Summit Community Care Provider Newsletter – March 2024

This month’s featured articles:

Education and Training

• Congenital syphilis intervention opportunities for neonatal and pediatric providers
• Resources to support your diverse patient panel

Policy Updates

• Notice of Material Amendment to Healthcare Contract
• MCG Care Guidelines 27th edition update

Medical Policy & Clinical Guidelines

• Notice of Material Amendment to Healthcare Contract
• Medical Policiesand Clinical Utilization Management Guidelines update

Prior Authorization

• Notice of Material Amendment to Healthcare Contract
• Prior authorization requirement changes effective June 1, 2024
• Pharmac
• Prior authorization updates for medications billed under the medical benefit

Quality Management

• Encourage Cervical Cancer Screening (CCS)
• HEDIS Breast Cancer Screening (BCS) update
• HEDIS 2024 documentation for Controlling High Blood Pressure (CBP) and Statin Therapy for Patients with Cardiovascular Disease (SPC)
• Cervical Cancer Screening (CCS) and Prenatal and Postpartum Care (PPC) for HEDIS

Anthem Provider Newsletter – Missouri March 2024

This month’s featured articles:

Administrative | Medicare Advantage

• CAA: Maintain your online provider directory information

Digital Solutions | Medicare Advantage

• Expansion of Carelon Medical Benefits Management, Inc. programs effective April 1, 2024

Digital Solutions | Commercial

• Expansion of Carelon Medical Benefits Management, Inc. programs
• Beginning February 2024, you can submit Physical Health prior authorizations through the Authorization application on Availity.com

Education and Training | Commercial

• Congenital syphilis intervention opportunities for neonatal and pediatric providers

Policy Updates | Medicare Advantage

• MCG Care Guidelines 27th edition update

Medical Policy & Clinical Guidelines | Medicare Advantage

• Clinical Criteriaupdates — December 2023

Prior Authorization | Medicare Advantage

• Prior authorization requirement changes effective May 1, 2024
• Prior authorization requirement changes effective May 1, 2024

Reimbursement Policies | Commercial

• Reimbursement policy update: Ambulance Transportation – Professional

Pharmacy | Commercial

• Specialty pharmacy updates — March 2024
• Important information about your Anthem patients’ Botox prescriptions
• Pharmacy information available on our provider website
• Prior authorization updates for therapeutic duplication of specialty drugs

Pharmacy | Medicare Advantage

• Anthem expands specialty pharmacy precertification list
• Overview of Medicare risk adjustment in-office prospective programs
• Notification of specialty pharmacy medical step therapy updates

Quality Management | Commercial

• Encourage Cervical Cancer Screening (CCS)
• Cervical Cancer Screening (CCS) and Prenatal and Postpartum Care (PPC) for HEDIS

Quality Management | Commercial / Medicare Advantage

• HEDIS 2024 documentation for Controlling High Blood Pressure (CBP) and Statin Therapy for Patients with Cardiovascular Disease (SPC)
• HEDIS Breast Cancer Screening (BCS) update

Quality Management | Medicare Advantage

• HEDIS^®2024 documentation for Care of Older Adults (COA)

Quality Management | Commercial

• Boost annual preventive care visits: Tips and resources: An ounce of prevention is worth a pound of cure

Effective February 12, 2024 and retroactive August 17, 2020 pre-authorization for trisomy 13, 18, 21, X and Y tests.  To be covered, testing must comply with the most recent American College of Obstetricians and Gynecologists guidelines.  Coverage for singleton pregnancies with a high risk of fetal aneuploidy is limited to claims dated to March 5, 2015 through August 16,2020.

Please view the attachment below for full details.

HNFS Prenatal

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

March 2024 Medica Connections

*Reminder to verify the plan type and location listed

The following topics are covered in this edition.

General News

• Beginning on or after May 2024 Medica will used Carelon to review prior authorization submissions for MSK, cardiology and radiology.
• Beginning with June 1, 2024 dates of admission Medica plans to expand their concurrent review program to include inpatient hospital admissions.  More information is available by reviewing their administrative manual. Link included in body of notice.

Clinical News

• Effective 04/22/2024 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.

Pharmacy News

• Effective 04/01/2024 Express Scripts will limit the dispensing of mail-order short-term prescriptions for certain Medica members.
• Various Humira biosimilar drugs are now covered by Medica.
• Effective 05/01/2024 new UM polices will be put into place for Aphexda and Uptravi.

Network News

• Effective 03/01/2024 Medica will update standard DME, O&P fee schedules for all products.

Administrative News

• Provider administrative training webinar for March: Setup and Billing for Elderly Waiver and Housing Stabilization.  This is scheduled for March 20 11:30pm – 1pm CST.  The registration link and additional information can be found on the attachment.
• Medica also offers educational sessions on various topics

CLINICAL DOCUMENTATION IMPROVEMENT WEBINARS

FEBRUARY 2024

Learn more about: Risk Adjustment Documentation and Coding

Each webinar includes an overview of Risk Adjustment (RA) and Hierarchical Condition Categories (HCCs).

Click on the following link for more information and registration.

view.email.homestatehealth.com/?qs=9e4ec6d22b7f15fe03d736d9f3d4b5dda6ba8757008df938afda32304d91f5abab93f56c211c0572bae81ca4e582179925cac6a4d543c53e4cc088b54e39d5db5623602fdcbc28b38e29eb86c2787ea1

Cigna – Reimbursement Policy Update – Current Procedure Termonology and Healthcare Common Procedure Coding System Codes with a Status B Indicator

We routinely review our coverage, reimbursement, and administrative policies for potential updates. In that review, we take into consideration one or more of the following: evidence-based medicine, professional society recommendations, Centers for Medicare & Medicaid Services guidance, industry standards, and our other existing policies.

As a result of a recent review, we will update the Code Editing Policy & Guidelines to add 10 codes with a status B indicator: Current Procedural Terminology codes 38204, 92921, 92925, 92929, 92934, 92938, 92944, and 97602 and Healthcare Common Procedure Coding System codes A4262 and A4263. These codes will be administratively denied when billed with another service not indicated as bundled.

Denials will affect the claim line only and include administrative appeal rights. This  update is effective for dates of service on or after May 11, 2024.

This is a reminder from HNFS regarding their progress note requirements under their Autism Care Demonstration program.  The notes bust contain all Tricare-required elements, support the respective claim and relate to the beneficiary’s approved treatment plan goals.

Full details can be found on the attachment.

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The February edition of the UHC Network News is now available for review by following the link below.

UHC Network News

Home State Health – Policy Update – Testing for Select Genitourinary Conditions 051524

Dear Provider,

Thank you for your continued partnership with Home State Health.

As you know, 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 updates to Home State Health’s Testing for Select Genitourinary Conditions clinical policy. These updates will be effective for Medicaid, Marketplace and Medicare plans effective May 15, 2024.

Arkansas BCBS – Providers News February 2024

This month’s featured articles:

• Post-Service Pre-Pay Review of Claims
• Organizational Determination/Benefit Inquiry
• Inpatient Admissions
• Inpatient Prior Authorization and Organizational Determination/Benefit Inquiry Requests
• Outpatient Prior Authorization and Organizational Determination/Benefit Inquiry Requests
• Specialty Medicine Prior Authorization and Organizational Determination/Benefit Inquiry Requests
• Prior Authorization Reminder
• Tyson Run Out
• Insurance Card Logo Examples
• Octave: The New Brand for Individual Coverage
• PaymodeX and Bottomline Technologies emails are legitimate