Cigna – Medicare Advantage Policy Uupdate Facility Claims for ER EM Services 082524

As a result of a recent review, we will review facility claims submitted with emergency room (ER) evaluation and management Current Procedural Terminology (CPT®) code 99285 for billing and coding accuracy. Claims may be adjusted and reimbursed at a more
appropriate CPT code level.

Administrative appeal rights are available. We will update the Emergency Room Services (MAR36) reimbursement policy to reflect this change.

This update is effective for dates of service on or after August 25, 2024, and applies if the customer was discharged from the ER.

Summit Community Care appreciates the compassion with which you care for your patients, our members. We know the delivery of high-quality mental healthcare services for Summit Community Care members requires successful collaboration. Because timely decisions and successful approvals of medically necessary services are an important part of collaboration, we encourage you to review the following information.

Summit Community Care – Understanding psychological and neuropsychological testing services

Beginning November 1, 2024, EviCore by Evernorth will manage precertification for Current Procedural Terminology® (CPT) codes for cardiac and vascular intervention procedures for Cigna Healthcare customers.

What this means to you
The newly added vascular intervention procedures will be managed on the CareCore portal. Both the MedSolutions and CareCore portals are accessible through the EviCore provider website.

To review the complete announcement from Cigna, clickon the link below.

Cigna – Precertifiation for Vascular Intervention Procedures 110124

EviCore by Evernorth currently manages a musculoskeletal utilization management program for Cigna Healthcare customers, which includes precertification for shoulder, hip, and knee joint procedures, and interventional pain management services.

Cigna Healthcare currently manages spine-related procedures.  To help improve efficiency, beginning November 1, 2024, EviCore will also manage precertification for decompression and fusion surgery of the cervical, thoracic, lumbar spine, and sacrum.

To reach the complete announcement from Cigna, please click on the link below.

Cigna – Precertification for Spine Surgeries and Related Procedures 110124

Summit Community Care Provider Newsletter – August 2024

This month’s featured articles:

Administrative

• Mutually exclusive places of service

Digital Solutions

• Save time and get better results with optimized CPT code search in Availity Essentials
• Admission, discharge, and transfer information is now available for Medicaid members

Education and Training

• August is National Breastfeeding Month
• No-cost health risk prevention training for direct support staff
• Coming soon: Provider e-Learning Resource Center for Payment Integrity

Policy Updates

Notice of Material Amendment to Healthcare Contract

• Carelon Medical Benefits Management, Inc. updates effective October 20, 2024

Prior Authorization

Notice of Material Amendment to Healthcare Contract

• Prior authorization requirement changes

Notice of Material Amendment to Healthcare Contract

• Prior authorization requirement changes

Reimbursement Policies

Notice of Material Amendment to Healthcare Contract

• Reimbursement policy update: Nurse Practitioner and Physician Assistant Services

Products & Programs

• Bringing whole-person care to sickle cell disease management

Anthem Provider Newsletter – Missouri August 2024

This month’s featured articles:

Administrative

• CAA: Providers required to verify their online provider directory information
• Incidental services — facility editing update
• Device-dependent procedures — facility editing update
• ICD-10-CM Excludes1 notes
• Personalized Match update
• Provider manual update available — effective November 1, 2024

Digital Solutions

• Expansion of Carelon Medical Benefits Management, Inc. programs
• Expansion of Carelon Medical Benefits Management, Inc. programs
• Coming soon: View your fee schedule in Availity Essentials Payer Spaces
• Coming soon — digital-only authorization case status notifications for Medicare

Education and Training

• Coming soon: Provider e-Learning Resource Center for Payment Integrity
• August is National Breastfeeding Month

Policy Updates

• Clinical Criteriaupdates

Medical Policy & Clinical Guidelines

• Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines
• Updates to Carelon Medical Benefits Management Clinical Appropriateness Guidelines
• MCG Care Guidelines 28th edition
• Medical Policiesand Clinical Guidelines updates — August 2024
• Medical Policiesand Clinical Utilization Management Guidelines update

Prior Authorization

• Notification of authorization fax number changes

Reimbursement Policies

• New reimbursement policy: Intraoperative Neuromonitoring — Professional
• Reimbursement policy update: Bundled Services and Supplies — Facility
• Reimbursement policy update: Professional Anesthesia Service
• Reimbursement policy update: Modifier 78
• Reimbursement policy update: Modifiers 26 and TC — Professional
• Reimbursement policy update: Outpatient Facility Revenue Code Billing Requirements — Facility
• Reimbursement policy update: Nurse Practitioner and Physician Assistant Services

Pharmacy

• Specialty pharmacy updates — February 2024
• Specialty pharmacy updates — August 2024

Medica Connections Monthly Newsletters

General News

• Reminder to refer to PA lists for service codes that require prior authorization.
  • To determine if a code requires a PA through Medica or Carelon please refer to the online PA list Prior Authorization List
  • If a request is for MSK, cardiovascular or radiology services managed through Carleon, you can submit those directly to Carelon.  The specific guidelines can be viewed here MSK, Cardiovascular, Radiology
• Included is a listing of the Availity provider portal payer names you may see when accessing Availity
• There is a new complaint/escalation process for case management issues.  More information on this process can be viewed here Complaint Review Process

Clinical News

• Reminder the most recent updates to Medica’s UM policies, coverage and clinical guidelines will be effective 09/16/2024. Medica post notification of updates at least 60 days in advance on Medica.com.  You can view the updated guidelines online by following this link or you can request printed copies by calling 1-800-458-5512, option 1, then option 8, then ext 2-2355.
  • https://partner.medica.com/providers/policies-and-guidelines
• The Medica Quality Improvement program goals for 2024 is available for review.  There are several programs that can assist with various areas of patient care and those can be viewed at 2024 Quality Initiatives

Pharmacy News

• Effective 10/01/2024 Medica will update their UM policy for melphalan and imetelstat
• Effective 10/01/2024 Medica will update their biosimilar-first step therapy for inflizimab policy

Network News

• Effective 10/01/2024 Medica will make quarterly updates to the Medicare physician fee schedules, standard reference lab fee schedule and home infusion therapy fee schedule.

Administrative News

• Reminder that taxonomy codes improve turn around time for Medicare Advantage claims

Tips and Training

• The training session for August is “Life of a Claim”. The session date is 08/08/2024 and 12:00 pm – 1:00 pm CT.
  • Registration can be done here
    • https://partner.medica.com/providers/provider-training

The full edition of the July Network News is available by following the link below

United Healthcare July Network News

The link below will allow you to access an overview of all policies updates, mandates, state-specific news, training and more Medicare Advantage, Medicaid and commercial plans.  You also have the option of accessing only Medical policy updates, Reimbursement policy updates, Specialty Medical Injectable Drug updates and Pharmacy and clinical update but following the links provided on the Network News.

July monthly overview | UHCprovider.com

Prior Authorization Updates

• Medicare: Prior authorization updates for continuous glucose monitors
  • CGM Auth Updates
• Updates for sacral nerve stimulation for urinary and fecal indications
  • Auth Updates
• Oncology and hematology prior auth updates effective 10/01/2024
  • 10/01/2024 Updates

Preferred Lab Network Updates

• Review the list of Preferred Lab Network Updates here:
  • July 2024 Preferred Lab Network List

Prescription Drug List Updates effective 09/01/2024

• Prescription Drug List

You will also find a reminder to complete MOC training for Special Needs Plans, a notice that you may be contacted to take part in a Risk Adjustment Data Validation audit program and a link and a reminder that time is running out to take a Network News survey

United Healthcare/Optum is offering a free course for providers who are interested in telehealth and how to reduce barriers to it’s use.  This course is open to several specialties such as Pharmacists/Pharmacy Techs, Physicians, Nurses, Psychologists and Social Workers.  The course is scheduled for 07/16 and full details regarding registration, CMEs available, etc can be viewed by following the link below.

Reducing Barriers to Telehealth

Summit Community Care Provider Newsletter – July 2024

This month’s featured articles:

Administrative

• Phoenix Sepsis Criteriafor coding and billing pediatric sepsis
• Anatomical modifiers

Education and Training

• July is Disability Awareness Month

Policy Updates

Notice of Material Amendment to Healthcare Contract

• Clinical Criteria updates
• Facility emergency department leveling

Notice of Material Amendment to Healthcare Contract

• Carelon Medical Benefits Management, Inc. updates

Medical Policy & Clinical Guidelines

Notice of Material Amendment to Healthcare Contract

• MCG Care Guidelines 28th edition

Prior Authorization

Notice of Material Amendment to Healthcare Contract

• Prior authorization requirement changes

Notice of Material Amendment to Healthcare Contract

• Prior authorization requirement changes effective October 1, 2024

Pharmacy

• Prior authorization updates for medications billed under the medical benefit