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.

New Payment Policy Effective June 1, 2024

Arkansas Health & Wellness is publishing a new payment policy to inform you about acceptable billing practices and reimbursement methodologies. The below policy is effective June 1, 2024:

NCD Non-Covered Lab Diagnosis — Enforcement of National Coverage Determination (NCD) guidelines when diagnostic lab testing services are billed only with a diagnosis that is not covered per the NCD

This policy applies to our Medicare and Marketplace lines of business. To view it and other important policies, visit ARHealthWellness.com/policies.

If you have questions about this notice, please call 1-800-294-3557 (TTY: 1-877-617-0392) or email .

Home State Health – Change Cybersecurity Incident 031324

CHANGE HEALTHCARE CYBERSECURITY INCIDENT

& It’s Impact to Home State Health, Ambetter from Home State Health, Wellcare, Wellcare by Allwell and Show Me Healthy Kids

On February 21, 2024 Change Healthcare, a software and data analytics subsidiary of UnitedHealth Group’s Optum unit, experienced a cybersecurity incident that has impacted its network and operations. The cybersecurity incident has created a service disruption impacting Home State Health, Ambetter from Home State Health, Wellcare, Wellcare by Allwell, and Show Me Healthy Kids’ (‘Home State Health Plan’) members and provider network in several ways.

As of now, Change Healthcare has not provided a timeline for resolution. To protect our members and providers, Home State Health Plan has fully disconnected system access to and from Change Healthcare on Feb. 21. We are working on multiple solutions to restore provider functionality and ensure continuity of care for our members. We will continue to provide updates as this situation evolves.

Electronic Claim Submission

The ability to electronically submit claims to the Home State Health Plan through Change Healthcare is currently down. Providers can easily submit electronic claims to the Home State Health Plan via many alternative methods including other claims clearinghouses, our secure provider portal, and mail. Our preferred clearinghouse for electronic claims submission is Availity. To enroll, please visit www.availity.com/Essentials-Portal-Registration and/or call Availity Client Services at 1-800-AVAILITY (1-800-282-4548). For step-by-step instructions for Availity, visit the resource page on our parent company Centene’s website at Change Healthcare (centene.com). Additional information on claims submission can be found in our Provider Manuals located on our website at www.HomeStateHealth.com

Reimbursement via Paper Check and Virtual Credit Card (VCC)

Some paper check and virtual credit card payment processes for the Home State Health Plan have been disrupted due to this incident. We apologize for any inconvenience this causes. Please know we are working quickly to implement a new process to ensure payments are operational as soon as possible. An alternate way to speed up your payment process is to set up an automated clearing house (ACH) for electronic funds transfer (EFT). Home State Health’s preferred ACH/EFT partner, PaySpan (now part of Zelis), has offered to help expedite the sign-up process for providers by calling 1-877-331-7154 or visiting www.payspanhealth.com.

Chart Retrieval

Change Healthcare performs retrieval of medical records for several of our programs, such as HEDIS® and Risk Adjustment. You may have received a request via phone or fax from Change Healthcare on behalf of Home State Health, where you either scheduled appointments or provided medical records. Change Healthcare is unable to honor any fulfillment requests at this time; however, we will be employing two of our existing medical record retrieval vendors, Datavant (formerly Ciox) and Datafied, to satisfy these prior commitments.

These retrievals are required to report on clinical quality measures and diagnosis data to Health and Human Services (HHS), the Centers for Medicare & Medicaid Services (CMS) and the National Committee for Quality Assurance (NCQA). We ask that you please honor the same commitment dates for these vendors, even if you have already committed to providing medical records to Change Healthcare. If you have provided medical records from the time period of Feb. 19, 2024 to current, you may be asked to provide these medical records again.

Thank you for your patience and partnership as we navigate this situation. We apologize for any inconvenience in this matter. If you have any questions, please contact your Provider Engagement representative or our Provider Services team at the numbers listed below or visit Change Healthcare (centene.com).

Home State Health – Availity Training Webinars 031124

AVAILITY TO HOST LIVE TRAINING WEBINARS FOR PROVIDERS

As you may be aware, the ability to electronically submit claims to Home State Health, Ambetter from Home State health, Wellcare, and Wellcare by Allwell through Change Healthcare is currently unavailable due to a cybersecurity incident that impacted its network and operations with no timeline for resolution. Availity, our preferred clearinghouse partner, is ready and available to help providers to enroll and begin submitting claims. They are offering several live training webinars for providers to get started with Availity Essentials.
Webinar registration is easy via the Availity Essentials Provider Portal. Providers must be enrolled with Availity Essentials to access webinars. Step-by-step instructions for Availity Essentials enrollment can be found on the Availity Lifeline website.

Live Webinar: Use Availity Essentials to Submit Professional Claims
Join Availity to explore using the Claims and Encounters application on Availity Essentials. In this 75-minute webinar, providers will learn how to:

• Get access and explore form options
• Save entry time including shortcuts when entering provider, patient, and code details
• Use key features that include options for submitting COB claims, corrected claims, and adding attachments
• Take important steps to follow up after you submit claims
• Navigate help, training and support tools

An expert Availity Essentials application trainer will also guide providers through key insights about the application and provide a downloadable quick-tips PDF that they can save to use later.
Upcoming webinar dates:

• March 11th – 12:00 pm EST
• March 13th – 11:00 am EST
• March 14th – 10:00 am EST
• March 15th – 10:00 am EST
• March 19th – 10:00 am EST

Live Webinar: Getting Started with Electronic Data Interchange (EDI) on Availity Essentials
Join Availity experts to learn about Electronic Data Interchange (EDI) on Availity Essentials. This webinar will cover:

• How to access the Availity EDI Companion Guide
• Availity payer list
• EDI reporting preferences

• Manage your file transfer protocol (FTP) mailbox
• Send and receive EDI files
• EDI response files
• Help and support resources

Upcoming webinar dates:

• March 11th – 1:30 pm EST
• March 13th – 3:30 pm EST
• March 14th – 2:30 pm EST
• March 15th – 2:00 pm EST

Registration: Webinar registration is easy via the Availity Essentials Provider Portal.
Thank you for your continued partnership as we navigate the Change Healthcare outage. If you have any questions, please contact your Provider Engagement representative or our Provider Services team at the numbers listed below or visit our Change Healthcare Outage Resource website.

The latest UHC Network News Policy and Protocol newsletter is now available for review.

UHC March Network News

In this issue you will find links to specific policy updates: Medical, Reimbursement, Specialty Medical Injectable Drug and Pharmacy and clinical updates. They also provide a feature where you can see a Monthly overview of the changes that have occurred.

If you access the provider portal using One Healthcare ID there are changes coming in the near future including the use of Authenticator to log on. They have attached additional resources reviewing the process and what will need to be done.  There is no date on this yet but they will be updating information as available.

Starting March 1, 2024 UHC will no longer be sending Inpatient Care Management courtesy faxes prior to issuing the final level of care outcome.  You will only receive notification once a review has been completed.  These are the ways UHC will provide notification:

• Sign in to the portal to review in real time
• You will receive a fax of the outcome once the review is complete
• You will only receive a written letter by fax or mail if the member does not meet inpatient criteria.

Starting April 1 the Prior Authorization crosswalk will feature new updates to include:

• More comprehensive list of CPT and HCPC codes
• Apply to more UHC plans
  • Commercial, Exchange, Medicare Advantage and Community Plan
• Will no longer have a Code Category column

Also provided are instructions on how to use the Crosswalk table.

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

This month’s featured articles:

Education and Training

• Congenital syphilis intervention opportunities for neonatal and pediatric providers
• Resources to support your diverse patient panel

Policy Updates

• Notice of Material Amendment to Healthcare Contract
• MCG Care Guidelines 27th edition update

Medical Policy & Clinical Guidelines

• Notice of Material Amendment to Healthcare Contract
• Medical Policiesand Clinical Utilization Management Guidelines update

Prior Authorization

• Notice of Material Amendment to Healthcare Contract
• Prior authorization requirement changes effective June 1, 2024
• Pharmac
• Prior authorization updates for medications billed under the medical benefit

Quality Management

• Encourage Cervical Cancer Screening (CCS)
• HEDIS Breast Cancer Screening (BCS) update
• HEDIS 2024 documentation for Controlling High Blood Pressure (CBP) and Statin Therapy for Patients with Cardiovascular Disease (SPC)
• Cervical Cancer Screening (CCS) and Prenatal and Postpartum Care (PPC) for HEDIS

Anthem Provider Newsletter – Missouri March 2024

This month’s featured articles:

Administrative | Medicare Advantage

• CAA: Maintain your online provider directory information

Digital Solutions | Medicare Advantage

• Expansion of Carelon Medical Benefits Management, Inc. programs effective April 1, 2024

Digital Solutions | Commercial

• Expansion of Carelon Medical Benefits Management, Inc. programs
• Beginning February 2024, you can submit Physical Health prior authorizations through the Authorization application on Availity.com

Education and Training | Commercial

• Congenital syphilis intervention opportunities for neonatal and pediatric providers

Policy Updates | Medicare Advantage

• MCG Care Guidelines 27th edition update

Medical Policy & Clinical Guidelines | Medicare Advantage

• Clinical Criteriaupdates — December 2023

Prior Authorization | Medicare Advantage

• Prior authorization requirement changes effective May 1, 2024
• Prior authorization requirement changes effective May 1, 2024

Reimbursement Policies | Commercial

• Reimbursement policy update: Ambulance Transportation – Professional

Pharmacy | Commercial

• Specialty pharmacy updates — March 2024
• Important information about your Anthem patients’ Botox prescriptions
• Pharmacy information available on our provider website
• Prior authorization updates for therapeutic duplication of specialty drugs

Pharmacy | Medicare Advantage

• Anthem expands specialty pharmacy precertification list
• Overview of Medicare risk adjustment in-office prospective programs
• Notification of specialty pharmacy medical step therapy updates

Quality Management | Commercial

• Encourage Cervical Cancer Screening (CCS)
• Cervical Cancer Screening (CCS) and Prenatal and Postpartum Care (PPC) for HEDIS

Quality Management | Commercial / Medicare Advantage

• HEDIS 2024 documentation for Controlling High Blood Pressure (CBP) and Statin Therapy for Patients with Cardiovascular Disease (SPC)
• HEDIS Breast Cancer Screening (BCS) update

Quality Management | Medicare Advantage

• HEDIS^®2024 documentation for Care of Older Adults (COA)

Quality Management | Commercial

• Boost annual preventive care visits: Tips and resources: An ounce of prevention is worth a pound of cure

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

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

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