PBM) company serving more than 100 million Americans. Express Scripts Pharmacy delivers specialized care that puts patients first through a smarter approach to pharmacy services.

Members have been notified in advance and will receive a new ID card with updated pharmacy information, so that they are prepared to begin having their prescriptions filled at participating network pharmacies when this change occurs.

Providers can direct members to call the Member Services phone number listed on their ID card should they have questions about this change. You can find frequently asked questions on our website here:

• https://www.homestatehealth.com/providers/allwell-provider-materials.html

• https://ambetter.homestatehealth.com/provider-resources/manuals-and-forms.html

• https://www.wellcare.com/providers/medicare-bulletins/express-scripts-transition

Please contact your Provider Engagement Administrator with any additional questions. As always, we appreciate the care you provide to our members.

Step Therapy programs are developed by Wellcare’s P&T Committee. They encourage the use of therapeutically equivalent, lower-cost medication alternatives (first-line therapy) before “stepping up” to alternatives that are usually less cost-effective.

Step Therapy programs are intended to be a safe and effective method of reducing the cost of treatment by ensuring that an adequate trial of a proven safe and cost-effective therapy is attempted before progressing to a more costly option. First-line drugs are recognized as safe, effective, and economically sound treatments.

The first-line drugs on Wellcare’s formulary have been evaluated through the use of clinical literature and are approved by Wellcare’s P&T Committee. Step therapy is failure of at least one different or less expensive drug prior to coverage of a drug on this list.

Drugs requiring step therapy effective January 01, 2024 can be found under “Resource Documents” here:
https://www.homestatehealth.com

The prescriber, patient, or authorized representative may ask for an exception. Step therapy applies if the drug has not been used in the past 365 days.

As always, we appreciate the care you provide to our members.