January 2023 Provider News
Date: 01/30/23
In this issue:
- General Updates - 2023 Provider Manuals Published
- Quality - Cervical Cancer Month, HEDIS Criteria: CCS, LSC, WCV, Wellcare: Glaucoma Awareness Month, Medicare NCCI Policy Manual, NIH Milestones with AI, 2023 MIPS
- Tribal - Medicaid Primary Care Provider Change Form
- Payment & Clinical Policy - Payment Policy Updates, Clinical Policy Updates
- Pharmacy Updates - February 1, 2023 Preferred Drug List (PDL) Changes
- Apple Health Core Connections - TF-CBT Training Opportunity March 22-23
- Training/Education - January Updates
- Wellcare - 2023 Manual updates and Bulletin updates
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General Updates
Provider Manuals Updated for 2023
All provider manuals have been updated for the 2023 plan year.
Coordinated Care - Foster Care/Medicaid
Wellcare - Medicare (National version, not Washington specific)
Wellcare - Medicare Quick Reference Guide (Washington specific)
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Quality
January is Cervical Cancer Month - Cervical Cancer Screening (CCS)
Criteria for HEDIS:
- Women 21 - 64 years of age who have had cervical cytology performed within last 3 yrs.
- Women 30 - 64 years of age who had cervical high risk human papillomavirus testing performed within the last 5 yrs.
- Women 30 - 64 years of age who had cervical/high risk human papillomavirus cotesting within the last 5 yrs.
Cervical Cancer Screening (CCS)
Lead Screening for Children (LSC)
Criteria for HEDIS:
Children 2 years of age who have had one or more capillary or venous lead blood tests for lead poisoning by their second birthday.
Lead Screening in Children (LSC)
Well-Care Visits (WCV)
Criteria for HEDIS:
Child and Adolescent Well-Care Visits: Assesses children 3 - 21 years of age who received one or more well care visits from a primary care practitioner or OB/GYN practitioner during the measurement year.
Child and Adolescent Well-Care Visits
Wellcare Quality
January is Glaucoma Awareness Month
According to the Glaucoma Research Foundation, more than 3 million people in the United States have glaucoma. The National Eye Institute projects this number will reach 4.2 million by 2030, a 58 percent increase.
Glaucoma is the leading cause of irreversible blindness, as much as 40% of vision can be lost without a person noticing.
Moreover, among African American and Latino populations, glaucoma is more prevalent. Glaucoma is 6 to 8 times more common in African Americans than Caucasians.
Over 3 million Americans, and over 60 million people worldwide, have glaucoma. Experts estimate that half of them don’t know they have it. Combined with our aging population, we can see an epidemic of blindness looming if we don’t raise awareness about the importance of regular eye examinations to preserve vision. The World Health Organization estimates that 4.5 million people worldwide are blind due to glaucoma.
Are you at risk for glaucoma? Those at higher risk include people of African, Asian, and Hispanic descent. Other high-risk groups include people over 60, family members of those already diagnosed, diabetics, and people who are severely nearsighted. Regular eye exams are especially important for those at higher risk for glaucoma and may help to prevent unnecessary vision loss.
Newly diagnosed persons or anyone seeking additional resources can go here.
Medicare NCCI Policy Manual
CMS updates the NCCI (National Correct Coding Initiative) Policy Manual for Medicare Services once a year. The NCCI Policy Manual should be used by Medicare Administrative Contractors (MACs) as a general reference tool that explains the rationale for NCCI edits. The most current policy manual, effective Jan. 1, 2023, was posted on Dec. 1, 2022. Additions and revisions to the manual are noted in red font. Additional prior versions of the National Correct Coding Initiative Policy Manual for Medicare Services are available in the Medicare NCCI Policy Manual Archive.
Visit here for links to the manual.
Wellcare Bulletin Update on 2023 Part D Coverage of Insulin
NIH (National Institute of Health) 2022 Milestones with AI (Artificial Intelligence)
NIH nod to 2022 AI contributions to health: In 2022, AI returned to take another well-deserved bow. This time, Science singled out AI’s now rapidly accelerating entry into once uniquely human attributes, such as artistic expression and scientific discovery.
On the scientific discovery side, Science singled out AI’s continued progress in getting creative with the design of novel proteins for vaccines and myriad other uses. One technique, called “hallucination,” generates new proteins from scratch. Researchers input random amino acid sequences into the computer, and it randomly and continuously mutates them into sequences that other AI tools are confident will fold into stable proteins. This greatly simplifies the process of protein design and frees researchers to focus their efforts on creating a protein. AI research now engages scientists around world, including hundreds of NIH grantees. NIH recently launched the Artificial Intelligence/Machine Learning Consortium to Advance Health Equity and Researcher Diversity (AIM-AHEAD) Program. The goal is to create greater diversity within the field, which is a must. A lack of diversity could perpetuate harmful biases in how AI is used, how algorithms are developed and trained, and how findings are interpreted to avoid health disparities and inequities for underrepresented communities.
Centers for Medicare & Medicaid Services (CMS) 2023 MIPS (Merit Based Incentive Payment System) Payment Adjustments in Effect Based on 2021 Performance
In August 2022, each MIPS eligible clinician received a 2021 MIPS final score and associated payment adjustment factor(s) as part of their 2021 MIPS performance feedback, available on the Quality Payment Program website; qpp.cms.gov/login
2023 MIPS payment adjustments, based on each MIPS eligible clinician’s 2021 MIPS final score, will now be applied to payments made for Part B covered professional services payable under the Physician Fee Schedule. Payment adjustments are determined by the final score associated with your Taxpayer Identification Number (TIN)/National Provider Identifier (NPI) combination.
MIPS eligible clinicians, identified by TIN/NPI combination for the 2021 performance year, will receive a positive, neutral, or negative MIPS payment adjustment in 2023 if they:
- Were a clinician type that was included in MIPS;
- Enrolled in Medicare prior to January 1, 2021;
- Weren’t a Qualifying Alternative Payment Model (APM) Participant (QP);
- Were a Partial Qualifying APM Participant (Partial QP) that elected to participate in MIPS as a MIPS eligible clinician; and
- Met one of the following criteria:
- Individually exceeded the low-volume threshold;
- Were in a practice that exceeded the low-volume threshold at the group level and submitted group or APM Entity data; or
- Were part of an approved virtual group.
For more information, visit QPP Resource Library for the 2023 MIPS Payment Adjustment User Guide and more Quality Payment Program resources.
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Tribal
Medicaid Primary Care Provider (PCP) Change Form
Coordinated Care’s systems now allow American Indians/Alaska Natives (AI/ANs) to be assigned to an Indian Health Care Providers (IHCPs) at the facility level. Contracting with us is not required.
We understand IHCPs have specific criteria for determining who they can provide care to. Our process is to refer AI/ANs to the IHCP to establish care and request the IHCP send in the PCP Change Form.
IHCPs can contact their Provider Relations Specialist or the Coordinated Care Tribal Liaison with any questions.
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Payment & Clinical Policy
Payment Policy
DRG CVV Provider Notification
In an ongoing effort to ensure high quality claims processing and payment, Coordinated Care is taking additional steps to verify the accuracy of payments made to our contracted facilities. Beginning on 5/1/23, Coordinated Care will begin auditing selected claims and associated medical records to ensure payments were applied in accordance with national correct coding standard rules.
Coordinated Care has contracted with Cotiviti to assist us in this effort. If you have claims selected for audit, you will receive a letter from Cotiviti requesting medical records for these claim audits on behalf of Coordinated Care
If you have any questions, please contact us at 1-877-644-4613 (TTY 1-866-862-9380). We appreciate your participation in our network and your dedication to the health and welfare of our members and your patients.
Inappropriate Primary Diagnosis Provider Notification
Thank you for your continued partnership with Health Plan Name. As you know, we are committed to continuously evaluating and improving overall Payment Integrity solutions as required by State and Federal governing entities. We are writing today to inform you of new policies Health Plan Name will be implementing effective on or after 3/1/2023.
Edit Name | Description | Lines of Business |
|---|---|---|
Inappropriate Primary Diagnosis | Deny or limit diagnosis codes based upon correct coding guidelines that are supported by CMS and ICD-10. Based on these guidelines, claims will deny when billed with unacceptable primary/principal diagnosis, manifestation diagnosis, and sequela diagnosis in outpatient or inpatient facilities. | Medicaid Medicare Marketplace |
Thank you for your continued participation and cooperation in our ongoing efforts to render quality health care to our members. We look forward to helping you provide the highest quality of care for our members.
Clinical Policies
The below clinical policies received updates as part of our regular monthly review in January. These policy changes are effective February 1, 2023. You will find the policies, including a description of the revisions, posted on the policy site.
| Policy Number | Policy Title | Line of Business |
|---|---|---|
WA.CP.MP.525 | Catheter Ablation for Supraventricular Tachyarrhythmia | Apple Health |
| CP.MP.50 | Drugs of Abuse: Definitive Testing | Ambetter |
| CP.MP.54 | Hospice Services | Ambetter |
| WA.CP.MP.54 | Hospice Services | Apple Health |
| CP.MP.69 | Intensity-Modulated Radiotherapy | Ambetter |
| WA.CP.MP.69 | Intensity-Modulated Radiotherapy | Apple Health |
| WA.CP.MP.500 | Mandibular Advancement Devices | Apple Health |
| CP.MP.91 | Obstetrical Home Health Care Programs | Ambetter |
| CP.MP.138 | Pediatric Heart Transplant | Apple Health & Ambetter |
| CP.MP.203 | Diaphragmatic/Phrenic Nerve Stimulation | Apple Health & Ambetter |
The below policy was updated as part of our regular monthly review in January. The policy changes are effective May 1, 2023. You will find the policy, including a description of the revisions, posted on the policy site.
| Policy Number | Policy Title | Effective Date | Line of Business |
|---|---|---|---|
CP.MP.107 | Durable Medical Equipment (DME) and Orthotics and Prosthetics Guidelines | 5/1/23 | Apple Health & Ambetter |
The below policy is new effective May 1, 2023. You will find the policy posted on the policy site.
| Policy Number | Policy Title | Effective Date | Line of Business |
|---|---|---|---|
CP.MP.247 | Transplant Service Documentation Requirements | 5/1/23 | Apple Health & Ambetter |
The below new policies were previously announced effective on the dates noted. You will find the policies posted on the policy site.
| Policy Number | Policy Title | Effective Date | Line of Business |
|---|---|---|---|
CP.MP.246 | Pediatric Kidney Transplant | 2/1/23 | Apple Health & Ambetter |
| CP.MP.242 | Pulmonary Function Testing | 2/1/23 | Apple Health & Ambetter |
The below policies were previously announced to have changes effective on the dates noted. You will find the policies, including a description of the revisions, posted on the policy site.
| Policy Number | Policy Title | Effective Date | Line of Business |
|---|---|---|---|
WA.CP.MP.117 | Percutaneous Electrical and Peripheral Nerve Stimulation | 2/1/23 | Apple Health & Ambetter |
| CP.MP.202 | Orthognathic Surgery | 3/1/23 | Apple Health & Ambetter |
| CP.MP.61 | IV Moderate Sedation, IV Deep Sedation and General Anesthesia for Dental Procedures | 3/1/23 | Ambetter |
| CP.MP.150 | Phototherapy for Neonatal Hyperbilirubinemia | 3/1/23 | Apple Health & Ambetter |
| CP.MP.145 | Electric Tumor Treating Fields | 4/1/23 | Ambetter |
| CP.MP.151 | Transcatheter Closure of Patent Foramen Ovale | 4/1/23 | Apple Health & Ambetter |
| CP.MP.180 | Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea | 4/1/23 | Apple Health & Ambetter |
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Pharmacy Updates
February 1, 2023, Preferred Drug List Changes
Effective 02/01/2023, the following medications will no longer be preferred.
| Effective Date | Drug Name | Potential Alternatives |
|---|---|---|
02/01/2023 | Vimpat Tablets (Brand) | Lacosamide Tablets (Generic) |
| 02/01/2023 | Lantus Insulin Glargine Injection (Brand) | Insulin Glargine Injection (Generic) Levemir Detemir Injection |
| 02/01/2023 | Lantus Solostar Insulin Glargine Solution Pen-Injector (Brand) | Insulin Glargine Solution Pen-Injector (Generic) Levemir Flextouch Solution Pen-Injector |
| 02/01/2023 | Novolog Mix 70/30 Prefilled Flexpen (Brand) | Insulin Aspart Protamine & Aspart Suspension Pen Injectable (Generic) Insulin Lispro Protamine/Insulin Lispro Kwikpen Humalog Mix Kwikpen Humulin 70/30 Kwikpen |
| 02/01/2023 | Esbriet Tablets (Brand) | Pirfenidone Tablets (Generic) with PA Esbriet Capsules with PA Ofev Capsules with PA |
| 02/01/2023 | Narcan Hydrochloride Nasal Spray (Brand) | Naloxone Hydrochloride Nasal Spray (Generic) Naloxone Hydrochloride Injection Naloxone Hcl Solution Cartridge Naloxone Hcl Solution Prefilled Syringe Vivitrol for Intramuscular Extended Release Suspension |
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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.
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 SBIRT, 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
Trauma Focused Cognitive Behavioral Therapy
Coordinated Care is providing a no-cost Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) Training for contracted, in-network Coordinated Care providers. This training will be held on Wednesday Mar 22 and Thursday Mar 23, 2023, from 8:30 a.m. to 5:00 p.m. Pacific time each day at: Confluence Technology Center, Wenatchee, WA. For more information reach out to Lindsey.C.Greene@coordinatedcareheatlh.com. Register here.
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Training/Education
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.
Harborview Abuse and Trauma Center. Weight and Health Bias in Rape Crisis Centers: How to create more inclusive, effective services. Registration coming soon. February 10, 2023 10-11am. Learn more here.
Partnership Access Line (PAL). 2023 Mental Health Conference. Free CME training for Washington primary care providers. Featured topics include: ADHD Update, Psychotropic Medications to Support Children with Autism, and Perinatal Mood Disorders. February 11, 2023, 8am-12:30pm. Register here.
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Wellcare
Wellcare 2023 Provider Portal Updates:
New Copies of the 2023 Manual and Quick Reference Guide can be found and downloaded from the Portal Resources page. We encourage all of our provider groups to please download the most up to date copies and distribute amongst their teams.
Wellcare Portal Bulletin update on Immunization Part D