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

Arkansas BCBS – Providers News November 2023

Featured Articles:

• Prior Authorization (PA) Intake Methods Changing
• Reminder on Prior Authorization Requirement Changes for 2024
• Organizational Determination/Benefit Inquiry
• Prenotifications
• Billed Codes Reminder
• FAQs

Cigna International Health is a segment of Cigna Healthcare business that offers solutions to globally mobile individuals and employers with a portion of their workforce that frequently spends extended time overseas. These plans provide a whole health service platform with a personalized, predictable, and simple customer experience that drives affordability of medical plans. As part of a global organization, we have access to health care support in more than 200 countries and territories around the world.

What you need to know

• Cigna International Health products are supported by our preferred provider organization and Open Access Plus network plans for services rendered in the United States.
• Coverage for Cigna International Health customers is included in the Cigna Healthcare provider agreement for participating providers in the United States.
• Participating providers will be reimbursed at the same rate for services provided to international customers as they would for any other Cigna Healthcare customer.

Types of international customers in the United States

• Returns – Citizens of the United States living abroad. Many of these expatriates and their families will receive routine medical care during annual visits home. In addition, they will often return to the United States for the treatment of serious conditions.
• Inpatriates – Foreign nationals who are living and working in the United States.
• Stay-behinds – Some expatriates leave their families at home in the United States when they go on assignment overseas. These dependents (or “stay-behinds”) have coverage through Cigna International Health.

Cigna International Health eligibility, benefits, and precertification

Providers can verify eligibility, benefits, and precertification requirements for many Cigna International Health customers by visiting the Cigna for Health Care Professionals website (CignaforHCP.com). If the information cannot be located on the website, please call the number on the back of the customer’s insurance ID card.

Cigna International Health claims submission process

Please submit your Uniform Billing claim form or Health Care Financing Administration claim form via an electronic data interchange using the payer ID 62308.

Important note: Contracted providers are required to request a copy of the Cigna International Health ID card and bill Cigna International Health directly. Any missing required information might result in a delay in payment.

Cigna International Health clinical and payment-related appeals process

Please submit your appeals for denied claims or precertification requests using the contact information provided on the explanation of benefits and/or denial letter.

Cigna International Health reconciliation process

• For issues with Cigna International Health claims please contact the phone number on the back of the members identification card.
  • This will differ from the standard United States customer service and provider services line.
• For any escalated issues please contact your U.S. Provider Relations representative

Through November and mid-December Optum will be offering an overview of the Veteran Affairs Community Care Network for Region 3.  This would include our Arkansas and Oklahoma communities.  Additional details and registration information can be found on the attachment.

Registration_Invite_4Q_2023

Cultural Resources You Can Use 

As a Cigna Healthcare provider, you have access to our cultural competency and health equity resources that can be used to help you and your staff enhance interactions with culturally diverse patient populations. For your convenience, some of these resources are listed below.

 CultureVision^®

This user-friendly online database gives you access to culturally relevant patient care information at no charge.¹ CultureVision contains information for nearly 75 ethnic groups, religious groups, and additional cultural communities. Contracted providers can access this database by going to CultureVision.com and using the following login and password:

Login: Cigna Providers

Password: explore12!

For more information, please visit our CultureVision dedicated web page.

Health disparities resources

Access patient resources, feature articles, short videos, and webinars to support you in delivering culturally responsive care to patients who have a greater likelihood of developing certain diseases, such as diabetes and heart disease.

• Health Disparities web page.
• African American/Black Health Disparities web page.
• Hispanic and Latino Health Disparities web page.
• South Asian Health Disparities web page.

Social determinants of health resources

• Addressing Health Inequities training:² Explore the impact of health inequities on patient outcomes and how you can confront socioeconomic barriers. One AMA PRA³ Category 1 Credit^TM is available through November 2023.
• Addressing Social Determinants of Health within Your Practice: Learn how you can identify and address non-medical factors that influence your patients’ health in this digital guide.
• Making Virtual Care Easy video (English) (Spanish): Digital health literacy is essential to successful virtual care visits. Share this short video with your patients.

Language assistance services²

Obtain discounted rates of up to 50 percent for language assistance services – such as telephonic and face-to-face interpretations, as well as for written translations – for eligible patients with Cigna Healthcare coverage. Your office works directly with professional language assistance vendors, with whom we’ve negotiated these savings, to schedule and pay for services.

Cultural competency training

Our eCourses can help you develop cultural competency, learn overall best practices, and gain a deeper understanding of subpopulations in the United States. The eCourses include topics such as:

• Gender disparities.
• Diabetes among subpopulations.
• Cultural agility.
• Culturally responsive care.

Tool kit: Gender-inclusive language guidelines

This one-page tool kit shares concrete examples of gender-inclusive language, an important aspect of delivering culturally responsive care in alignment with CLAS Standards.⁴ It will also help you to be compliant with Section 1557 of the Affordable Care Act.

KMAP has rescinded this policy that was scheduled to go into effect 11/01/2023.  Based on this policy a claim where the Ordering/Referring NPI is the same as the Performing/Billing NPI would be denied.  This would have an impact on the Kansas Managed Medicaid plans-Sunflower Medicaid, Aetna Better Health and UHC Community Plan-KS.

While this has been rescinded the expectation is that they policy will be put into place at a later date.