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.

Home State Health – Wellcare by Allwell Prior Authorization List 100123

Please click on the above link to access the announcement from Wellcare by Allwell regarding updates to their prior authorization list effective 10/1/2023.

Home State Health Provider News – Babylon Provider Alert

We’d like to update you on some important information regarding our Ambetter Virtual Access members’ telehealth coverage. Babylon Health’s telehealth services are no longer available as of August 7, 2023. Due to this change, you may receive new requests for both virtual and in-person services from Ambetter Virtual Access members as you are currently in our network.

As always, please verify each member’s eligibility, benefits, and
referral requirements before rendering care.

To view the full announcement, click on the link above.

As you know, we took important steps through COVID-19 to deliver timely accommodations to providers and customers, helping to ensure that customers had continued access to COVID-19 diagnostic services, testing, and treatment in safe settings.

How we reimbursed COVID-19 services

As a reminder, we have been reimbursing providers at contracted rates for COVID-19 related services (e.g., vaccine administration, infusion treatments, and testing) only when provider-specific rates were in place for certain COVID-19 services. When no contracted rates were in place, we reimbursed providers for all covered COVID-19 services billed under the medical benefit at the established national Centers for Medicare & Medicaid Services (CMS) rates.

This reimbursement approach was put in place at the onset of the pandemic to ensure that providers received timely, consistent, and reasonable reimbursement.

Updating how we reimburse these services as of August 1, 2023

At the end of the public health emergency period – May 12, 2023 – we communicated that we would continue to follow this reimbursement guidance in the interim while targeting August 1 to pay all providers at contracted rates, including reverting to a default discount for providers who don’t have specifically negotiated rates for COVID-19-related services.

Please note that we are now reimbursing all participating providers at contracted rates for COVID-19-related services beginning with August 1 dates of service (subject to applicable law).

Get the most up-to-date information

Our dedicated COVID-19 provider web page was recently updated to highlight these changes. I encourage you to review this page for the latest information.

Click on the following links to access the current edition of Cigna Network News

Cigna Network News 3rd Quarter 2023

Cigna – Coverage Policy Update – Transthoracic Echocardiography Codes 102523

As a result of a recent review, we will update the Transthoracic
Echocardiography in Adults (0510) medical coverage policy to remove
151 International Classification of Diseases, Tenth Revision (ICD-10)
codes and add eight ICD-10 codes.

Denials will affect the claim line only and include medical necessity appeal
rights. This update is effective for dates of service on or after October 25, 2023.

For more information about our policy updates, visit the Cigna for Health Care Professionals website:  (CignaforHCP.com) >Resources> Coverage Policies> Policy Updates .

Cigna Reimbursement Policy Update – Bone Graft Substitutes 102523

As a result of a recent review, we will administratively deny bone graft
substitutes as incidental to a facility’s global surgical fee when billed under
revenue code 278. Denials will affect the claim line only and include
administrative appeal rights.

This update is effective for dates of service on or after October 25, 2023.
We will update the Facility Routine Service, Supplies, and Equipment
(R12) reimbursement policy to reflect this change.

HealthChoice Network News Summer 2023

In this issue

• HealthChoice contracts and applications
• EGID Network Management
• Updating your billing address
• Fee schedule updates
• HealthChoice contact information

Anthem Provider Newsletter – Missouri August 2023

This month’s featured articles:

Featured Articles

• Looking to earn CME credits? Check out the CME Engagement Hub!
• Reminder: Start using the Provider Data Management application now on Availity Essentials — retirement of previous intake channels October 1, 2023

Administrative

• Urinary tract infection tool kits are on the way
• Anthem Blue Cross and Blue Shield appropriate coding helps provide a comprehensive picture of patients’ health and services provided
• Clinical Laboratory Improvement Amendments
• Federal Consolidated Appropriations Act (CAA) Gag Clause
• CAA: Review your online provider directory information regularly

Policy Updates

• Clinical Criteria updates – March 2023
• Updates to Carelon Medical Benefits Management, Inc. Joint Surgery, Small Joint Surgery, and MSK Level of Care
• Expansion of Carelon Medical Benefits Management, Inc. cardiology programs effective October 1, 2023
• Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines for joint surgery and MSK level of care
• Prior authorization requirement changes effective November 1, 2023
• Technology Assisted Surgical Procedures

Products & Programs

• Specialty pharmacy updates – August 2023
• Specialty pharmacy updates – July 2023
• Pharmacy information available on our provider website
• Medication adherence: Back to the basics
• Why statin therapy is important in your patients with diabetes
• Healthy blood pressure recheck initiative
• Pharmacotherapy Management of COPD Exacerbation (PCE) HEDIS® Measure
• Congenital syphilis is a sentinel health event

Cigna – Reimbursement Policy Update – Hospital in the Home 100123

We will implement a new reimbursement policy, Hospital in the Home (R42), to outline the reimbursement of these services for Centers for Medicare & Medicaid Services-approved hospitals that participate in the Acute Hospital Care at Home program.

• This update is effective for dates of service on or after October 1, 2023, and applies to customers over 18 years of age with Cigna Healthcare commercial and Individual & Family Plans only.
• Precertification is required and the policy is limited to specific conditions.
• Only direct admissions to hospital in the home from the emergency room are eligible.
• A discount off the current contracted inpatient reimbursement rate will be applied to  hospital in the home admissions.
• For additional information, please contact your Cigna Healthcare provider contracting representative.

Cigna Reimbursement Policy Update – Anesthesia 101423

As a result of a recenfreview, we want to make you aware that we will make the following updates effective for dates of service on or after October 14, 2023.

• We will deny the unbundled Current Procedural Terminology (CPT®) code when billed  with one or more of the following anesthesia codes by the same provider on the same day,
• We will reduce reimbursement to four units for anesthesia claims submitted with modifier AD and CPT codes 00100-01999.
• For additional information, call Cigna Healthcare Customer Service at 800.88Cigna
  (882.4462).