Cigna – Reimbursement Policy Update – Revenue codes 270-279 billed without a procedure code UPDATE

We recently sent a letter informing you about a reimbursement policy update that would administratively deny revenue codes 249-259 and 637 when billed without a procedure code. We have reevaluated this reimbursement policy change, which affects its implementation.

What this means to you
• The previously communicated update to the Revenue Code Billing Requirements (R41)
reimbursement policy is no longer effective for claims submitted. with revenue codes 249-259 and 637 without a procedure code.
• Claims you may have submitted for dates of service on or after September 17, 2023 that were denied as a result of this policy update will be automatically reprocessed. You do not need to take any action.

If we decide to proceed with this policy update, we will communicate _a new imp!ementation date and additional details. at a later time.

As a First Health provider, you are considered an in-network provider for Curative members.

Curative, a health plan administrator with $0 deductible, $0 copay, and $0 out-of-pocket costs for all in-network care, is now accessing the First Health Network*. Curative has recently expanded its services to include employer groups that will access the network, and our goal is to ensure that there is no question about your network participation and no disruption in care.

Please make sure that your scheduling and front office staff know about your First Health participation so that Curative members can access your services with their in-network benefit. If you have any questions about your network status, please call First Health at 1-800-226-5116, First Choice of the Midwest at 1-888-246-9949, and Cofinity at 1-800-831-1166.

Please ensure that you are reviewing the health plan ID card and submitting claims as indicated on the ID card.

To confirm patient eligibility, please visit https: /curative.corn/eligibility. For electronic billing, please use payer ID: CURTV.

For more information, please visit the First Hea!F1 Network provider page at https:// curatlve. com/first health- network.

Questions about Curative’s plan? Reach out to or call provider support at 855-414-1083.  To learn more about Curative, please visit https:/curative.corn.

*Every Curative member qualifies for the $0 deductible, $0 copay for in-network care, and preferred prescriptions by completing a Baseline Visit within 120 days of the plan effective date. See https:/curatlve.corn to learn more.

Arkansas BCBS – Providers News December 2023

This month’s featured articles:

Arkansas Blue Cross and Blue Shield

• Coverage Policy Manual Updates
• DispatchHealth
• Electronic Data Interchange (EDI) Unique Submitter Identification Number No Longer Required for Claims Submission
• Medical Pharmacy Coverage changes
• Medical Records Review Process Improvements
• New Prior Authorization for GLP1 Receptor Agonist Drug Class
• Overpayments: Payer-Identified Overpayments now Available on Availity Essentials Portal
• Paper Claim Reduction
• Please Hold Claims Incurred During the Credentialing Process
• Please Use Availity During Open Enrollment
• Prior Authorization (PA) Intake Methods Changing
• Provider enrollment and re-credentialing
• Medical specialty medications prior authorization update
• Quality of Care (QOC) Complaints
• Metallic Formulary changes effective January 1, 2024
• Standard formulary changes effective January 1, 2024
• Value formulary changes effective January 1, 2024
• USAble MCO and Workers’ Compensation
• Zero-dollar CPT codes

Federal Employee Program

• 2024 FEP Benefit Changes
• Plan-specific updates
• HEDIS Improvement Coding Guide for Practitioners and Coders Prenatal and Postpartum Care Measures
• FEP Reminders

Medicare Advantage

• CMS Requirement for Provider Certification on National Plan and Provider Enumeration System (NPPES)
• CMS Part D Guidance
• HIPAA and HITECH Reminders
• Medicare Advantage Pharmacy Update
• Medicare Part B Step Therapy
• Paper Remittance Advice Changes: Arkansas Blue Medicare
• Reminder on Billing Qualified Medicare Beneficiaries
• Requirements for Medicare Outpatient Observation Notice

Blue & You Fitness Challenge

• 21st Annual Blue & You Fitness Challenge

EFFECTIVE JANUARY 1, 2024

We are pleased to announce that, effective January 1, 2024, Express Scripts® will begin processing pharmacy claims for our plan members.

Express Scripts is a pharmacy benefit management (PBM) company serving more than 100 million Americans. Express Scripts Pharmacy delivers specialized care that puts patients first through a smarter approach to pharmacy services.

Members have been notified in advance and will receive a new ID card with updated pharmacy information, so that they are prepared to begin having their prescriptions filled at participating network pharmacies when this change occurs.

Providers can direct members to call the Member Services phone number listed on their ID card should they have questions about this change. You can find frequently asked questions on our website here:

• https://www.homestatehealth.com/providers/allwell-provider-materials.html

• https://ambetter.homestatehealth.com/provider-resources/manuals-and-forms.html

• https://www.wellcare.com/providers/medicare-bulletins/express-scripts-transition

Please contact your Provider Engagement Administrator with any additional questions. As always, we appreciate the care you provide to our members.

Step Therapy programs are developed by Wellcare’s P&T Committee. They encourage the use of therapeutically equivalent, lower-cost medication alternatives (first-line therapy) before “stepping up” to alternatives that are usually less cost-effective.

Step Therapy programs are intended to be a safe and effective method of reducing the cost of treatment by ensuring that an adequate trial of a proven safe and cost-effective therapy is attempted before progressing to a more costly option. First-line drugs are recognized as safe, effective, and economically sound treatments.

The first-line drugs on Wellcare’s formulary have been evaluated through the use of clinical literature and are approved by Wellcare’s P&T Committee. Step therapy is failure of at least one different or less expensive drug prior to coverage of a drug on this list.

Drugs requiring step therapy effective January 01, 2024 can be found under “Resource Documents” here:
https://www.homestatehealth.com

The prescriber, patient, or authorized representative may ask for an exception. Step therapy applies if the drug has not been used in the past 365 days.

As always, we appreciate the care you provide to our members.

Cigna MA – Secondary Diagnosis Codes Update 010124

As a result of a recent review, we will administratively deny a secondary diagnosis code  when billed as the primary or sole diagnosis on a claim.

This update aligns with the International Classification of Diseases, 10th Revision, Clinical Modification guidelines and is effective for dates of service on or after January 1, 2024.

Anthem Provider Newsletter – Missouri December 2023

Featured Articles

• CarelonRx, Inc. Mail will change to CarelonRx Pharmacy on January 1, 2024
• Model of care training reminder

Administrative

• Updates to correct coding editing
• New vendor administering Primary Care Access Survey
• New vendor administering behavioral health access survey
• Outpatient system updates for 2024
• Professional system updates for 2024
• Important information about utilization management
• Notification about submitting itemized bills
• New requirements for credentialing and recredentialing
• Case Management Program
• Coordination of care
• CAA: Review your online provider directory information
• Clinical practice and preventive health guidelines
• Members’ Rights and Responsibilities
• Clinical Documentation Lookup Tool
• Process for Carelon Post Acute Solutions, LLC redirection and Availity Essentials clinical denial/approval outcome notifications

Policy Updates

• Medical Policiesand Clinical Utilization Management Guidelines update for May 2023
• Medical Policiesand Clinical Guidelines updates — December 2023
• Medical Policies andClinical Guidelines updates — December 2023
• Glucagon-Like Peptide-1 prior authorization changes
• Transition to Carelon Medical Benefits Management, Inc. Genetic Testing Guidelines
• Transition to Carelon Medical Benefits Management, Inc. Genetic Testing Guidelines
• Prior authorization requirement changes effective March 1, 2024 – Codes 0738T and 0739T
• Prior authorization requirement changes effective March 1, 2024 – Codes Q4272 – Q4284
• Prior authorization requirement changes effective March 1, 2024  – Code E0761
• Prior authorization requirement changes effective March 1, 2024 – Codes 33275 and 33274

Products & Programs

• Introducing the High Performing Provider designation
• Federal Employee Program updates member ID cards
• 2024 Federal Employee Program Benefit information available online
• Pharmacy information available on our provider website
• Notification of specialty pharmacy medical step therapy updates
• HEDIS 2023 Electronic Clinical Data Systems (ECDS)

IMPORTANT HOME STATE & NIA NOTICE

Effective March 1, 2024

All of us at Home State Health, Ambetter from Home State Health, WellCare, and Wellcare By Allwell are committed to continuous improvement of quality services for our members. With that in mind, Home State Health, Ambetter from Home State Health, WellCare, and Wellcare By Allwell have entered an expanded partnership with National Imaging Associates, Inc. (NIA)¹, to implement a new Musculoskeletal (MSK) Management program.

This MSK program includes prior authorization for inpatient and outpatient hip, knee, shoulder, lumbar, and cervical spine surgeries for Home State Health, Ambetter from Home State Health, WellCare, and Wellcare by Allwell members. The decision to implement this program is consistent with industry-wide efforts to ensure clinically appropriate quality of care and to manage the increasing utilization of these services.

In consideration of this agreement, Home State Health, Ambetter from Home State Health, WellCare, and Wellcare By Allwell will terminate the current MSK program with TurningPoint Healthcare as of February 29, 2024.

Under terms of the agreement between Home State Health, Ambetter from Home State Health, WellCare, and Wellcare By Allwell and NIA:

• Home State Health, Ambetter from Home State Health, WellCare, and Wellcare By Allwell will oversee the MSK program and continue to be responsible for claims adjudication and medical policies.
• NIA will manage inpatient and outpatient MSK surgeries through the existing contractual relationships with Home State Health, Ambetter from Home State Health, WellCare, and Wellcare By Allwell.

Planned for a March 1, 2024, implementation, this correspondence serves as notice under your Participating Home State Health, Ambetter from Home State Health, WellCare, and Wellcare By Allwell Provider Agreements of changes to the program.

Providers may begin contacting NIA on March 1, 2024, to seek prior authorization for procedures scheduled on or after March 1, 2024. Any authorization requests prior to March 1, 2024 should continue to be submitted to TurningPoint, even for dates of service after March 1, 2024. Those authorizations will be shared with NIA to enter into their system.

IMPORTANT PHARMACY CLAIMS PROCESSING CHANGE

EFFECTIVE JANUARY 1, 2024

We are pleased to announce that, effective January 1, 2024, Express Scripts® will begin processing pharmacy claims for our plan members.

Express Scripts is a pharmacy benefit management (PBM) company serving more than 100 million Americans. Express Scripts Pharmacy delivers specialized care that puts patients first through a smarter approach to pharmacy services.

Members have been notified in advance and will receive a new ID card with updated pharmacy information, so that they are prepared to begin having their prescriptions filled at participating network pharmacies when this change occurs.

Providers can direct members to call the Member Services phone number listed on their ID card should they have questions about this change.

You can find frequently asked questions on our website here:

https://www.homestatehealth.com/providers/allwell-provider-materials.html