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.

Arkansas BCBS – Providers News September 2023

This month’s featured articles:

Arkansas Blue Cross and Blue Shield

• 2023 Open enrollment – Please use Availity
• Availity Essentials Portal: Send unsolicited attachments with claims and upload solicited attachments in the Availity dashboard
• Coronary Fractional Flow Reserve (FFR) and Instantaneous Flow Reserve (iFR)
• Coverage policy manual updates
• Medical specialty medications prior authorization update
• Paper Claim Reduction: How Availity Essentials portal can help
• Prior Authorization Requirement Changes for 2024
• Prosthodontia Service Benefit/Payment Changes
• Metallic Formulary changes effective October 1, 2023
• Standard formulary changes effective October 1, 2023
• Update on pre-payment review of high-dollar inpatient claims
• Update on claims inventories

Federal Employee Program

• Back to School and Welcome back to Germs
• Diabetes Management

Medicare Advantage

• CMS Requirement for Provider Certification on National Plan and Provider Enumeration System (“NPPES”)
• New Requirement for Provider Language Disclosure and Linguistic Capabilities
• Reminder on billing qualified Medicare beneficiaries
• Requirements for Medicare Outpatient Observation Notice

Blue & You Fitness Challenge

• 21st Annual Blue & You Fitness Challenge

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

Oct2023Conn – Final

The following topics are covered in this edition.

General News

• Medica portal EDI transactions moving to Availity Essentials portal, starting Jan. 1, 2024
• New resubmission option for denied prior authorizations aims to reduce appeals for medicalnecessity, eff. Oct. 1

Clinical News

• Medical Policies and clinical guidelines to be updated effective 11/20/2023

Pharmacy News

• Medica to add new UM policies for 4 new medical pharmacy drugs, 12/01/2023

Administrative News

• Self-service resources, featuring: Timely filing and late claim guidelines
• Provider administrative training webinar for October

Both current and historical updates from UHC can be viewed by following the link below.

UHC September Network News

Some items noted are:

Effective 01/01/2024 UHC will be reducing some Medicare Advantage service areas and discontinuing some plans.  UHC will send notices to the patients to advise them of the change and to review their options.  Patients can call the Customer Service number on their ID card or the number listed on the notice from UHC.

Reminder of ongoing Medicaid or CHIP eligibility review is ongoing and that your patient may need to change plans if they are no longer eligible.

You can view the The September 2023 Newsletter in full by following the link below.

Sept 2023 Newsletter

The topics covered include:

• Submitting Prior Authorization
• Personalized match phase 1: Specialist provider overview
• Available training this monty
  • Youth mental health in today’s world
  • Submit prior authorizations digitally through ICR
• Clinical Criteria updates
• Prior authorization changes effective 11/01/2023 and 12/01/2023
• Expanded specialty pharmacy list
• Specialty pharmacy medical step therapy for hyaluronan
• Medication reconciliation post inpatient discharge

Anthem Provider Newsletter – Missouri September 2023

This month’s featured articles:

Administrative

• Update – Enhanced outpatient facility editing for National Correct Coding
• Initiative
• CAA: Have you reviewed your online provider directory information lately?
• Support documentation for Carelon Medical Benefits Management, Inc . prior
• authorization requests
• HCPCS to revenue code alignment
• Help your patients continue their care and navigate Medicaid renewal

Digital Tools

• Improvements to Digital RFAI Attachment filtering and reporting
• Personalized match phase 1: Specialist provider overview
• Simplifying claims attachments: Digital Request for Additional Information
• through Availity.com
• Member search feature enhancement: Search for a patient without using
• member ID in Availity Essentials

Educational and Training

• You’re invited: Thriving, not just surviving: Youth mental health in today’s world
• Policy Updates
• Clinical Criteria updates – May 2023

Medical Policy and Clinical Guidelines

• Medical policies and clinical guidelines updates – September 2023
• Medical policies and clinical guidelines moving to pre-cert
• Medical policies and clinical guidelines updates

Prior Authorization

• Prior authorization requirement changes effective December 1, 2023
• Carelon Medical Benefits Management, Inc. advanced imaging – Imaging of
• the brain CPT code list update

Reimbursement Policies

• Reimbursement policy update: Documentation Standards for Episodes of Care –
• Professional
• Clarification to reimbursement policy update: Prolonged Services – Professional
• Reimbursement policy update: Documentation and Reporting Guidelines for
• Evaluation and Management Services – Professional
• Reimbursement policy update: Place of Service – Facility
• New reimbursement policy: Split Care Surgical Modifiers – Professional

Products and Programs

• Reminder: Review the health reimbursement arrangement and care plan updates in Availity Essentials
• Specialty pharmacy updates – September 2023
• Sublocade® update

Pharmacy

• Specialty pharmacy medical step therapy for hyaluronan injections
• UPDATED: Anthem Blue Cross and Blue Shield expands specialty pharmacy precertification list

Quality Management

• Medication reconciliation post inpatient discharge

As a result of a recent review, we will deny respiratory pathogen panel testing as not medically necessary when administered at a frequency greater than either 12 in a 12-month rolling timeframe or one per day.  Denials will affect the claim line only and include medical necessity appeal rights.

This update is effective for dates of service on or after November 12, 2023. We will update the Nucleic Acid Pathogen Testing (0530) medical coverage policy to reflect this change.

Cigna – Medical Coverage Policy Update – Respiratory Pathogen Panel Testing

Cigna – ClaimsXten Update 111223

As a result of a recent review, we will update the Bundled Service ClaimsXten rule to add 22 service codes. This rule administratively denies claims submitted with bundled codes when billed with any other procedure code not indicated as bundled.

Denials will affect the claim line only and include administrative appeal rights. This update is effective for dates of service on or after November 12, 2023.

Cigna has updated their precertification list.  They have removed over 600 codes that previously needed authorization.

Removal of Precertification Codes August 23

Master Precertification Updated List August

The UHC September Virtual Provider Expo is scheduled for September 12, 2023 from 8:30 – 3:00 PM Central Time.  There will be several sessions throughout the day with the option to earn continuing education credits for attending these presentations:

• Coding education
• Smart Edits
• Payment Integrity

You can find more information on this as well as how to register by following the link below.

UHC September Provider Expo

The September edition of the Medica Connections is now available for review by following the attached link.

Sept2023Conn – Final

The following topics are covered in this edition.

General News

• Annual notice: Medica encourages its members to get flu vaccinations
• Reminder: Use electronic prior authorization option for easy submission

Pharmacy News

• Medica to add new UM policies for 5 new medical pharmacy drugs, eff. Nov. 1
• Medica to add 1 new drug UM policy for Mayo Medical Plan, eff. Nov. 1
• Upcoming changes to Medica Part D drug formularies, eff. Sept. 1

Administrative News

• Self-service resources, featuring: Medical pharmacy guidelines
• Provider administrative training webinar for September