July 2023 Provider News
Date: 07/31/23
In this issue:
- General Updates - HCA Updates for Medicaid, Infant-Early Childhood Mental Health (IECMH), B-5 at BHAs presentation, Administrative Days
- Quality - Medicaid: Preventative and Clinical Practice Guidelines. Wildfire Season, Asthma and 90 day refills, Mammograms, Cervical Cancer Screening, Telehealth, and Antidepressant Medication Management, Wellcare: National Minority Mental Health Awareness Month
- Tribal - Reminder: IHCP email inbox effective 6/27/23
- Payment & Clinical Policy - Clinical Policy Monthly Updates
- Wellcare - New Century Health (NCH) Cardiology Management Program
- Apple Health Core Connections - Reproductive Health for Youth Impacted by Child Welfare
- Training/Education - WISe symposium, Pedia Link, Wildfire Smoke and Your Patients, TF-CBT training
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General Updates
HCA Updates for Medicaid
Please see the notification from HCA below:
Effective August 1, 2023- Apple Health is changing CPT code 84112 to non-covered.
84112 - Evaluation of cervicovaginal fluid for specific amniotic fluid protein(s) (eg, placental alpha microglobulin-1 [PAMG-1], placental protein 12 [PP12], alpha-fetoprotein), qualitative, each specimen.
Current research and evidence do not support this test as medically necessary.
Please make the necessary system updates and notify Reg Ops when completed.
If you have any questions, please contact Christina Hinchman (Christina.Hinchman@coordinatedcarehealth.com) and cc: to TAC_CCW HCA Contacts ccw_hca_contacts@centene.com.
Infant-Early Childhood Mental Health (IECMH)
- Emotional Health of Babies and Toddlers: This set of flyers is about the basics of emotional health for babies and toddlers, and how we all can play a role in supporting families of young children. These flyers are designed for either print or digital distribution, with customized content for different audiences, including behavioral health providers! The flyers were codeveloped by the Barnard Center for Infant Mental Health, the Washington Association for Infant Mental Health, The Practice Northwest, the Department of Children, Youth, and Families, and the Health Care Authority, with support from Zero To Three. These flyers can be found on HCA’s IECMH provider webpage under “Other IECMH resources”
- B-5 at BHAs presentation: In June 2023, the HCA IECMH team presented at the Washington Behavioral Health conference about infant-early childhood mental health best practices and opportunities for behavioral health agencies. These slides are a useful tool for any provider interested in providing mental health services to young children and families. The slides can be found on HCA’s IECMH provider webpage under “Other IECMH resources”
Learn more about the IECMH statewide tour. IECMH will be visiting the North Sound, Pierce, and King County regions.
Administrative Days
Coordinated Care of WA will be making process changes to our Medicaid Inpatient Medical Administrative Days process effective 11/1/23.
These changes are designed to increase process standardization across the Centene family of plans to improve operational efficiency between provider and plan.
The changes will be:
- Timing of authorizations: To align with the process of other IP authorizations, administrative day reviews and authorization decisions will focus on a prospective approach.
- Length of authorizations: Administrative Day Authorizations will be for 7 calendar days and subsequent authorizations up to 7 days, except postpartum parents for whom initial approval will be five days.
- Authorization Processing: Administrative days will remain on the same authorization as was completed for the inpatient authorization.
What stays the same:
- Administrative day request form is still required and will be sent with the Denial letter
- Members converting back to medically necessary inpatient stay from Administrative days, will still require a Change of Condition form. A copy of the form will be included with the Administrative day notification.
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Quality
Medicaid Quality
Clinical Practice Guidelines
Reminder that the Preventative and Clinical Practice Guidelines are on the Provider Website (last review June 2023)
Wildfire Season
For those impacted by fires in Washington, status updates and shelter resources can be found here.
Asthma and 90 Day Medication Refills
Moving patients with asthma to 90-day refills may help increase their adherence to maintenance medication.
Mammograms (HEDIS Measure)
The HEDIS measure assesses women ages 50-74 who had at least one mammogram to screen for breast cancer in the past 2 years.
Cervical Cancer Screening (HEDIS Measure)
The HEDIS measure assesses women ages 21-64 who fit certain criteria. Please refer to the following link for more information
Telehealth
Telehealth increases access to physicians and specialists to help patients receive the right care, at the right place, at the right time.
Telehealth resources for providers
Antidepressant Medication Management (HEDIS Measure)
The HEDIS measure assess adults 18 years of age and older with a diagnosis of major depression who were newly treated with antidepressant medication and remained on their antidepressant medications.
Medicaid Quality
National Minority Mental Health Awareness Month
July’s observation of National Minority Mental Health Awareness Month brings awareness to the unique struggles that racial and ethnic minority communities face regarding mental illness in the United States.
The Veteran Health Administration in 2021 estimated that only 39 percent Black or African American adults, 25 percent of Asian adults, and 26 percent of Hispanic/Latino adults with any mental illness were treated, compared to 52 percent of non-Hispanic white adults. American Indian Alaska Native Veteran report experiencing post-traumatic stress disorder (PTSD) at double the rate of non-Hispanic white Veterans- 20.5 percent compared to 11.6 percent.
Psychological health is important to one’s overall health according to “Psychological Health, Well-Being, and the Mind-Heart-Body Connection,” the American Heart Association Scientific Statement (2021). Statement highlights include:
- Improving psychological health can lead to a healthier heart and healthier body.
- Negative psychological health conditions are associated with less healthy heart and body. Conditions include depression, chronic stress, anxiety, anger, pessimism and dissatisfaction with one’s current life. These conditions are associated with potentially harmful biological responses, such as:
- irregularities of heart rate and rhythm;
- increased digestive complaints;
- increased blood pressure;
- reduced blood flow to the heart.
- Health care professionals should consider patients’ psychological health when evaluating or treating people with or at risk for heart disease.
Celebrating Disability Pride Month
July recognizes people with disabilities and celebrates their achievements. It also serves as a reminder about the importance of disability rights and the value of fighting for those rights. The World Health Organization has estimated that 15% of the world’s population lives with some type of disability.
Disability pride has been described as “accepting and honoring each person’s uniqueness and seeing it as a natural and beautiful part of human diversity.”
Ardra, “Tripping on Air” blogger who has had multiple sclerosis for 19 years, said “Being proud to be disabled isn’t about liking my disability... Rather, claiming disability pride is a rejection of the notion that I should feel ashamed of my body or my disability…”
People living with disabilities face barriers to adequate health care, like not having access to a regular health care provider and routine check-ups. As a result, they have poorer overall health outcomes, including increased likelihood of obesity (41.6%), diabetes (15.9%), and depression (43.0%).
Find out how you can help:
- Health observances
- Web based training, Modernizing Health Care to Improve Physical Accessibility
- Coverage to Care
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Tribal
Reminder: IHCP email inbox is active
Coordinated Care is excited to announce that we have created an inbox specifically for Indian Health Care Providers (IHCP’s). Effective 6/27/23, when sending an inquiry related to Coordinated Care / Ambetter / Wellcare issues or questions, please send your email to IndianHealthCareProviderAssistance@coordinatedcarehealth.com. We will continue to have the same anticipated response times:
- Respond within 24-48 hours to confirm receipt of your inquiry
- We do our best to resolve any issues within 30 business days.
- If the issue takes a little longer, we will be in communication with you to explain why.
Why are we making this change? We have heard your feedback that it is helpful to have a standard email inbox in case personnel change at the payer. Using an inbox allows our designated subject matter enthusiasts to have visibility into the questions you are asking, rather than having it directed to one individual.
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Payment & Clinical Policy
Clinical Policy Updates
Monthly Updates
The below clinical policies received updates as part of our regular monthly review in July. These policy changes are effective August 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 |
|---|---|---|
CP.MP.175 | Air Ambulance | Ambetter |
| CP.MP.93 | Bone-anchored Hearing Aid | Apple Health & Ambetter |
| CP.MP.94 | Clinical Trials | Apple Health & Ambetter |
| CP.MP.115 | Discography | Apple Health & Ambetter |
| CP.MP.248 | Facility Based Sleep Studies for Obstructive Sleep Apnea | Apple Health & Ambetter |
| CP.MP.184 | Home Ventilators | Apple Health & Ambetter |
| CP.MP.142 | Urinary Incontinence Devices and Treatments | Apple Health & Ambetter |
| CP.MP.249 | Omisirge (omidubicel): Nicotinamide-modified allogeneic hematopoietic progenitor cell therapy | Apple Health & Ambetter |
The below policies were previously announced as revised on the dates noted. You will find the policies posted on the policy site.
| Policy Number | Policy Title | Effective Date | Line of Business |
|---|---|---|---|
CP.BH.201 | Deep Transcranial Magnetic Stimulation for Treatment of Obsessive Compulsive Disorder | 9/1/23 | Ambetter |
| CP.MP.146 | Sclerotherapy and Chemical Endovenous Ablation of Varicose Veins and Other Symptomatic Venous Disorders | 9/1/23 | Ambetter |
| CP.BH.200 | Transcranial Magnetic Stimulation for Treatment Resistant Major Depression | 9/1/2 | Apple Health & Ambetter |
| WA.CP.MP.522 | Varicose Vein Treatment | 9/1/23 | Apple Health |
| CP.MP.46 | Ventricular Assist Devices | 10/1/23 | Apple Health |
| CP.MP.182 | Short Inpatient Hospital Stay | 10/1/23 | Apple Health & Ambetter |
The below genetic testing policies were previously announced as revised effective September 1, 2023. You will find the policies posted on the policy site. Most policy numbers have changed to V2.2023.
| Policy Number | Policy Title | Line of Business |
|---|---|---|
V2.2023 | CG Aortopathies and Connective Tissue Disorders | Apple Health & Ambetter |
| V2.2023 | CG Cardiac Disorders | Apple Health & Ambetter |
| V2.2023 | CG Dermatologic Conditions | Apple Health & Ambetter |
| V2.2023 | CG Epilepsy Neurodegenerative and Neuromuscular Conditions | Apple Health & Ambetter |
| V2.2023 | CG Exome and Genome Sequencing for DX of Genetic Disorders | Apple Health & Ambetter |
| V2.2023 | CG Eye Disorders | Apple Health & Ambetter |
| V2.2023 | CG Gastroenterologic Disorders Non-cancerous | Apple Health & Ambetter |
| V2.2023 | CG General Approach to Genetic Testing | Apple Health & Ambetter |
| V2.2023 | CG Hearing Loss | Apple Health & Ambetter |
| V2.2023 | CG Hematologic Conditions Non-cancerous | Apple Health & Ambetter |
| V2.2023 | CG Hereditary Cancer Susceptibility | Apple Health & Ambetter |
| V2.2023 | CG Immune Autoimmune and Rheumatoid Disorders | Apple Health & Ambetter |
| V2.2023 | CG Kidney Disorders | Apple Health & Ambetter |
| V2.2023 | CG Lung Disorders | Apple Health & Ambetter |
| V2.2023 | CG Metabolic Endocrine Mitochondrial Disorders | Apple Health & Ambetter |
| V2.2023 | CG Multisystem Inherited Disorders, Intellectual Disability and Developmental Delay | Ambetter |
| WA.CP.MP.230 | CG Multisystem Inherited Disorders, Intellectual Disability and Developmental Delay | Apple Health |
| V2.2023 | CG Non-Invasive Prenatal Screening | Ambetter |
| WA.CP.MP.231 | CG Non-Invasive Prenatal Screening | Apple Health |
| V2.2023 | CG Oncology Algorithmic Testing | Apple Health & Ambetter |
| V2.2023 | CG Oncology Cancer Screening | Apple Health & Ambetter |
| V2.2023 | CG Oncology Circulating Tumor DNA Tumor Cells Liquid Biopsy | Apple Health & Ambetter |
| V2.2023 | CG Oncology Cytogenetic Testing | Apple Health & Ambetter |
| V2.2023 | CG Oncology Molecular Analysis Solid Tumors & Hematologic Malignancies | Apple Health & Ambetter |
| V2.2023 | CG Pharmacogenetics | Apple Health & Ambetter |
| V2.2023 | CG Preimplantation Genetic Testing | Apple Health & Ambetter |
| V2.2023 | CG Prenatal and Preconception Carrier Screening | Apple Health & Ambetter |
| V2.2023 | CG Prenatal Diagnosis Pregnancy Loss | Apple Health & Ambetter |
| V2.2023 | CG Skeletal Dysplasia Rare Bone Disorders | Apple Health & Ambetter |
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Wellcare
REMINDER
New Century Health (NCH) Cardiology Management Program
Wellcare has partnered with New Century Health (NCH) to implement a new cardiology prior authorization program, the Cardiology Management Program. This program is intended to help providers easily and effectively deliver quality patient care.
Effective July 1, 2023, cardiology services rendered in a physician’s office, in an outpatient hospital ambulatory setting, or in an inpatient setting (planned professional services only) must be submitted to NCH for prior authorization. Approvals issued by Wellcare before July 1, 2023, are effective until the authorization end date, but all prior authorization requests needed after July 1, 2023, must be submitted to NCH. This requirement applies to all of your Medicare members ages 18 and older.
Frequently Asked Questions:
Wellcare Cardiology Management Program Effective July 1, 2023
What is New Century Health (NCH)?
- NCH is a comprehensive oncology quality management (OQM) and cardiology management specialty company whose goal is the application of evidence-based medicine for the delivery of adult ambulatory cancer care and cardiology care.
What is the Wellcare Cardiology Management Program?
- The Wellcare Cardiology Management Program provides prior authorization management for cardiology services rendered in a physician’s office, in an outpatient hospital ambulatory setting, or in an inpatient setting (planned professional services only). The program emphasizes and supports the selection of preferred pathways for patient care and is administered by New Century Health.
Is this for all Wellcare members?
- The Wellcare Cardiology Management Program is for WellCare Medicare members ages 18 and older who are enrolled in the following lines of business: HMO, PPO, PPO-DSNP, DSNP, PFFs, and C-SNP.
When will the Wellcare Cardiology Management Program begin?
- The program will begin July 1, 2023.
How can a physician’s office request training for this program?
- A provider network specialist will contact you to schedule an introductory meeting and training. If you have any questions prior to the introductory meeting, please contact NCH at 1-888-999-7713, Option 6 or email providertraining@newcenturyhealth.com. You can also self-register online at my.newcenturyhealth.com or call Wellcare directly at 1-855-538-0454.
What are some key features of the program?
The online provider portal is always available, offering:
- Real-time authorizations for treatment care pathway.
- Real-time status of authorization requests.
- Eligibility verification.
- Authorization support staff are available at 1-888-999-7713, Option 1, Monday through Friday, from 5 a.m. to 5 p.m., Pacific time.
- Quick turnaround time on authorization requests submitted via portal or phone.
- Physician discussion by cardiologists.
- New Century Health provider representatives are available for support as needed.
What is the transition of care process?
- Approvals issued by Wellcare before July 1, 2023, are effective until the authorization end date. Starting July 1, 2023, please submit prior authorization requests to NCH.
Who should obtain prior authorization?
- The physician organization ordering the cardiology services must request prior authorization through New Century Health.
How do I obtain prior authorization?
- Submit cardiology service requests to New Century Health via one of the following methods:
- Logging into New Century Health’s provider web portal at my.newcenturyhealth.com.
- Contacting New Century Health’s Utilization Management Intake Department at 1-888-999-7713, Option 1, Monday through Friday, from 5 a.m. to 5 p.m., Pacific time.
What is the turn-around time (TAT) for processing prior authorization requests?
- Standard Medical: 14 calendar days.
- Expedited Medical: 72 hours.
What services / specialists are included in the Wellcare Cardiology Management Program?
The program will apply to all specialties for the following interventional cardio services only:
- ABLATION
- ANGIOGRAPHY
- AORTIC VALVE SURGERY
- BYPASS GRAFT IN-SITU VEIN
- BYPASS GRAFT VEIN
- CARDIAC CATHETERIZATION
- CONGENITAL HEART DISESE SURGERY
- CORONARY ARTERY DISEASE SURGERY
- DEVICE IMPLANTATION/ELECTRICAL CARDIOVERSION
- DEVICE MONITORING
- ELECTROPHYSIOLOGY STUDIES (EPS)
- ENDOVASCULAR INTERVENTIONS
- EXCISION, EXPLORATION, REPAIR, REVISION
- STRIPPINGS/LIGATIONS
- INTERVENTIONAL CARDIOLOGY
- INTERVENTIONAL RADIOLOGY
- LEFT ATRIAL APPENDAGE CLOSURE
- MITRAL VALVE SURGERY
- PULMONARY ARTERY SURGERY
- PULMONARY VALVE SURGERY
- REPAIR/EXCISION FOR ANEURYSM, OCCLUSIVE DISEASE, ETC.
- SAVR
- TAVR
- THERAPEUTIC SERVICES
- THROMBOENDARTERECTOMY
- TRICUSPID VALVE SURGERY
Who at New Century Health will be reviewing cardiology requests?
- New Century Health medical reviewers are licensed cardiologists using nationally recognized clinical guidelines when performing reviews. Guidelines are available at my.newcenturyhealth.com or by contacting New Century Health at 1-888-999-7713, Option 1.
- If the request does not meet evidence-based treatment guidelines, New Century Health may request additional information or initiate a physician discussion with the requesting provider.
What will the New Century Health authorization look like, and how long is it valid?
- The New Century Health authorization will start with “AR” followed by at least four digits (e.g., AR1000). It is valid for the duration indicated on the Service Request Authorization (SRA).
What place(s) of service does this prior authorization review process include?
- The Wellcare Cardiology Management Program provides prior authorization management for cardiology services rendered in a physician’s office, in an outpatient hospital ambulatory setting, or in an inpatient setting (planned professional services only).
Does a prior authorization guarantee payment?
- No, a prior authorization does not guarantee payment for services. Payment of claims is dependent on eligibility, covered benefits, provider contracts, and correct coding and billing practices. For specific details, please refer to your Provider Manual.
Who is responsible for responding to grievances and appeals?
- Wellcare will continue to respond to member grievances and appeals. Members can continue to follow processes outlined on our website and in the Member Handbook to submit either a grievance or an appeal. Providers can initiate a grievance or appeal with Wellcare by following the processes outlined in your Provider Manual or by calling Provider Services at 1-855-538-0454.
What will happen if the physician does not request and obtain an authorization?
- If a required authorization is not obtained, Wellcare may deny payment for the relevant services. Members cannot be held responsible or billed for denied charges / services. Providers may only collect the applicable cost share amount directly from the member.
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Apple Health Core Connections
Reproductive Health for Youth Impacted by Child Welfare
At Coordinated Care, we believe that every person should have the information and health care access they need to decide if, when, and how they become a parent.
In 2022, the most common diagnosis for youth in the AHCC Alumni population (ages 18-26) was pregnancy.
For youth who want to become parents, we offer our Start Smart for Baby program and care coordination benefits for the baby and parent together. For youth who do not want to become pregnant, we help connect with providers to get access to contraception.
We encourage providers to make contraception and STI prevention information and options available to youth at every opportunity.
Information on which family planning methods, including Long Acting Reversible Contraception (LARC) are covered and can be found here.
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), children reunified with their parents, and youth in the Unaccompanied Refugee Minor population. Coordinated Care’s program is named “Apple Health Core Connections.” You can reach our Care Coordination team at 1-844-354-9876 or AHCCTeam@coordinatedcarehealth.com .
The Coordinated Care Community Education (CE) 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
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Training/Education
2023 WISe symposium, the Mission of the WISe Workforce Collaborative is to advance best practices for youth and their families in the state of Washington and to strengthen relationships among youth, families, and their community’s resources and support. The symposium is August 15-16, 2023 Register here.
FREE PediaLink Module: Helping Families Navigate Systems: Special Education and SSI for Children with Disabilities The AAP, with support from the CDC, recently recorded an educational event with subject matter experts to provide pediatric clinicians with the practical tips, knowledge, and resources to navigate systems of care to support families/caregivers of children who were recently identified with a delay or disability. Learners will understand the role of pediatric clinicians in helping families/caregivers apply for Supplemental Security Income (SSI) benefits and navigate the special education system, including Individualized Education Programs (IEPs) and Section 504 plans. Interested participants can register here.
Wildfire Smoke and Your Patients’ Health Learn about the health effects associated with wildfire smoke and steps to advise patients to take before and during a wildfire to reduce smoke exposure. Register here.
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 August 23-25, 2023, from 8:30 a.m. to 2:30 p.m. each day via Zoom. Learn more and register here.