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.

The attachment provides information on helping to meet minimum parent/caregiver training to help manage children’s ABA treatment.

HNFS Autism Care Demonstration

This link contains a reminder on how to access overpayment and appeal decision letters online.  These can be located through Document Library on the Provider Portal or by using an Application Programing Interface (API).  There is also an option to enroll in Direct Connect via the portal.

What you need to know about accessing letters electronically

Cigna – Reimbursement Policy Update – E&M Codes Billed with Modifier 25 052523 UPDATE

You were recently informed of an update we planned to make that would require the submission of office notes with claims submitted with evaluation and management (E&M) Current Procedural Terminology (CPT®) codes 99212, 99213, 99214, and 99215 and modifier 25 when a minor surgical procedure is billed. The E&M line would be administratively denied unless we received documentation to support that a significant and separately identifiable service was performed.

Delaying the implementation of this policy update
Since announcing this policy update, provider feedback indicated that while there is general consensus that modifier 25 is often inappropriately billed, the process we proposed for how to submit office notes requires further assessment. Additionally, national medical societies committed to work with us to educate their membership on the inappropriate billing of modifier 25. As a result, we are currently reevaluating this reimbursementpolicy update, which will delay implementation.

We will communicate a new implementation date and additional details at a later time.

Please click on the above link for the complete announcement from Cigna.

June 2023 Provider Newsletter – Provider News (anthem.com)

This month’s featured articles:

Featured Articles

• Introducing Roster Automation to improve turnaround times and data accuracy
• Correction: Federal Employee Program® Quality Reimbursement program update

Administrative

• CAA: Have you reviewed your online provider directory information lately?
• Consider a FIT kit for your patients aged 45 and older at average risk for colon cancer
• Digital notifications are coming June 1, 2023
• Building Vaccine Confidence – A webinar hosted by Pfizer

Policy Updates

• MCG Care Guidelines 27th Edition
• HCPCS to revenue code alignment – Evaluation/Management
• Clinical Criteria Updates December 2022
• Clinical Criteria Updates February 2023
• MCG Care Guidelines 27th Edition
• Updates to Carelon Medical Benefits Management, Inc. Advanced Imaging, Sleep Disorder Management, and Spine Surgery Clinical Appropriateness Guidelines
• Medical Policies and Clinical Guidelines Updates — June 2023
• Updates to Carelon Medical Benefits Management, Inc. Advanced Imaging, Sleep Disorder Management, and Spine Surgery Clinical Appropriateness Guidelines
• Medicare Part B Step Therapy Vegzelma
• Effective August 1, 2023, Carelon Medical Benefits Management, Inc. programs will expand
• Program delay announcement authorizations for post-acute care services for commercial members
• Medicare Part B Precert Expansion Briumvi Leqembi
• Reimbursement Policy update: Bundled Services and Supplies policy – Professional
• Reimbursement Policy update: Bundled Services and Supplies — Professional
• New reimbursement policy: Provider Preventable Conditions – Professional and Facility

Products & Programs

• Expansion of Back Pain Guide Program effective July 1, 2023
• OBRA 93 claim filing for Federal Employee Program
• Specialty pharmacy updates – June 2023
• Pharmacy information available on our provider website
• BioPlus provider FAQ
• Patient Safety Skilled Nursing Facility (SNF) Survey
• Colorectal Cancer Screening (COL) and Care for Older Adults (COA) for HEDIS
• SPC Exclusions

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.

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

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

May 2023 Provider News – Provider News (anthem.com)

This month’s featured articles:

Administrative

• Moving Toward Equity in Asthma Care CME Training and Asthma Medication Ratio HEDIS measure update
• Consolidated Appropriations Act: Review your online provider directory information regularly
• Looking to earn CME credits? Check out the CME Engagement Hub!
• You are invited! Skilled Nursing Facility (SNF) providers: Fall prevention and patient safety
• Updated 2023 provider manual now available
• Submit corrected claims electronically for the Federal Employee Program®
• Important information for providers registered to use Medical Attachments on Availity.com
• Enhanced Provider News website and email communications launching May 1, 2023

Policy Updates

• Transition to Carelon Medical Benefits Management, Inc.* MRI Breast Clinical Appropriateness Guidelines
• New Reimbursement policy: Bundled Supplies and Services – Facility
• Reimbursement policy update: Technology Assisted Surgical Procedures – Professional and Facility
• Reimbursement policy update: Multiple and Bilateral Surgery Processing – Professional

Products & Programs

• Specialty pharmacy updates – May 2023

State & Federal

• Update: Authorizations for DMEPOS services for Medicare Advantage Individual, Group Retiree Solutions, and Dual-Eligible plan members
• Did your patient have a recent fracture?
• Genetic testing
• Keep up with Medicare News – May 2023