Anthem Provider Newsletter – April 2024

April 01, 2024

Anthem Provider Newsletter – Missouri April 2024

This month’s featured articles:

Administrative

Education and Training

Prior Authorization- Medicare

Prior Authorization – Commercial

Reimbursement Policies

Pharmacy

Quality Management

Medica Connections April 2024

March 25, 2024

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

April 2024 Medica Connections

*Reminder to verify the plan type and location listed

The following topics are covered in this edition.

General News

  • Eligibility, benefits functionality (270/271 transactions) now live on Availity Portal. If you are unfamiliar with Availity Medica provides a link to their microsite as well as live webinars once you are registered. Mercy would use Medica Individual and Family, Payer ID 124222
  • Claim Status (HIPAA 276/277 transactions) will be the next to move to Availity
  • Reminder that Beginning on or after May 2024 Medica will used Carelon to review prior authorization submissions for MSK, cardiology and radiology
  • Medica is offering webinars for both radiology/cardiology and MSK through April.  Registration is required

Clinical News

  • Effective May 20, 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.

Administrative News

  • Effective on or after June 1, 2024 Medica will be implementing a new reimbursement policy related to Emergency Department Evaluation and Management Codes – Facility.
    • Medica will implement a new facility policy to provide reimbursement guidelines for the reporting of Emergency Department evaluation and management (E/M) codes. These codes are eligible for reimbursement when billed at the appropriate level. Medica follows interpretive guidelines sourced to Centers for Medicare and Medicaid Services (CMS) coding guidelines, American Medical Association (AMA) Current Procedural Terminology (CPT®) code descriptors, and specialty society guidelines for the reimbursement of Emergency Department E/M codes. This new policy will apply to outpatient facility claims reported on a UB-04 claim form or its electronic equivalent for all Medica members.
    • Medica will review level 4 and level 5 Emergency Department E/M codes using the Optum Emergency Department Claim (EDC) Analyzer tool. The Optum EDC AnalyzerTM tool determines E/M coding based on data received from the claim. The Optum EDC Analyzer will use the following claim data to recommend the appropriate level:
      • Patient’s presented health issues
      • Diagnostic services performed during the visit
      • Any complicating conditions the patient has
    • If the Optum EDC Analyzer tool determines a lower level of service should be submitted, Medica will deny the claim line, as the information submitted would not support the level of service. Facilities may submit an appeal for reconsideration of payment.
  • Effective on or after June 01, 2024 Medica will update the reimbursement policy on Inpatient Hospital Readmissions.
    • This policy addresses the reimbursement of readmissions to the same hospital, billed on a UB-04 claim form or its electronic equivalent. Medica’s Inpatient Hospital Readmission reimbursement policy will be expanded to apply to readmissions to the same facility (i.e., same provider number) within 30 calendar days following discharge to include commercial and Individual and Family Business (IFB) plans in the following states: Iowa, Minnesota, North Dakota,South Dakota and Wisconsin.
    • Medica will not reimburse for more than one admission to the same hospital within 30 calendar days of discharge when the readmission is for the same, similar, or related condition and/or deemed a preventable readmission. The subsequent admissions will be denied and only the initial hospital stay will be reimbursed. This policy applies to all states and all of Medica’s products except Medicaid-only plans — Medica’s Minnesota Senior Care Plus (MSC+), Special Needs BasicCare (SNBC), Prepaid Medical Assistance Program (PMAP) and MinnesotaCare plans — which follow the Minnesota Department of Human Services (DHS) guideline of 15 calendar days.

Cigna – Reimbursement Update – Unacceptable Primary or Principal Diagnosis Codes

March 25, 2024

Cigna – Reimbursement Update – Unacceptable Primary or Principal Diagnosis Codes 061624

As a result of a recent review, we will administratively deny claims when an unacceptable primary or principal diagnosis code is the only code billed. Denials will include administrative appeal rights. However, a corrected claim should first be submitted for payment.

This aligns with the current Unacceptable Primary/Principal Diagnosis (R38)  reimbursement policy. It is effective for dates of service on or after June 16, 2024.

Additional information
For more information about our policy updates, visit the Cigna for Health Care Professionals website (CignaforHCP.com)>Resources>Coverage Policies>Policy Updates.

Cigna – Reimbursement Policy Update – Facility Claims for 3D Rendering with CPT 76376

March 25, 2024

Cigna – Reimbursement Policy Update – Facility Claims for 3D Rendering CPT 76377 061624

As a result of a recent review, we will administratively deny facility claims billed with Current Procedural Terminology (CPT®) code 76376 as incidental, consistent with the process in place for professional claims.  Denials will affect the claim line only and include administrative appeal rights.

We will update the Omnibus Reimbursement Policy (R24) to reflect this change. This update is effective for dates of service on or after June 16, 2024.

Additional information
For more information about our policy updates, visit the Cigna for Health Care  Professionals website (CignaforHCP.com) > Resources > Coverage Policies > Policy Updates.

Cigna – Reimbursement policy update – Unspecified laterality diagnosis codes

March 22, 2024

Cigna – Reimbursement Policy Update – Unspecified Laterality Diagnosis Code 031624

As a result of a recent review, we will administratively deny claims submitted with an unspecified laterality diagnosis code when it is the only code billed on the claim. Denials will include administrative appeal rights. However, a corrected claim should first be submitted for payment.

We will update the Diagnosis Coding Requirements (R47) reimbursement policy to reflect this change.  This update is effective for dates of service on or after June 16, 2024.

Cigna – Medical Mutual Members’ Access to Cigna Healthcare PPO Providers

March 20, 2024

Cigna – Medical Mutual Members

In January 2023, Cigna Healthcare and Medical Mutual of Ohio (Medical Mutual), based in Cleveland, Ohio, entered into a collaboration under which eligible Medical Mutual members have access to the Cigna Healthcare preferred provider organization (PPO1) network of providers when outside of the Medical Mutual service area (the state of Ohio and Kenton, Campbell and Boone counties in Kentucky).

You are considered a participating provider for eligible Medical Mutual members if you participate in the Cigna Healthcare PPO network. This means your care is in network for Medical Mutual members with a Cigna Healthcare logo on the back of their ID card. If an ID card does not show the Cigna Healthcare logo, please call 800.362.1279 to verify eligibility. All terms of your current Cigna Healthcare provider agreement will apply.

To help answer your questions about plan administration, please refer to the chart below. There are also two sample ID cards below to help you identify Medical Mutual members. Although there are many different plans, Medical Mutual ID cards will include the Cigna Healthcare logo and claim submission information, when applicable. If you have additional questions, please call Medical Mutual customer service at 800.362.1279.

Sample ID Cards are attached.

 

Home State Health – Clinical and Payment Policy Updates March 2024

March 19, 2024

Home State Health – Clinical and Payment Policy Updates March 2024

Dear Provider,

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 new clinical and payment policies. Policy documents will be available on line the week of March 18, 2024.  These updates will be effective for Marketplace and Medicare plans effective June 15, 2024.

Policy Number Policy Name Policy Description
CG.PP.551 Genetic and Molecular Testing Services This policy expands health plan requirements for billing of molecular and genetic testing to advance the reliability of laboratory quality information and reduce variability in billing.
CG.CC.PP.01 Concert Laboratory Payment Policy This policy outlines how provides of laboratory services must bill according to the  Centers for Medicare & Medicaid Services (CMS), National Correct Coding Initiative (NCCI), and the American Medical Association (AMA) standards and requirements.
CG.CP.MP.01
CG.PP.MP.02
CG.PP.MP.03
CG.PP.MP.04
CG.PP.MP.05
CG.PP.MP.06
CG.PP.MP.07
– Respiratory Testing
– Multisystem Testing
– Dermatological Testing
– Gastroenterologic Testing
– Primary Care Preventive Testing
– Vector Borne and Tropical Disease Testing
– Genitourinary Testing
These policies outline medically necessary  requirements for specific tests related to diagnosis and treatment of associated Infectious Disease related conditions.

 

For detailed information about these policies, please refer to our website at www.homestatehealth.com. And for questions about this or any of our payment policies, please reach out to our line of business-specific Provider Services team at the phone numbers listed below.

Healthy Blue Medicaid Cranial Remolding Orhtosis

March 19, 2024

Effective on May 31, 2024, in accordance with MO HealthNet Managed Care (Medicaid) requirements, Healthy Blue will require that prior authorization (PA) requests for cranial remolding orthoses (CRO), HCPCS code S1040 (Cranial remolding orthosis, pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustments) for Healthy Blue members between the ages of birth and 12 months must be accompanied by documentation showing that the member has had a face-to-face visit with a neurosurgeon and/or a licensed clinical practitioner who is part of a craniofacial (such as plastic and reconstructive surgery) team.

This documentation must show that a face-to-face visit with the above referenced practitioner has taken place to assess the member for concerns about head shape and that the visit occurred prior to or immediately incident to an assessment by an orthotist who is trained and certified to evaluate, modify, and dispense a CRO that has FDA 510(k) clearance.

Full details related to this change can be accessed here:

Cranial remolding orthosis – Provider News (healthybluemo.com)

United Healthcare March Updates

March 19, 2024

UHC has published their March Updates and the link to the full update has been added below.

UHC March updates

Items covered are:

Surest plan news:

UHC is updating Surest to include OON benefits effective 04/01/2024.  Those are limited to the patient state of residence and the immediate bordering counties. Referral to out of network providers outside of the updated expansion are will result in denials.  Keep in mind that Mercy is in network with this plan.

They are offering a Surest/Behavioral Health webinar on Thursday 03/21 from 12:00 – 1:00.  Registration and highlights are available via the link.

Preferred Drug Changes

On Dec. 26, 2023, the U.S. Food and Drug Administration approved Udenyca Onbody™, an on-body injector (OBI) presentation of Udenyca®. It can be administered on the same day after chemotherapy to decrease the possibility of infection from febrile neutropenia. With this approval, Udenyca Onbody is now a preferred pegfilgrastim product, similar to Udenyca, Neulasta® and Neulasta Onpro®.

We require prior authorization for pegfilgrastim products and will review requests according to our White Blood Cell Colony Stimulating Factor Medical Benefit Drug Policy

Announcments

Change Healthcare:  UHC is working diligently to support providers with any issues that may be related.

More secure One Healthcare ID sign-in options are now available.  You should be able to make any needed updates via the UHC Provider Portal.

Act now

Arkansas Blue Cross Blue Shield – Providers’ News March 2024

March 15, 2024

Arkansas BCBS – Providers News March 2024

This month’s featured articles:

Arkansas Blue Cross and Blue Shield

  • A9500 Pricing (HCPCS Diagnostic Radiology Code Modifier for Nuclear Medicine Procedures)
  • Coverage Policy Manual Updates
  • Medical Benefit Medicine Prior Authorization and Organizational Determination/Benefit Inquiry Requests
  • Medical Specialty Medications Prior Authorization Update
  • Metallic Formulary Changes Effective May 1, 2024
  • Standard Formulary Changes Effective April 1, 2024
  • Octave: The New Brand for Individual Coverage
  • Paper Claim Reduction Reminder
  • Payment Policy Process
  • Payment Message
  • Pharmacy Standard Formulary – Humira No Longer Covered
  • Prior Authorizations for Hepatitis C Medications
  • Utilization Management Reminders
  • When to Contact your Network Development Representative (NDR)

Federal Employee Program

  • Antidepressant Medication Management and Lucet Behavioral Health
  • Provider Availability

Medicare Advantage

  • Centers for Medicare and Medicaid Services (CMS) Preclusion List
  • CMS Requirement for Provider Certification on National Plan and Provider Enumeration System (NPPES)
  • HIPAA and HITECH Reminders
  • Reminder on Billing Qualified Medicare Beneficiaries
  • Requirements for outpatient observation care