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.

Cigna – Administrative Policy Update – Preventive Care Services

December 20, 2024

Cigna – Admin Policy Update – Preventive Care Services 031725

As a result of a recent review, and in accordance with Affordable Care Act guidelines, coverage for certain services billed as preventive will be subject to criteria including age, frequency, and diagnosis codes. submitted. Based on these factors, we may determine that related claims are not reimbursable, or claims may be reimbursed with the appropriate cost share under the medical benefit.

This update applies to certain claims billed as preventive care for abdominal aortic aneurysm, cervical cancer, colorectal cancer, human papilloma virus, osteoporosis, and lung cancer screenings. We will update the Preventive Care Services (A004) administrative policy to reflect this change,

Denials will affect the claim line only. This update is effective for dates of service on or after March 17, 2025.

Evernorth Behavioral Health – Prior authorization requirements for partial hospitalization level of care effective January 1, 2025

December 09, 2024

EverNorth Behavioral Health Authorization Requements for Partial Hospitalization Level of Care4 010125

Dear Behavioral Health Provider,

Evernorth® Behavioral Health (Evernorth) is committed to helping you deliver timely care to your patients by reducing your administrative burden. Therefore, effective January 1, 2025, we are updating our prior authorization requirements for partial hospitalization (PHP) level of care.

What this means

  • Prior authorization will no longer be required for PHP level of care for your patients with coverage under most Evernorth plans. However, a small number of plans will still require prior authorization.
  • Dates of service prior to January 1, 2025, may require prior authorization.
  • For patients with Cigna Connect IFP plans, services rendered outside of their state of residence are considered out of network. Therefore, always verify benefits, eligibility and prior authorization requirements prior to rendering services. You can easily identify patients with Cigna Connect IFP plans by viewing their ID card, which will indicate the plan name. A Partial Hospitalization (PHP) Network Exception Request Form is now available on Provider.Evernorth.com (Resources > Forms Center > Behavioral Health Forms) to submit a request for prior authorization.

To verify patient benefits, eligibility and prior authorization requirements

Continue to use the same process you use today to verify a patient’s benefit plan details and prior authorization requirements before rendering services.

  • Call Provider Services at 800.926.2273.
  • Log in to the provider portal on Provider.Evernorth.com.
    Register here to access the portal if you have not already registered. The portal provides 24/7 secure access to patient information such as eligibility and benefits, and allows you to check prior authorization requirements, view remittance reports, enroll in electronic funds transfer (EFT), and make directory profile updates.

Assistance with additional resources and discharge planning is available by calling Provider Services at 800.926.2273.

Thank you for your ongoing commitment to provide quality behavioral health services to our customers.

Sincerely,

Network Operations Management
Evernorth Behavioral Health

Summit Community Care Provider Newsletter – December 2024

December 02, 2024

Summit Community Care Provider Newsletter – December 2024

This month’s featured articles:

Administrative

Notice of Material Amendment to Healthcare Contract

Digital Solutions

Education & Training

Policy Updates

Notice of Material Amendment to Healthcare Contract

Notice of Material Amendment to Healthcare Contract

Long-Term Services & Supports

Pharmacy

Notice of Material Amendment to Healthcare Contract

 

Anthem Provider Newsletter – December 2024

December 02, 2024

Anthem Provider Newsletter – Missouri December 2024

This month’s featured articles:

Administrative

Digital Solutions

Behavioral Health

Education & Training

Policy Updates

Reimbursement Policies

Products & Programs

Federal Employee Program (FEP)

Pharmacy

Quality Management

Cigna Healthcare administrative quick tip guide

November 06, 2024

Cigna Healthcare Administrative Quick Tips

To help ease your administrative burden and support you in spending more time your patients, Cigna has developed this administrative quick tip guide. It provides at-a-glance information and resources to help you work with us in the most efficient manner possible. Topics include:

  • Benefits and features of the Cigna for Health Care Professionals website (CignaforHCP.com).
  • Provider Newsroom
  • Credentialing
  • Claim reconsiderations and appeals
  • Claim attachment submissions
  • Claim escalations
  • Third-party administrator claim escalations
  • Cigna International Health claim reconciliation requests

Healthy Blue Provider Newsletter November 2024

November 01, 2024

Healthy Blue Provider Newsletter November 2024

This month’s featured articles:

Administrative

Digital Solutions

Education and Training

Policy Updates 

Medical Policy & Clinical Guidelines

Prior Authorization

Pharmacy

Quality Management 

 

Summit Community Care Newsletter – November 2024

November 01, 2024

Summit Community Care Provider Newsletter – November 2024

This month’s featured articles:

Education and Training

Policy Updates

Notice of Material Amendment to Healthcare Contract

Medical Policy & Clinical Guidelines

Notice of Material Amendment to Healthcare Contract

Prior Authorization

Notice of Material Amendment to Healthcare Contract

Quality Management

Anthem Provider Newsletter – November 2024

November 01, 2024

Anthem Provider Newsletter – Missouri November 2024

This month’s featured articles:

Administrative

Digital Solutions

Behavioral Health

Education and Training

Policy Updates

Reimbursement Policies

Products & Programs

Pharmacy 

Community Care – Oklahoma: Update on Implementation of Oncology – Prior Authorization Management by Evolent

October 30, 2024

CommunityCare is excited to notify you that effective Friday, November 1, 2024, Evolent (formerly New Century Health) will begin managing prior authorizations for most oncology-related services.

As previously noted in a late July notification, the following will require a prior authorization from Evolent before being administered in either the provider office, outpatient hospital, ambulatory setting or infusion center: physician administered and oncology-related infused and injectable chemotherapeutic drugs, supportive agents, symptom management medications and radiation oncology treatment requests.
Treatment plans will be reviewed using nationally recognized evidence-based guidelines and not be more restrictive than CMS criteria.

Prior authorization requirements will apply to all CommunityCare Commercial and Marketplace members of all ages and Medicare Advantage members 18 years of age and older.

Please note the following:

• Real-time authorizations for treatment plans meeting best evidence-guided therapy may be submitted via the Evolent CarePro provider portal at https://my.newcenturyhealth.com.
o The Evolent CarePro provider portal may also be accessed from a link in the CommunityCare provider portal, CareWeb.
• Authorization status updates will be available in the Evolent CarePro provider portal.
o After determination, authorizations will also show in CommunityCare’s provider portal, CareWeb.
• Telephone authorization requests – Providers needing to request an authorization may call 1-888-999-7713, (Oncology – Option 2) (Radiation Oncology – Option 3). Staff are available Monday-Friday, from 7 a.m. to 7 p.m. CST

• Oncologists and radiation oncologists are on staff for clinical discussions with physicians.
• A dedicated Evolent Provider Solutions Manager is available to contact directly for any issues or questions.

All prior authorizations for surgical oncology treatment after November 1, 2024, should be directed to CommunityCare via the CareWeb portal.

Any CommunityCare prior authorizations approved before November 1, 2024, are effective and valid until the authorization end date. Upon expiration, authorization requests must be submitted to Evolent. For services/treatment that did not require an authorization prior to November 1, 2024, an authorization may be required from Evolent for service/treatment dates on and after November 1, 2024.

If your office has not been contacted by an Evolent Provider Solutions Manager to schedule an introductory meeting and training session to prepare users for the upcoming transition, please contact Evolent at 1-888-999-7713, (Option 6) or via email at .

If you have questions, please contact CommunityCare’s Medical Management department at (918) 594-5228 or (800) 594-0089 or contact your Provider Services Representative.

Cigna – Demographic data updates for providers in Colorado, District of Columbia, and Illinois

October 08, 2024

Earlier this year, we began a partnership with LexisNexis®1 Risk Solutions to help ensure we remain compliant with local and federal data validation mandates and that our provider directory remains accurate.

What this means to you

  • Beginning October 4, 2024, your office may receive phone calls from a LexisNexis Risk Solutions representative identifying themselves as being affiliated with Cigna HealthcareSM. Please be assured that these calls are authorized by Cigna Healthcare and are not spam.
  • The LexisNexis Risk Solutions representative will request confirmation of specific demographic information, which may include, but not be limited to, the following:
    • Office address/phone number.
    • Billing address/phone number.
    • National Provider Identifier.
    • Tax Identification Number.

Additional information
We appreciate your partnership in this critical effort to help ensure the collective accuracy of provider data, which ultimately helps your patients with Cigna Healthcare coverage find you when they need care.

For any questions, please call Cigna Healthcare Provider Service at 800.88Cigna (882.4462).