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 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 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

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

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.

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.

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)

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 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

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).