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January 2022 Provider News

Date: 01/28/22

In this issue: 

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Billing/Claims Updates

Billing and Rendering Taxonomy Requirements: Changes Active as of January 1, 2022

Beginning on January 1, 2022 Coordinated Care began denying any Medicaid claims submitted without valid billing and/or rendering taxonomy codes. Claims submitted without a valid billing and/or rendering taxonomy will deny EXXW = TAXONOMY REQUIRED FOR PAYMENT.

Additional information about Taxonomy codes can be found here.

Behavioral Health Providers should consult the Mental Health Services Billing Guide for more information on billing and appropriate use of taxonomy codes.

Tribal providers should consult the Tribal Health Billing Guide for more details on billing with a valid taxonomy. Tribal provider claims must include both the appropriate billing taxonomy and the appropriate American Indian/Alaska Native (AI/AN) or non-AI/AN tribal modifier to pay the IHS tribal encounter rate.

Additional information about submitting claims with an appropriate billing and/or rendering taxonomy is available in the 2022 Coordinated Care Provider Manual. If you have questions about billing and rendering taxonomy requirements, please contact your Provider Network Specialist.

Inactive NPIs: Requirement for Revalidation

Beginning January 1, 2022, Coordinated Care began denying all claims submitted with an inactive NPI.

The Affordable Care Act (ACA) requires state Medicaid agencies to revalidate the enrollment of all Medicaid providers once every five years. To avoid any potential denials for inactive NPI, providers should ensure they respond to HCA notices to complete revalidation. Upon receipt of a revalidation notification letter, a provider should gather and submit all documents requested on their Revalidation Checklist, complete the online revalidation process, and complete any other documents that may be required specific to their provider type. More information on the revalidation process can be found here.

If providers do not respond to their revalidation notification and therefore become inactive in ProviderOne, Coordinated Care will deny their claims beginning January 1, 2022. Please note that on Professional HCFA Claims both the Rendering (box 24j) & Billing (box 33a) NPIs need to be active for payment. For Facility UB Claims, both Billing (box 56) & Attending (box 76) NPIs need to be active for payment. If either the individual or group NPI is inactive, the entire claim is denied EXnZ (NPI NOT REGISTERED. COMPLETE NPI ENROLLMENT/REVALIDATION PROCESS W/ HCA).

If a provider’s enrollment with HCA has lapsed or they have never enrolled with HCA, they should complete the enrollment process specific to their provider type. More information about enrolling as a Medicaid Provider can be found here.

Please note that HCA will review requests for retro-active registration of providers if a provider’s registration has lapsed. A provider would need to complete the Effective Date Change form and other required documentation to be considered for retro-active registration.

As of December 2021: The HCA is currently experiencing an extraordinarily high volume of applications and there is no automated way to track the status of pending applications. Therefore, Coordinated Care and the HCA ask providers to put on all applications the desired effective date of when enrollment needs to begin.

Claims denied EXnZ will be reprocessed for providers whose retro-active registration is approved, eliminating the need for providers to resubmit their claims or request reprocessing.

Please reach out to your Provider Network Specialist if you have any questions about the revalidation process.

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Quality

January is Cervical Cancer Awareness Month

  1. Regular Pap testing along with the addition of hrHPV (High risk HPV) screenings are credited with significant reductions in the number of cases/deaths associated with cervical cancer since the 1970's.
  2. Recommendations from the United States Preventative Services Task Force (USPSTF) 2018:
            a. Age 21 - 29 screening every 3 years w/Pap testing along.
            b. Age 30 - 65 screening
                        1. every 3 years w/Pap testing alone;
                        2. every 5 years w/hrHPV testing alone; or
                        3. every 5 years with hrHPV testing in combination with Pap testing

Sources:

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Apple Health Core Connections

Coordinated Care is the single managed care organization to administer the Integrated Managed Care Apple Health Foster Care program in collaboration with the Health Care Authority and Department of Children Youth and Families. This program serves children and youth in foster care, adoption support, alumni of foster care (ages 18-26), and children reunified with their parents. Coordinated Care's program is named "Apple Health Core Connections." You can reach us at 1-844-354-9876 or AHCCTeam@coordinatedcarehealth.com.

DCYF COVID Vaccine Process Updated for Youth in Foster Care (now for ages 5-17)

The Washington State Department of Children, Youth, and Families (DCYF) has released updated guidance for youth in out-of-home (foster) care to get consent for and access to COVID vaccinations. The guidance now covers ages 5-17 with the FDA approval of the Pfizer vaccine covering ages 5-11. (Youth ages 18 and up do not need any additional consent to receive the vaccine.)

Primary care providers and vaccination sites may be asked to vaccinate youth in foster care, and youth will arrive with caregivers with the Youth and Parent Consent forms shown below. UPDATE: Youth under age 13 do not need to have the Youth Consent Form, only the Parent Consent form or a court order for the vaccine. Examples of the forms are below.

If a bio-parent does not consent for a youth to receive the vaccine, or if a court order is needed, you may also be asked to determine if a youth is healthy enough to receive the COVID vaccine. This consultation can occur in an office visit or by telehealth. DCYF will accept your COVID Vaccine recommendation on a Visit Summary as documentation.

For more information, please contact:

DCYF - COVID Vaccine Guidance for Children in Care

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Clinical Policy

Clinical Policy Updates

The below policies received updates as part of our regular monthly review in January. These policy changes are effective February 1, 2022. You will find the policies, including a description of the revisions, posted on the policy site.

Policy NumberPolicy TitleLine of Business

CP.MP.107

Durable Medical Equipment (DME)

Apple Health & Ambetter

CP.MP.138

Pediatric Heart Transplant

Apple Health & Ambetter

CP.MP.144

Mechanical Stretching Devices

Ambetter

CP.MP.145

Electric Tumor Treatment Fields

Ambetter

CP.MP.168

Biofeedback

Ambetter

CP.MP.170

Nerve Blocks for Pain Management

Apple Health & Ambetter

CP.MP.182

Short Inpatient Hospital Stay

Apple Health & Ambetter

CP.MP.186

Burn Surgery

Apple Health & Ambetter

CP.MP.203

Diaphragmatic/Phrenic Nerve Stimulation

Apple Health & Ambetter

WA.CP.MP.54

Hospice Services

Apple Health

CP.MP.54

Hospice Services

Ambetter

WA.CP.MP.69

Intensity-Modulated Radiotherapy

Apple Health

CP.MP.69

Intensity-Modulated Radiotherapy

Ambetter

CP.MP.89

Genetic and Pharmacogenetic Testing

Apple Health & Ambetter

CP.MP.91

Obstetrical Home Health Care Programs

Ambetter

CP.MP.209

GI Pathogen Panel Testing

Apple Health & Ambetter

CP.MP.113

Holter Monitor

Apple Health & Ambetter

The below new policies were previously announced to be effective on the date noted. You will find the policies posted on the policy site.

Policy NumberPolicy TitleEffective DateLine of Business

WA.CP.MP.523

Sleep Apnea Diagnosis and Treatment

2/1/22

Ambetter

CP.MP.194

Osteogenic Stimulation

2/1/22

Apple Health & Ambetter

CP.MP.202

Orthognathic Surgery

3/1/22

Apple Health & Ambetter

The below policy was previously announced as retired effective on the date noted. You will find the policy posted on the policy site until the retirement date. This policy is being replaced by CP.MP.194.

Policy NumberPolicy TitleEffective DateLine of Business

WA.CP.MP.508

Bone Growth Stimulator                                      

2/1/22

Apple Health

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General Updates

Provider Manuals Updated for 2022

All Provider Manuals have been updated to reflect the 2022 plan year.

Coordinated Care – IMC/IFC

Ambetter – Marketplace

Wellcare – Medicare

Mental Health EBP Reporting for Behavioral Health Providers

Coordinated Care would like to remind all clinics and providers who deliver Children’s Mental Health Evidence Based Practices (EBPs) to clients under age 18 that they should include the appropriate SERI code for Mental Health providers when billing for these services. EBP codes are specially designated identifiers on a claim or encounter that are used to report specific research- or evidence-based practices for children’s public mental health care provided by licensed or certified mental health providers to children and youth under 18 in Washington State. Coordinated Care is required by law to track and report quarterly to HCA, all children’s mental health visits and how many of these visits were billed as an Evidence Based Practice. EBP codes and all associated history and criteria can be found in the Evidence-Based Practices Reporting Guide.

The utilization of EBP codes does not impact payment of your claims. Coordinated Care will not deny any claims due to EBP code utilization. Additionally, please know that billing correctly also helps Coordinated Care to be able to refer new clients to you for Evidence Based Practices.

Please reach out to your Provider Network Specialist if you have any questions/concerns about billing with EBP codes. 

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Training/Education

Coordinated Care is the single managed care organization to administer the Integrated Managed Care Apple Health Foster Care program in collaboration with the Health Care Authority and Department of Children Youth and Families. This program serves children and youth in foster care, adoption support, alumni of foster care (ages 18-26), and children reunified with their parents. Coordinated Care’s program is named “Apple Health Core Connections.” You can reach us at 1-844-354-9876 or AHCCTeam@coordinatedcarehealth.com .

The Coordinated Care Community Education Team serves providers and their staff with training to support the needs of the Medicaid population. The CE Team can offer training on topics such as Adoption Success, Trauma Informed Care, ACEs, Resilience, and Secondary Trauma and Self Care. To request more information or to schedule no-cost training please email: communityeducation@coordinatedcarehealth.com

Visit Centene’s Clinical Provider Training website to find webinar events available to all Coordinated Care providers. Webinars are on clinical behavioral health topics and usually offer free continuing education hours. Click on the "National Provider Webinars" button on the right side of the page and scroll down to find a complete listing.

  • NWMHTCC is a hosting a webinar titled Grief, Exhaustion, and Finding Vitality in Behavioral Health Care on February 10, 2022 from 11:00-12:15pm. Register here.
  • The Academy of Pediatrics recently launched a new course that can be taken at your convenience titled, Innovative Strategies for Improving Developmental Surveillance and Screening. Register here.
  • The Seattle Children’s Partnership Access Line (PAL) Program is hosting a Pediatric Mental Health Conference with free CME on February 26, 2022 from 8am-12:30pm. Register here.

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New Century Health Notification

Oncology Quality Management

On behalf of J. Mark Maddox, MD – Chief Medical Director of Ambetter from Coordinated Care:

Ambetter from Coordinated Care Corporation is pleased to announce its collaboration with New Century Health (NCH), an oncology quality management company, to implement a new prior authorization program. The program will simplify the administrative process for providers to support the effective delivery of quality patient care.

Beginning May 2, 2022, oncology-related infused and oral chemotherapeutic drugs/supportive agents will require a prior authorization from NCH before being administered in either the provider’s office, outpatient hospital, ambulatory setting, or infusion center. This prior authorization requirement applies to both pharmacies dispensed, and office administered medication requests for all Ambetter (Exchange) members ages 19 and over.

Benefits include:

  • The use of clinical criteria, based on nationally recognized guidelines, to promote evidence-based cancer care.
  • Increased collaboration with provider offices to foster a team approach.
  • Physician discussions with a true peer, medical oncologists who can understand and better discuss treatment plans.  
  • A provider web portal to:
        - Obtain real-time approvals when selecting evidence-based NCH treatment care pathways.
        - Determine which clinical documentation is necessary for medical necessity review.
        - View all submitted requests for authorization in one location.
        - Check member eligibility.

Prior Authorization Process:

The requesting provider must complete an authorization request using one of the following methods:

  • Logging into the NCH Provider Web Portal: https://my.newcenturyhealth.com
  • Calling 1-888-999-7713, Medical Oncology- Option 1, Monday–Friday (5 AM to 5 PM PST)

Transition of Care:

Authorizations issued by Ambetter or Envolve Pharmacy Solutions before May 2, 2022, are effective until the authorization end date. Upon expiration, authorization requests must be submitted to NCH. If continued authorization is not obtained from NCH, affected claims may be denied. For services/treatment that did not require an authorization prior to May 2, 2022, an authorization will be required from New Century Health for service/treatment dates on and after May 2, 2022.

A Provider Network Specialist will contact you soon to schedule an introductory meeting and training. Should you have any questions prior to the introductory meeting, please call Ambetter at 1-877-687-1197. You may also contact NCH at 1-888-999-7713, Option 6.

We look forward to offering you this program and hope that it will enhance your experience with your oncology service authorizations.  

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