Cigna Reimbursement Policy Update – E&M Codes Billed with ICD10 Clinical Modification Code 071424

As a result of a recent review, we will administratively deny the medical evaluation and management (E&M) code when billed with a preventive E&M code and only an International Classification of Diseases, 10th Revision, Clinical Modification Z diagnosis code on the claim. Denials will affect the claim line only and include administrative appeal rights.

We will update the Evaluation and Management (R30) reimbursement policy to reflect this change. This update is effective for dates of service on or after July 14, 2024.

Summit Community Care Provider Newsletter – 041524

Summit Community Care Provider Newsletter – April 2024

This month’s featured articles:

Education and Training 

• New digital learning platform for providers
• April is National Minority Health Month and Stress Awareness Month

Policy Updates

Notice of Material Amendment to Healthcare Contract

• Carelon Medical Benefits Management, Inc.updates

Medical Policy & Clinical Guidelines

Notice of Material Amendment to Healthcare Contract

• Clinical Criteriaupdates — December 2023

Quality Management 

• HEDIS^®2024 documentation for Colorectal Cancer Screening (COL-E)

Anthem Provider Newsletter – Missouri April 2024

This month’s featured articles:

Administrative

• Important reminder: The correct original claim number must be included if submitting a corrected claim
• Review your online provider directory information
• HCPCS to revenue code alignment for behavioral health
• Coming soon — digital-only authorization case status notifications
• Emergency department protocol for Special Investigation Unit review

Education and Training

• April is National Minority Health Month and Stress Awareness Month
• Blue High Performance Network
• Medical Policy & Clinical Guidelines
• Medical Policies and Clinical Utilization Management Guidelines update
• Medical Policies and Clinical Guidelines updates — April 2024

Prior Authorization- Medicare

• Prior authorization requirement changes effective July 1, 2024

Prior Authorization – Commercial

• Carelon Medical Benefits Management, Inc. genetic testing code updates
• Expansion of Carelon Medical Benefits Management, Inc. programs

Reimbursement Policies

• Reimbursement policy update: Virtual Visits — Professional and Facility

Pharmacy

• Expansion of specialty pharmacy precertification list

Quality Management

• HEDIS^®2024 documentation for Colorectal Cancer Screening (COL-E)

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 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.