July 2024 Provider News
Date: 07/29/24
In this issue:
- General Updates - NEW July 2024 Medicaid Admin Days Policy, Hepatitis C Treatment—Mayvret, Behavioral Health Workforce Survey
- Quality - Clinical Practice Guidelines update
- Payment & Clinical Policy - Monthly Clinical & Payment Policy Updates
- Pharmacy Update - August 1, 2024 Preferred Drug List (PDL) Changes, Opioid overdose: Did You Know…
- Wellcare - Swing Bed authorization submission process, Prescriptions through Amazon end July 1st
- Apple Health Core Connections - New Comprehensive Sexual Healthcare Webpage
- Training/Education - Upcoming Training Opportunities
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General Updates
NEW July 2024 Medicaid Admin Days Policy
As of 7/1/2024 the Health Care Authority (HCA) Admin Days Policy has changed.
Facilities will no longer ask for Admin Days but will be given them when claims are denied and member stays in the hospital, due to no appropriate discharge placement. This is an automatic function of this policy; nothing needs to be done by the facility. Both a denial letter and an Admin letter will be produced and mailed.
If peer-to-peer or an appeal overturns this claim denial, then Admin Days will be recouped.
If you have any questions or need clarification about the HCAs new policy, please reach out to your Provider Engagement Administrator.
Policy can be found here (PDF).
Hepatitis C Treatment—Mayvret
Coordinated Care would like to remind you that:
- Anti-viral MAVYRET can cure Hepatitis C.
- These daily pills are allowed for up to a 12-week supply at one time.
- Effective for claims on or after March 1, 2024, the Health Care Authority, Apple Health Fee-For-Service (FFS) has increased the maximum allowable days’ supply for Mavyret (glecaprevir/pibrentasvir).
- Pharmacies may dispense and submit claims for up to a 12-week (84 days) supply of Mavyret in a single fill.
- Mavyret is preferred and does not require prior authorization
- To ensure patients receive the full course of treatment, Mavyret prescriptions should be written in a manner to allow the pharmacy to dispense the entire 8-week or 12-week course of treatment.
- Other anti-viral medications will require review and be approved only if Mavyret is not clinically appropriate.
- CDC recommends that all adults 18 years and older be screened for Hep C at least once, as well as pregnant women during each pregnancy.
- Injection drug use is the primary risk for Hepatitis C. Any person requesting HCV screening should receive it.
- Direct-acting antiviral (DAA) medications can be prescribed for children aged 3 and up.
- Patients who have certain liver problems or are taking medicines (atazanavir or rifampin) are not eligible to take MAVYRET.
- Anyone licensed to prescribe direct acting anti-viral medications is allowed to screen and treat Apple Health members, including primary care doctors and pharmacists.
- To find providers in your area who have prescribed Mayvret, go to: https://www.mavyret.com/locator.
Learn more at:
- Eliminating Hepatitis C | Washington State Health Care Authority
- Eliminating Hepatitis C | Washington State Department of Health
- Mail order pharmacy resource for Mayvret (PDF)
- For questions, email: applehealthpharmacypolicy@hca.wa.gov
Behavioral Health Workforce Survey
The Workforce Development team within the Office of Forensic Mental Health Services (OFMHS) which is part of the State of Washington Department of Social and Health Services (DSHS) is being tasked with bringing forward initiatives that educate and train people to create, sustain and retain a viable workforce that meets current and future staffing needs within behavioral health.
In 2022, this team reached out to professionals who have their finger on the pulse of behavioral health hiring strategies and trends. The data collected in 2022 has informed the work and impacted the approaches to supporting recruitment and retention practices for the behavioral health workforce across the State. They would now like to use your experience to inform the work moving forward. It’s time for a data refresh!
If you could please take a moment to share your thoughts and experiences through this brief 2 Question Behavioral Health Workforce Survey here.
Expect to set aside five minutes or less to complete the survey. Your time and all that you have to offer in your responses is appreciated.
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Quality
Medicaid Quality
Clinical Practice Guidelines
The following Practice Guidelines on the Provider Website have been updated:
- Asthma
- Behavioral Health
- Cancer
- Chronic Obstructive Pulmonary Disease
- Coronavirus Disease
- Coronary Artery Disease
- Diabetes
- Frailty and Special Populations
- Hemophilia
- Hyperlipidemia
- Immunizations
- Long Term Care
- Opioids for Chronic Pain
- Osteoporosis
- Pneumonia
- Preventative Care
- Sickle Cell
- Weight Management
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.
Telehealth
Telehealth increases access to physicians and specialists to help patients receive the right care, at the right place, at the right time.
More information:
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.
Wellcare Quality
Help People Living with Disabilities Get the Care They Need is the July Medicare Learning Network Highlight
It is known that people living with disabilities face unique barriers and health care challenges, 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 heart disease (9.6%)). During Disability Pride Month and the Americans with Disabilities Act anniversary month, find out how you can help address these challenges. Please see the following resources:
- Modernizing Health Care to Improve Physical Accessibility web-based training
- Getting the Care You Need: Guide for People with Disabilities publication (PDF)
- Improving Access to Care for People with Disabilities webpage
- How to Improve Physical Accessibility at Your Health Care Facility booklet (PDF)
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Payment & Clinical Policy Updates
Clinical Policy Updates
Policy WA.CP.MP.519, Administrative Days, was further updated to reflect HCA Billing Guidelines during July, with changes remaining effective July 1. The latest revisions are listed here. The policy will be available on the policy site shortly.
- References reviewed and updated. Added references for acute PM&R. Description updated to clarify the process for social admissions per WAC 182-550-4550. WAC reference removed from description and replaced with Washington State Health Care Authority. Section I. approval requirements changed from “all” to “A. and B. or C.” per the HCA billing guidelines. Section IV. D. removed.
The below policies were updated as part of our regular monthly review in June. The policy changes are effective August 1, 2024. 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.509 | Upper GI Endoscopy for GERD | Apple Health |
WA.CP.MP.518 | Negative Pressure Wound Therapy for Home Use | Apple Health |
| CP.MP.24 | Multiple Sleep Latency Testing | Apple Health & Ambetter |
| CP.MP.58 | Intestinal and Multivisceral Transplant | Apple Health & Ambetter |
| CP.MP.87 | Therapeutic Utilization of Inhaled Nitric Oxide | Apple Health & Ambetter |
| CP.MP.115 | Discography | Apple Health & Ambetter |
| CP.MP.116 | Lysis of Epidural Lesions | Apple Health & Ambetter |
| CP.MP.91 | Obstetrical Home Health Care Programs | Ambetter |
| CP.MP.120 | Pediatric Liver Transplant | Apple Health & Ambetter |
| CP.MP.147 | Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention | Ambetter |
| CP.MP.175 | Air Ambulance | Ambetter |
| CP.MP.188 | Pediatric Oral Function Therapy | Apple Health & Ambetter |
| CP.MP.210 | Repair of Nasal Valve Compromise | Apple Health & Ambetter |
| CP.MP.244 | Liposuction of Lipedema | Apple Health & Ambetter |
The below policies were updated as part of our regular monthly review in June. The policy changes are effective November 1, 2024. 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.69 | Intensity-Modulated Radiotherapy | Apple Health & Ambetter |
| CP.MP.107 | Durable Medical Equipment (DME) and Orthotics and Prosthetics Guidelines | Apple Health & Ambetter |
| CP.MP.146 | Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins | Ambetter |
| WA.CP.MP.522 | Varicose Vein Treatment | Apple Health |
| CP.MP.184 | Home Ventilators | Apple Health & Ambetter |
The below genetic testing policies received updates as part of our twice-yearly review. These policy changes are effective August 1, 2024. You will find the policies, including a description of the revisions, posted on the policy site. WA.CP.MP.232, Genetic Testing Pharmacogenetics, is a new policy replacing V2.2024 CG Pharmacogenetics for Apple Health, only.
| Policy Number | Policy Title | Line of Business |
|---|---|---|
| V2.2024 | CG Aortopathies and Connective Tissue Disorders | Apple Health & Ambetter |
| V2.2024 | CG Cardiac Disorders | Apple Health & Ambetter |
| V2.2024 | CG Dermatologic Conditions | Apple Health & Ambetter |
| V2.2024 | CG Epilepsy Neurodegenerative and Neuromuscular Conditions | Apple Health & Ambetter |
| V2.2024 | CG Exome and Genome Sequencing for DX of Genetic Disorders | Apple Health & Ambetter |
| V2.2024 | CG Eye Disorders | Apple Health & Ambetter |
| V2.2024 | CG Gastroenterologic Disorders Non-cancerous | Apple Health & Ambetter |
| V2.2024 | CG General Approach to Genetic Testing | Apple Health & Ambetter |
| V2.2024 | CG Hearing Loss | Apple Health & Ambetter |
| V2.2024 | CG Hematologic Conditions Non-cancerous | Apple Health & Ambetter |
| V2.2024 | CG Hereditary Cancer Susceptibility | Apple Health & Ambetter |
| V2.2024 | CG Immune Autoimmune and Rheumatoid Disorders | Apple Health & Ambetter |
| V2.2024 | CG Kidney Disorders | Apple Health & Ambetter |
| V2.2024 | CG Lung Disorders | Apple Health & Ambetter |
| V2.2024 | CG Metabolic Endocrine Mitochondrial Disorders | Apple Health & Ambetter |
| V2.2024 | CG Multisystem Inherited Disorders, Intellectual Disability and Developmental Delay | Ambetter |
| WA.CP.MP.230 | Genetic Testing Multisystem Inherited Disorders, Intellectual Disability and Developmental Delay | Apple Health |
| V2.2024 | CG Non-Invasive Prenatal Screening | Ambetter |
| WA.CP.MP.231 | Genetic Testing Non-Invasive Prenatal Screening (NIPS) | Apple Health |
| V2.2024 | CG Oncology Algorithmic Testing | Apple Health & Ambetter |
| V2.2024 | CG Oncology Cancer Screening | Apple Health & Ambetter |
| V2.2024 | CG Oncology Circulating Tumor DNA Tumor Cells Liquid Biopsy | Apple Health & Ambetter |
| V2.2024 | CG Oncology Cytogenetic Testing | Apple Health & Ambetter |
| V2.2024 | CG Oncology Molecular Analysis Solid Tumors & Hematologic Malignancies | Apple Health & Ambetter |
| V2.2024 | CG Pharmacogenetics | Ambetter |
| WA.CP.MP.232 | Genetic Testing Pharmacogenetics | Apple Health |
| V2.2024 | CG Preimplantation Genetic Testing | Apple Health & Ambetter |
| V2.2024 | CG Prenatal and Preconception Carrier Screening | Apple Health & Ambetter |
| V2.2024 | CG Prenatal Diagnosis Pregnancy Loss | Apple Health & Ambetter |
| V2.2024 | CG Skeletal Dysplasia Rare Bone Disorders | Apple Health & Ambetter |
The below policy is new effective July 1, 2024. You will find the policy posted on the policy site.
| Policy Number | Policy Title | Line of Business |
|---|---|---|
| WA.CP.MP.22 | Stereotactic Body Radiation Therapy | Apple Health |
The below policy is new effective August 1, 2024. You will find the policy posted on the policy site.
| Policy Number | Policy Title | Line of Business |
|---|---|---|
| CP.MP.114 | Disc Decompression Procedures | Apple Health & Ambetter |
The below policy will be archived effective July 1, 2024.
| Policy Number | Policy Title | Line of Business |
|---|---|---|
| CP.MP.22 | Stereotactic Body Radiation Therapy | Apple Health |
The below policies were previously announced as revised on
the date noted. You will find the policies posted on the policy site.
Policy Number | Policy Title | Effective Date | Line of Business |
CP.MP.40 | Gastric Electrical Stimulation | 9/1/24 | Apple Health & Ambetter |
| CP.MP.91 | Obstetrical Home Health Care Programs | 9/1/24 | Ambetter |
| CP.MP.132 | Heart-Lung Transplant | 9/1/24 | Apple Health & Ambetter |
| CP.MP.141 | Non-Myeloablative Allogenic Stem Cell Transplants | 9/1/24 | Apple Health & Ambetter |
| CP.MP.185 | Skin and Soft Tissue Substitutes for Chronic Wounds | 9/1/24 | Ambetter |
| WA.CP.MP.185 | Skin and Soft Tissue Substitutes for Chronic Wounds | 9/1/24 | Apple Health |
| CP.MP.176 | Outpatient Cardiac Rehabilitation | 10/1/24 | Ambetter |
| CP.BH.201 | Deep TMS for OCD | 10/1/24 | Ambetter |
Payment Policy Updates
Reimbursement Policy for Genetic/Molecular Test Coding Policy
Beginning 11/1/2024, Coordinated Care will expand the requirements for billing of genetic and molecular testing. In accordance with the Reimbursement Policy for Genetic/Molecular Test Coding Policy, all providers billing for genetic and molecular testing services will be required to adhere to the coding recommendation in the Concert Genetics portal.
The portal can be accessed here. The quality and billing integrity requirements in the reimbursement policy will be facilitated by Concert Genetics--our partner and a software and managed services company that promotes health by providing the digital infrastructure for reliable and efficient management of genetic testing and precision medicine.
Advancements in the science of genetics and genomics have led to remarkable new options for medical professionals to diagnose, treat, and prevent disease. As genetic testing has increasingly become the standard of care, our health plan is committed to providing the highest levels of access, quality, and value for members in this exciting and dynamic segment of health care. To achieve these goals, our health plan is asking for your support in the next phase of its genetic testing program. The goals of this phase are twofold -- advance the reliability of laboratory quality information and reduce variability in billing.
What does this mean for our laboratory partners?
We are asking you, our laboratory partner, to do the following:
- Register with Concert Genetics upon outreach to you by the Concert Genetics team.
- Self-report on quality metrics in a common framework supplied by Concert
- Verify accuracy of test catalog and view coding recommendations and fee schedule
- Utilize Concert’s recommended codes when billing for genetic and molecular tests
Thank you for your support and continued partnership on providing our members with access to high-quality health care at an affordable price.
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Pharmacy Updates
Effective August 1, 2024, The Coordinated Care Apple Health Preferred Drug List will have the following updates:
| EFFECTIVE DATE | DRUG NAME | Update |
|---|---|---|
| 08/01/2024 | PHENTOLAMINE MESYLATE 5 MG | Phentolamine Mesylate must be submitted as a medical claim |
| 08/01/2024 | RESTASIS MULTIDOSE 0.05% RESTASIS 0.05% ADVAIR HFA CYCLOSPORINE 0.05 % REPATHA SURECLICK 140 MG/ML FLUTICASONE-SALMETEROL | These drugs will no longer be available as a 90-day supply. Members will be able to obtain up to a one-month supply |
Opioid overdose: Did You Know…
Prescribing naloxone with opioids is encouraged when:
- Taking 50 MME/day or more
- Also taking benzodiazepines
- History if substance use disorder is present
- Using other illicit drugs that may be contaminated (laced with fentanyl)
- Otherwise at high risk of opioid overdose (accordance with WA state law)
- [Sources: CDC Clinical Practice Guideline for Prescribing Opioids for Pain 2022; WA DOH Pub 630-145; WA State SB 5195]
Covered options (no prior authorization required at pharmacy):
- Medicaid: all naloxone generics (tier 1), naloxone brands (tier 2), and Opvee (tier 2); Over-The-Counter naloxone/Narcan nasal sprays
- Ambetter Exchange: generic naloxone (nasal spray, vials); Over-The-Counter naloxone nasal sprays
Informational:
If your organization still needs naloxone for people who do not have insurance, you can apply to become a naloxone distribution program with the WA Department of Health Overdose Education and Naloxone Distribution Program.
Email: naloxoneprogram@doh.wa.gov
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Wellcare
SWING BED Authorization – Supplemental Guide
For our Critical Access Hospitals who utilize Swing Beds, they will need to submit portal authorization’s under the coding of Waitlist. This is how Swing Beds are triaged and received by the Wellcare UM team via the Provider Portal.
Please follow the below steps for portal submission for Swing Bed Claims:
- Open and download the How to Submit an Authorization Guide from the Wellcare website. Follow the directions, taking note of the top of page 10 which notates various service types and sub types. Waitlist will be in the service type grid.
- Upon filling out the Authorization information select Inpatient Services as the Service Type. Once this field is selected then the Subtype field will populate. Select Waitlist as the Subtype Field. Once this field is selected then the Place of Service field will populate.
- In the Place of Service field, click on the field then click on the DOWN arrow on your keyboard. This will then trigger the service options in which Inpatient Hospital will need to be selected.
- Return to the How to Submit and Authorization guide to finish out submission.
For additional guidance or question please reach out to your provider engagement administrator for Wellcare.
Preferred Pharmacy Network Our Medicare Advantage* and Prescription Drug Plans
As of July 1, 2024 we are offering a robust, dependable pharmacy network with over 60,000 pharmacies in network — many offering preferred cost-sharing!* A member’s cost-share may be lower when prescriptions are filled through one of our preferred retail pharmacies or our preferred mail-order pharmacy, Express Scripts.® However, members may have prescriptions filled at any network pharmacy. Walgreens,® CVS,® grocers, and select independents pharmacies remain within the preferred 2024 pharmacy network.
Amazon® is no longer a preferred pharmacy but remains in the pharmacy network. Remember, some retail pharmacies offer both retail and home delivery options. If a member fills a prescription with a retail pharmacy that also offers home delivery, the retail cost share will apply, and pharmacies may charge a delivery fee.
Please utilize the Find a Provider tool to find an in-network pharmacy. This will also allow you to find an in-network pharmacy’s network status (standard vs preferred and if 90/100-day fill is offered). *Preferred pharmacy network not available for Wellcare D-SNPs.
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Apple Health Core Connections (AHCC)
New Comprehensive Sexual Healthcare Webpage! Coordinated Care is proud to launch a new webpage educating youth and young adults about coverage related to reproductive health, including pregnancy testing and support, birth control, abortion, and STI testing. The webpage also includes critical information about privacy rights, healthy relationships, LGBTQIA+ support, and additional resources for youth and young adults. We are grateful for Passion 2 Action, DCYF’s youth advisory group, for partnering with us on developing this content. Please feel welcome to reference our webpage as an additional resource for information when supporting our members.
Additionally, AHCC’s specialized Care Management team is committed to supporting adolescents as they transition to adulthood. Our team strives to connect with every member around the age of 17 to complete a transition-aged youth assessment where we discuss medical and behavioral health needs as well as social drivers of health. In addition to connecting youth with providers, we help members develop a plan for housing, employment, access to food, education, and more. Please talk with your patients about connecting with Coordinated Care to get support as they transition into adulthood. You can also submit a referral for a transition-aged youth assessment by emailing AHCCteam@coordinatedcarehealth.com with patient name, member ID, date of birth, and a request to complete the TAY assessment. Our team will contact the member soon after your referral.
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Training/Education
Supporting LGBTQIA+ Youth in Foster Care This curriculum was developed through Amara with input from Coordinated Care and guidance from many community organizations. This training is for caregivers and professionals who work in the child welfare setting. August 1st 10am. Register here.
Trauma 101 What is Trauma? This training answers this question by defining trauma, how trauma affects children, and what caregivers can do to assist children. The presentation will heighten the caregiver’s awareness of children’s cues so they will know what to expect and how to respond when a child experiences trauma triggers. August 2nd 1pm. Register here.
Secondary Trauma and Self-Care Caring for children who have experienced trauma can be difficult, draining, exhausting, and frustrating. This training will help caregivers and service providers to understand the differences between Secondary Traumatic Stress, Compassion fatigue and Vicarious trauma. Participants will also be able to recognize warning signs and personal triggers, as well as understand why self-care is important and develop a personal self-care plan. August 5th 10am. Register here.
Attachment: Beyond Infancy: Attachment is the foundation of all relationships, and when caring for children with a history of trauma and trust issues, it does not always occur easily. This training addresses the need for Attachment focused care, including some practical tips on how to strengthen bonding to children. This training can help caregivers and professionals understand the basics of how attachment issues are extremely common in children who have experienced complex trauma. These same issues are often a core reason why caretakers and children have challenges in the placement and/or disrupt from the home. Facilitated by Zia Freeman, MA, LMHC When: Aug 1, 2024 11:30 AM– 02:30 PM. Register here.
Back to School We Go! School is often a challenge for children with a history of trauma and it can be challenging to all involved to help kids succeed. This training provides tips & guidance on how professionals and caregivers can help children ease back into school, especially if there are learning or behavioral challenges, and/or being in a new placement. Facilitated by Zia Freeman, MA, LMHC Aug 6, 2024 01:00 -02:30 PM. Register here.
Hygiene Concerns & Solutions in Youth with a Complex History: Does your teen not like to bathe? Does your child seem less than fully potty trained (and they are no longer toddlers!) Will the adolescent rarely change their clothes? There is more to these tendencies than just resistant behavior. Learn the causes of poor hygiene and practical solutions to help fix it, intended for anyone who may be working with youth with a challenging background. Facilitated by Zia Freeman, MA, LMHC When: Aug 9, 2024 12:01 – 1:35PM. Register here.
Naloxone and Fentanyl: How do they work?: Naloxone has become a popular item for folks to carry and use in case of an Opioid overdose in users, but many do not really know what it does or the best way to use it. In addition, the Opioid Fentanyl has grown in popularity for youth and adults, and it is often added to other drugs unbeknownst to the user, which makes it even more dangerous. Learn more about the history of Fentanyl in this training, details of how to use Naloxone, where to obtain it, and recommendations on how to provide assistance to those in need. Facilitated by Mark Varela, BA, SUDP Aug 13, 2024 03:30 - 04:30PM. Register here.
Apple Health Core Connections Overview: Coordinated Care's Apple Health Foster Care Overview includes program information, insurance coverage and special benefits for youth in foster care, adoption support, alumni of foster care and reunified families that choose Coordinated Care. Caregivers may be surprised at the benefits that can help them, and if you are a professional supporting youth with this insurance come learn about those resources to share with others! Facilitated by Zia Freeman, MA, LMHC Aug 15, 2024 01:00-02:30PM. Register here.