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

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

This month’s featured articles:

Administrative

• Availity Essentials single claim submission response reports
• Digital RFAI Availity training

Education and Training

• Rotary to ground educational message
• Thriving, not just surviving: navigating challenging times as a clinician
• June is LGBTQIA+ Pride Month
• Introducing advanced eLearning features for MyDiversePatients.com

Policy Updates

Notice of Material Amendment to Healthcare Contract

• Clinical Criteriaupdates — November 2023

Notice of Material Amendment to Healthcare Contract

• Medical Policiesand Clinical Utilization Management Guidelines update

Products & Programs

Notice of Material Amendment to Healthcare Contract

• Prior authorization updates for medications billed under the medical benefit

Quality Management

• Tips to Improve Adolescent Immunization (IMA) Rates
• New resources to improve your HEDIS^®and CAHPS^® quality rates
• Complex Case Management program
• Members’ Rights and Responsibilitiessection
• Important information about utilization management

Cigna – MA reimbursement policy update – Bilateral Procedure Codes Billed Without the Requested Modifier 081724

As a result of a recent review, we will implement a new reimbursement policy, Modifier SO Bilateral Procedures (MAMS0), to administratively deny bilateral procedure codes when billed without the required modifier, LT (left side), RT (right side) or SO, as appropriate.

Denials will affect the claim line only and include administrative appeal rights. However, a corrected claim should first be submitted for payment. This update is effective for dates of service on or after August 17, 2024.

Cigna – Medical coverage policy update – Folate Testing Billing with CPT 82746 and 82747 081724

As a result of a recent review, we will implement a new medical coverage policy, Serum Folate and Red Blood Cell Folate (0567), for folate testing billed with Current Procedural Terminology (CPT®) codes 82746 and 82747. We will administratively deny CPT code 82746 when billed with a diagnosis code that is not reimbursable. In addition, we will
administratively deny CPT code 82747 regardless of the diagnosis, as it is not reimbursable.

Denials will affect the claim line only and include administrative appeal rights. However, a corrected claim should first be submitted for payment for claims billed with CPT code 82746. This update is effective for dates of service on or after August 17, 2024.

HealthChoice Network News Spring 2024

In this issue

• Provider customer service
• Corrected claims
• Using the provider portal
• Coming soon: submitting medical records with claims
• Direct data entry of claims and group numbers
• Payment methods
• Medicare crossover claims
• Fee schedule updates
• HealthChoice contact information

Please click the following attachment to see Cigna’s announcement regarding their roll out of digital claim and precertification correspondence to be made available on Cigna for HCP website.

Cigna Healthcare to make digital claim and precertification correspondence available

Cigna Reimbursement Policy Update – Modifier 50 071424

As a result of a recent review, we will administratively deny unilateral
procedure codes when billed with modifier 50. Denials will affect the
claim line only and include administrative appeal rights.

We will update the Bilateral Procedures (MS0) reimbursement policy to reflect this change. This update is effective for dates of service on or after July 14, 2024.

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

United Healthcare May 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.

May monthly overview | UHCprovider.com

There are also links provided for these items:

• A reminder regarding the UHC Provider Portal
• Review of Surest Medical injectable policy updates
• 2023 Quality Improvement survey results
• A link to medicaid.gov

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

May 2024 Medica Connections

*Reminder to verify the plan type and location listed

The following topics are covered in this edition.

General News

• Carelon updates:
  • A link to the Carelon provider portal is included
  • Prior auth list shows specific services, codes requiring submission of requests to Carelon.  A link to the full of services is provided
  • Correction and clarification of excluded services related to radiology and MSK.
    • Correction to information published last month:  Procedures performed in an inpatient setting (i.e., those services performed during an inpatient stay) or on an emergent basis (i.e., those services performed as part of being evaluated at the ER and prior to the patient’s discharge from the hospital) are not included in the Carelon cardiology and radiology programs.  Procedures performed on an emergent basis (as part of being evaluated at the ER an prior to the patient’s discharge from the hospital) are not included in the Carelon MSK program while certain non-emergent inpatient services are.

Pharmacy News

• Effective 07/01/2024 Medica will be making changes to their commercial drug formulary
• Effective 07/01/2024 Medica will update the step criteria for VEGH inhibitors to list bevacizumab as the preferred first-line treatment for AMD, DME and RVO indications.  More in-depth information and a link to their drug policy page can be found on the Newsletter.
• Effective 07/01/2024 new UM policies are available for Amtagvi, Lenmeldy and Tevimra

Network News

• Effective 07/01/2024 Medica will make quarterly updates to fee schedules

Administrative News

• A reminder that lab referrals need to be made to in-network providers
• A link to the Provider Manual and a reminder that updates may show up on this Newsletter prior to the changes being added to the Manual

Tips and Training

• Reminder that many answers to coding questions regarding a denied claim can be found in their reimbursement policies. A link is provided
• Training for May will be “Navigating Provider Resources” and will be held on May 9^th from Noon – 1pm CST. A link to the registration page is provided.

Summit Community Care Provider Newsletter – May 2024

Administrative

• Reminder: reimbursement for early elective deliveries
• Inaccurate laterality and diagnosis combination

Digital Solutions

• Ready, set, renew
• Coming soon — Submit behavioral health authorizations through the Authorization application on Availity
• Introducing new functionality for non-medical providers
• Roster automation update
• Digital Request for Additional Information is now available for all lines of business

Pharmacy

Notice of Material Amendment to Healthcare Contract

• Prior authorization updates for medications billed under the medical benefit

Quality Management

• Take action to improve adolescent immunizations rates