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.

HealthChoice Oklahoma Bulletin – March 1, 2024

March 01, 2024

Billing for DOC inmates

To be reimbursed for medical or dental services provided to DOC inmates, you must bill the Department of Corrections within 120 days of providing services and adhere to following the directions below.

You may file claims electronically with payer ID 71065, through the provider portal (you can upload a claim with PCH or you can manually key a claim with iEDI), or mail paper claims to DOC Claims, P.O. Box 30522, Salt Lake City, UT 84130-0522.

  • Bill with group number 76415170.
  • Add the prefix 365000 to the DOC inmate ID number if it is 6 digits.
  • Add the prefix 36500 to the DOC inmate ID number if it is 7 digits.
  • Enter the updated prefix+ digit DOC inmate ID number when making a DOC inquiry using the IVR system or provider portal.

The updated DOC inmate ID number, after adding the prefix, should always be 12 digits. To verify the DOC inmate ID number, visit the DOC offender search.

You cannot invoice or balance bill the inmate for reimbursement. Invoices received by DOC or the inmate will be disregarded. DOC claims are paid at 100% of the fee schedule allowable. You can view allowable amounts for DOC claims by logging into the DOC Fee Schedule.

For questions, call the Customer Care team at toll-free 800-323-3710. TTY users call 711.

Summit Community Care Provider Newsletter – March, 2024

March 01, 2024

Summit Community Care Provider Newsletter – March 2024

This month’s featured articles:

Education and Training

Policy Updates

Medical Policy & Clinical Guidelines

Prior Authorization

Quality Management

Anthem Provider Newsletter – March, 2024

March 01, 2024

Anthem Provider Newsletter – Missouri March 2024

This month’s featured articles:

Administrative | Medicare Advantage

Digital Solutions | Medicare Advantage

Digital Solutions | Commercial

Education and Training | Commercial

Policy Updates | Medicare Advantage

Medical Policy & Clinical Guidelines | Medicare Advantage

Prior Authorization | Medicare Advantage

Reimbursement Policies | Commercial

Pharmacy | Commercial

Pharmacy | Medicare Advantage

Quality Management | Commercial

Quality Management | Commercial / Medicare Advantage

Quality Management | Medicare Advantage

Quality Management | Commercial

Health Net Federal Services Tricare West Prenatal Screening Update Under the LDT Demonstration Project

February 28, 2024

Effective February 12, 2024 and retroactive August 17, 2020 pre-authorization for trisomy 13, 18, 21, X and Y tests.  To be covered, testing must comply with the most recent American College of Obstetricians and Gynecologists guidelines.  Coverage for singleton pregnancies with a high risk of fetal aneuploidy is limited to claims dated to March 5, 2015 through August 16,2020.

Please view the attachment below for full details.

HNFS Prenatal

Medica Connections March 2024

February 28, 2024

The March edition of the Medica Connections is now available for review by following the link below.

March 2024 Medica Connections

*Reminder to verify the plan type and location listed

The following topics are covered in this edition.

General News

  • Beginning on or after May 2024 Medica will used Carelon to review prior authorization submissions for MSK, cardiology and radiology.
  • Beginning with June 1, 2024 dates of admission Medica plans to expand their concurrent review program to include inpatient hospital admissions.  More information is available by reviewing their administrative manual. Link included in body of notice.

Clinical News

  • Effective 04/22/2024 Medica will update one or more UM policies, coverage policies and clinical guidelines. Specific details can be found by following the link in the notice.

Pharmacy News

  • Effective 04/01/2024 Express Scripts will limit the dispensing of mail-order short-term prescriptions for certain Medica members.
  • Various Humira biosimilar drugs are now covered by Medica.
  • Effective 05/01/2024 new UM polices will be put into place for Aphexda and Uptravi.

Network News

  • Effective 03/01/2024 Medica will update standard DME, O&P fee schedules for all products.

Administrative News

  • Provider administrative training webinar for March: Setup and Billing for Elderly Waiver and Housing Stabilization.  This is scheduled for March 20 11:30pm – 1pm CST.  The registration link and additional information can be found on the attachment.
  • Medica also offers educational sessions on various topics

February 20, 2024

CLINICAL DOCUMENTATION IMPROVEMENT WEBINARS

FEBRUARY 2024

Learn more about: Risk Adjustment Documentation and Coding

Each webinar includes an overview of Risk Adjustment (RA) and Hierarchical Condition Categories (HCCs).

Click on the following link for more information and registration.

view.email.homestatehealth.com/?qs=9e4ec6d22b7f15fe03d736d9f3d4b5dda6ba8757008df938afda32304d91f5abab93f56c211c0572bae81ca4e582179925cac6a4d543c53e4cc088b54e39d5db5623602fdcbc28b38e29eb86c2787ea1

Cigna – Reimbursement Policy Update – Current Procedure Terminology and Healthcare Common Procedure Coding System codes with a status B indicator

February 16, 2024

Cigna – Reimbursement Policy Update – Current Procedure Termonology and Healthcare Common Procedure Coding System Codes with a Status B Indicator

We routinely review our coverage, reimbursement, and administrative policies for potential updates. In that review, we take into consideration one or more of the following: evidence-based medicine, professional society recommendations, Centers for Medicare & Medicaid Services guidance, industry standards, and our other existing policies.

As a result of a recent review, we will update the Code Editing Policy & Guidelines to add 10 codes with a status B indicator: Current Procedural Terminology codes 38204, 92921, 92925, 92929, 92934, 92938, 92944, and 97602 and Healthcare Common Procedure Coding System codes A4262 and A4263. These codes will be administratively denied when billed with another service 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 May 11, 2024.

 

Health Net Federal Services Autism Care Reminder

February 13, 2024

This is a reminder from HNFS regarding their progress note requirements under their Autism Care Demonstration program.  The notes bust contain all Tricare-required elements, support the respective claim and relate to the beneficiary’s approved treatment plan goals.

Full details can be found on the attachment.

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UHC February Network News

February 13, 2024

The February edition of the UHC Network News is now available for review by following the link below.

UHC Network News

Home State Health – Clinical Policy Update: Testing for Select Genitourinary Conditions

February 13, 2024

Home State Health – Policy Update – Testing for Select Genitourinary Conditions 051524

Dear Provider,

Thank you for your continued partnership with Home State Health.

As you know, we continually review and update our payment and clinical policies to ensure that they are designed to comply with industry standards while delivering the best patient experience to our members.

We write to inform you of updates to Home State Health’s Testing for Select Genitourinary Conditions clinical policy. These updates will be effective for Medicaid, Marketplace and Medicare plans effective May 15, 2024.

Policy Number Policy Name Policy Description
CP.MP.97 Testing for Select Genitourinary Conditions Revisions Include:

  • Added 0330U and 0352U as not medically necessary for members 13 years and older.
  • Updated requirements for ICD-10 B37.3 to apply to B37.31 and B37.32 which together now replace B37.3.
  • Changed CPT 87481 from not medically necessary in any circumstance to not medically necessary when paired with certain diagnosis for members 13 and older.