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

Anthem Provider Newsletter – Missouri July 2024

This month’s featured articles:

Administrative

• Drugs and biologic
• Timely receipt of other carrier EOBor rejection helps avoid timely filing denials
• Anesthesia modifiers — professional editing update
• Recovery room — facility editing update
• Phoenix Sepsis Criteria for coding and billing pediatric sepsis
• CAA: Maintain your online provider directory information

Digital Solutions

• Admission, discharge, and transfer information is now available for Medicare Advantage members
• Adopting digital member ID cards
• Digital-only authorization case status notification coming to you

Education and Training

• July is Disability Awareness Month
• Important reminder: The correct original claim number must be included if submitting a corrected claim
• Faster notification of EDI corrected claims errors

Policy Updates

• Clinical Criteriaupdates
• Clinical Criteriaupdates — November 2023
• Carelon Medical Benefits Management, Inc. updates

Medical Policy & Clinical Guidelines

• Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines
• Medical Policiesand Clinical Guidelines updates for July 2024
• Medical Policiesand Clinical Utilization Management Guidelines update

Prior Authorization

• Carelon Medical Benefits Management, Inc. genetic testing code updates
• Reimbursement policy update: Incident to Services — Professional

Reimbursement Policies

• Reimbursement policy update: Frequency Editing — Professional
• New reimbursement policy: Diagnostic Radiopharmaceuticals and Contrast Materials — Professional and Facility

Federal Employee Program (FEP)

• Antidepressant Medication Management (AMM)

Pharmacy | Commercial

• Specialty pharmacy updates — July 2024
• Anthem expands specialty pharmacy precertification list

Quality Management

• Understanding your role in the Health Outcomes Survey

Medica Connections Monthly Newsletters

General News

• Durations for Carelon prior authorization approvals for MSK, cardiovascular or radiology services
  • Radiology: order numbers are valid from the date entered + 60 calendar days
  • Cardiovascular: order numbers are valid from the date entered + 60 calendar days
  • MSK:
    • Joint and Spine: order numbers are valid from the date entered + 60 calendar days
    • Interventional Pain: order numbers are valid for 10 business days from the date of service
    • Inpatient: order numbers are valid from the date of service + expected length of stay
  • Claim appeals submitted through Availity to result in online responses

Clinical News

• Reminder the most recent updates to Medica’s UM policies, coverage and clinical guidelines will be effective 08/19/2024. 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

Pharmacy News

• Effective 09/01/2024 Medica will expand step therapy for long-acting GCSF drug class and the full list can be viewed on the newsletter
• Effective 09/01/2024 prior authorization will be required for Imdeltra

Network News

• Effective 09/01/2024 Medica will make annual ancillary fee schedule updates for all products

Tips and Training

• The training session for July is “Setup and billing for EW (Elderly Waiver) and HSS (Housing Stabilization Service Providers)”. The session date is 07/16/2024 and 11:30 am – 1:00 pm CT.
  • Registration can be done here
    • https://partner.medica.com/providers/provider-training

Cigna – EviCore by Evernorth Quick Reference Guide 6.12.24

This guide is designed to assist providers with the precertification process.

Arkansas BCBS – Providers News June 2024

This month’s featured articles:

Arkansas Blue Cross and Blue Shield

• 2024 Spring Provider Workshops
• ABCBS to Match CMS fiscal year for DRG Inpatient Updates
• Bevacizumab for Ophthalmologic Indications
• Billing For Services to Provider Family Members Prohibited
• Claims Incurred During the Credentialing Process
• Corrected Claim Submission and Correcting Claim Rejections/Errors
• Coverage Policy Manual Updates
• Lucet and Carelon’s Post-Service Prepay
• Medical Specialty Prior Authorization Medications
• Meet New Network Development Representative (NDR) Dawn Roberts and JoalyVelasquez
• Metallic Formulary Changes Effective July 1, 2024
• Provider Data Management: New Provider Information Search
• Standard Formulary Changes Effective July 1, 2024
• Timely Filing Review

Federal Employee Program

• Cervical Cancer Screenings
• LBP KX Modifier: Coding for use of imaging for lower back pain diagnosis

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

21 st Blue & You Fitness Challenge

Cigna Reimbursement Policy Update – Exams billed with ICD10 Z diagnosis codes 081724

As a result of a recent review, we will administratively deny claims when International Classification of Diseases, 10th Revision, Clinical Modification Z diagnosis codes Z02.0-Z02.6, Z02.71, Z02.79, Z02.82- Z02.83, Z02.89-Z02.9, Z13.9, Z56.1, Z62.21, or Z63.6 are the only codes on the claim. Denials will include administrative appeal rights.

We will update the Diagnosis Coding Guidelines (R47) reimbursement
policy to reflect this change. This update is effective for dates of
service on or after August 17, 2024.

June 2024 Provider Newsletter – Provider News (anthem.com)

This month’s featured articles:

Administrative

• Availity Essentials single claim submission response reports
• Implant — Facility Editingupdate
• CAA: Review your online provider directory information
• Expansion of Carelon Medical Benefits Management, Inc. programs
• Digital RFAI Availity training

Education and Training

• June is LGBTQIA+ Pride Month
• You are invited: Thriving, not just surviving: navigating challenging times as a clinician
• Introducing advanced eLearning features for MyDiversePatients.com

Policy Updates

• Clinical Criteriaupdates
• Medical Policiesand Clinical Guidelines updates – June 2024
• MCG Care Guidelines 28th edition
• MCG Care Guidelines 28th edition
• Carelon Medical Benefits Management, Inc. genetic testing code updates
• Updates to Carelon Post-Acute Care Clinical Appropriateness Guidelines
• Expansion of Carelon Medical Benefits Management, Inc. programs

Products & Programs

• Addressing medication adherence gaps
• Improving patient outcomes with statin therapy in diabetes
• Pharmacy information available on our provider website

Quality Management

• Enhance patient access to digital health resources
• Improving patient health and digital literacies
• Tips to Improve Adolescent Immunization (IMA) Rates
• New resources to improve your HEDIS^®and CAHPS^® quality rates
• Statin Use in Persons with Cardiovascular Disease (SPC) measure exclusion criteria: HEDIS^®2024 measurement year