March 2023 Provider News
Date: 03/31/23
In this issue:
- General Updates - METS- BH for Medicaid only, FQHC pay class changes, Inpatient Concurrent Review, HCA Ends SNF/HH Incentives
- Quality - Medicaid: ADHD Follow up, Asthma and 90 Day Refills, Breast Cancer Screening, Wellcare: National Nutrition Month, National Colorectal Cancer Awareness Month, National Disability Awareness Month
- Tribal - 2023 Encounter Rate increase
- Payment & Clinical Policy - March Updates
- Wellcare - CMS lab ordering guidelines, Wellcare and Medicaid Redetermination, New Century Health (NCH) Cardiac Program
- Apple Health Core Connections - Program Updates
- Training/Education - Centene’s Clinical Provider Training, Our Climate's Impact on Health: Acting Now for a Resilient Future, New Journeys, TeleBehavioral Health Summit, 2023 Washington Behavioral Healthcare Conference
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General Updates
FQHC Pay Class Changes
For our Medicaid WA Health Plans contracted with Medicaid. Please be advised of upcoming FQHC pay class changes.
Encounters:
- Must be billed with one of these revenue codes: "521", "522", "524", "525", "527", "528", "519", "900"
- And one of these HCPCS: "G0466", "G0467", "G0468", "G0469", "G0470", "G0511", "G0512"
- Must be billed on a UB04
Non-Encounters (adjunct codes):
- Must be billed on a HCFA 1500
Members Empowered to Succeed (METS) is a Behavioral Health clinical program within Coordinated Care
METS takes a unique approach to member care focusing on individualized needs to create a recovery roadmap that is personalized to the member. We partner with both the provider and the member to ensure the member achieves the ultimate level of recovery and resiliency. Our Clinical Liaisons are licensed clinicians that work directly with BH providers to identify the member’s treatment and supports needed for successful progress in treatment. Our Member Engagement Service Coordinators reach out telephonically to the member to identify needs and resources to meet the member’s behavioral health, social, and medical needs.
Benefits and Outcomes of METS:
- Integrated, whole health approach to member’s needs and care including behavioral health, medical, therapeutic, pharmacy, and supplemental
- Cross-care team partnership to ensure coordination of care and collaborative problem solving
- Coordination of services and treatment between multiple providers
- Knowledge of covered services such as expanded benefits or new programs and how to access
- Access to various physicians and specialists to promote diversity among providers and treatment team
Note: no release of information is required. PHI that is used or disclosed for purposes of treatment, payment, or healthcare operations is permitted by HIPAA Privacy Rules (45 CFR 164.506) and does not require consent or authorization from the member.
For questions, please contact your assigned Provider Engagement Representative.
Changes to Inpatient Concurrent Review Process
Coordinated Care of WA will be making process changes to our Inpatient Concurrent Review process effective 7/1/23. These changes are designed to 1) increase process standardization across the Centene family of plans to improve operational efficiency and pave the way for increased use of process automation afforded by advances in technology and interoperability standards, and 2) provide continued to support our members through discharge.
The changes will be in three primary areas:
- Timing of authorizations: As of 7/1/23, IP reviews and authorization decisions will focus on a prospective approach.
- Length of authorizations:
- For facilities with a DRG based payment structure, when the clinical information supports medical necessity, initial authorization will be for 7 calendar days and subsequent authorizations up to 7 days
- For facilities with a per diem based payment structure, authorization length will be based on member clinical acuity
- Monitoring of admissions through discharge to support transition planning: we will continue to monitor members even when they no longer meet acute care criteria through clinical records review and coordination with discharge planning teams. If a member’s clinical status changes and IP acute care criteria are again met, we will send notification of approval and continue concurrent reviews.
Discharge Needs:
We will continue to partner with our facilities on discharge planning, transition management, and coordination of post-acute care needs to enable a safe and timely discharge. Our Complex Discharge Planning team will continue to support for members with complex needs.
For additional questions, please contact your Provider Engagement representative.
HH and SNF Incentive Ending
As we start the public health emergency (PHE) unwind, the HCA has made the decision to end the $3,000 home health incentive, and the $6,000 skilled nursing facility incentive on March 31st, 2023.
Coordinated Care will make every effort possible to support discharge planning moving forward, including continued care coordination, leveling up to the highest allowable SNF rate, expedited turnaround time for prior authorizations, etc.
Please reach out with any questions or concerns.
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Quality
Medicaid Quality
ADHD Follow Up on Kids
Children with new prescription for ADHD medication should receive a follow up visit within 30 days of starting the medication.
Asthma and 90 Day Medication Refills
Moving members with asthma prescriptions to 90-day medication refills may increase their maintenance medication adherence.
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.
Wellcare Quality
March National Health Observances: Nutrition, Colorectal Cancer, and National Disability Month
The Office of Disease prevention and Health Promotion (ODPHP) features select monthly National Health Observances (NHOs) that align with their priorities for improving health across our nation. We are highlighting nutrition and colorectal cancer out of the of the several ODPHP awareness topics featured this March.
We’ve pulled together some of ODPHP’s resources below that your health practice can use to promote these important health topics.
National Nutrition Month
Every March, the Academy of Nutrition and Dietetics sponsors National Nutrition Month to help people make informed food choices and develop positive eating habits. Your health practice can join the conversation by using the National Nutrition Month Social Kit, U.S. Department of Agriculture’s MyPlate resources or Nutrition Education Resources & Materials. For bilingual options, you can use the Dietary Guidelines toolkit for professionals.
National Colorectal Cancer Awareness Month
The Colorectal Cancer Alliance (CCA) recognizes National Colorectal Cancer Awareness Month to raise awareness about colorectal cancer prevention. Your health practice can encourage members to learn more about colon cancer screenings and to talk to their doctors about what preventative measures and interventions are right for them. Also, check out the Colorectal Cancer Alliance’s statement on the importance of Colorectal cancer screening.
Top Colorectal Cancer Facts
- In 2023, it is estimated that 153,020 people will be diagnosed with colorectal cancer in the U.S., and an estimated 52,550 will die — making this disease the second-leading cause of cancer deaths.
- The average lifetime risk of colorectal cancer is one in 24, and age is the biggest risk factor. Most cases are diagnosed in people over age 50.
- Unlike most cancers, colorectal cancer is preventable with screening. With early detection, it’s treatable. Localized colorectal cancer (the earliest stage) has a 91% survival rate with treatment.
- The most common symptom of colorectal cancer is no symptom. When symptoms are present, they include blood in or on stool, persistent abdominal discomfort, and unexplained weight loss.
- People who have a first-degree relative (parent, sibling, offspring) with colorectal cancer have two to three times the risk of developing the disease. They should speak to a doctor about getting screened earlier than normal.
- Simple ways to reduce the risk of colorectal cancer include eating healthy, not smoking, exercising regularly, maintaining a healthy weight, limiting red meat intake, and adding calcium and vitamin D to your diet.
Who does colorectal cancer affect?
1 in 23 men and 1 in 25 women will be diagnosed with colorectal (colon or rectal) cancer in their lifetime. This disease affects men and women of all racial and ethnic groups and is most often found in people 50 years or older.
Incidence in those younger than 50, or young-onset colorectal cancer, is on the rise. Among those under age 55, the incidence rate is increasing by 1.5% every year. According to the latest data, colorectal cancer is the leading cause of cancer death among men aged 20-–49 years.
Screening disparities are also evident among Black and Alaskan Native communities, which experience higher incidence and mortality rates.
Getting checked for colorectal cancer can save lives. If caught early, there is a 90% chance of survival.
Encourage your patients to learn about screening options available, how, and when they should get checked.
National Disability Awareness Month
The National Association of Councils on Developmental Disabilities (NACDD), encourages all individuals, agencies and organizations to raise awareness this March to support the rights of people with disabilities. In recognition of people with disabilities and their contributions to our communities and society, the NACDD encourages people and agencies to participate with their own appropriate observances and activities directed toward increasing public awareness of the contributions and potential of Americans with disabilities.
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Tribal
2023 All Inclusive Rate Update
The 2023 All Inclusive Rate was published on February 27, 2023, by the Indian Health Service, HHS. The rate for 2023 has increased to $654 for outpatient per visit rate with an effective date of 1/1/23. Coordinated Care added this updated rate into production as of 2/27/23 and all current claims will process at the updated 2023 encounter rate. There are several projects currently underway to identify and reprocess claims processed prior to the rate being updated; IHCP’s who receive their payments via EFT will begin to see updated Explanation of Payments (EOP’s) for the claims being reprocessed mid-March. Those who receive payments via paper checks will begin to see updated EOP’s for the claims being reprocessed by early April.
We are highly encouraging all IHCP’s to ensure they are signed up for EFT payments- this helps to receive your payments more timely via electronic funds so there is no delay due to mail. Find additional information on how to enroll here or reach out to your Provider Relations rep for assistance.
If you find there are outstanding claims which did not get included in the Projects for the rate increase, please send an email to Carin Moritz carin.moritz@coordinatedcarehealth.com with a list of the outstanding Coordinated Care claim numbers for further review and research.
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Payment & Clinical Policy
Clinical Policy
Vendor Reminders and Updates:
Interventional Pain Management
Effective June 1, 2023, interventional pain management services will be reviewed by National Imaging Associates, Inc. (NIA) to determine if the services are medically necessary and covered under Coordinated Care health plans. You will find the policies on the NIA Website. A link is available under “provider resources” on CoordinatedCareHealth.com. Policy names are listed below.
Policy Number | Policy Title | Line of Business |
|---|---|---|
| NIA.CG.300 | Epidural Spine Injections | Apple Health & Ambetter |
| NIA.CG.301 | Facet Joint Injections | Apple Health & Ambetter |
| NIA.CG.302 | Facet Joint Denervation | Apple Health & Ambetter |
| NIA.CG.305 | Sacroiliac Join Injection | Apple Health & Ambetter |
CPT codes considered interventional pain management and addressed in the above policies are: 0213T-0218T, 0228T-0231T, G0260, 27096, 62320-62323, 64479, 64480, 64483, 64484, 64490-64495, 64633-64636. All these codes currently require prior authorization, but effective 6/1/23, authorization will be provided by NIA.
The below policies will be archived effective June 1, 2023. The policies will be replaced with NIA versions of the policies described above.
| Policy Number | Policy Title | Line of Business |
|---|---|---|
CP.MP.164 | Caudal or Interlaminar Epidural Steroid Injections for Pain Management | Apple Health & Ambetter |
| CP.MP.171 | Facet Joint Interventions for Pain Management | Ambetter |
| WA.CP.MP.171 | Facet Joint Interventions for Pain Management | Apple Health |
| CP.MP.166 | Sacroiliac Joint Interventions for Pain Management | Apple Health & Ambetter |
| CP.MP.165 | Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management | Apple Health & Ambetter |
Monthly Updates:
The below clinical policies received updates as part of our regular monthly review in March. These policy changes are effective April 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.519 | Administrative Days | Apple Health |
| WA.CP.BH.521 | Behavioral Health Personal Care Services | Apple Health |
| WA.CP.MP.502 | Cochlear Implants: Bilateral vs. Unilateral | Apple Health |
| WA.CP.MP.501 | Continuous Glucose Monitoring | Apple Health |
| CP.MP.57 | Lung Transplantation | Apple Health & Ambetter |
| CP.MP.85 | Neonatal Sepsis Management | Apple Health & Ambetter |
| CP.MP.81 | NICU Discharge Guidelines | Apple Health & Ambetter |
| CP.MP.141 | Non-Myeloablative Allogenic Stem Cell Transplants | Apple Health & Ambetter |
| WA.CP.MP.503 | Private Duty Nursing Services | Apple Health |
| WA.CP.MP.46 | Ventricular Assist Devices | Apple Health |
| CP.MP.46 | Ventricular Assist Devices | Ambetter |
The below policies were updated as part of our regular monthly review in March. The policy changes are effective July 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.100 | Allergy Testing and Therapy | Apple Health & Ambetter |
| CP.MP.108 | Allogenic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia | Apple Health & Ambetter |
| CP.MP.101 | Donor lymphocyte infusion | Apple Health & Ambetter |
| WA.CP.MP.36 | Experimental Technologies | Apple Health |
| CP.MP.36 | Experimental Technologies | Ambetter |
| CP.MP.40 | Gastric Electrical Stimulation | Apple Health & Ambetter |
| CP.MP.132 | Heart-Lung Transplant | Apple Health & Ambetter |
| CP.MP.86 | Neonatal Abstinence Syndrome Guidelines | Apple Health & Ambetter |
| CP.MP.102 | Pancreas Transplantation | Apple Health & Ambetter |
| CP.MP.120 | Pediatric Liver Transplant | Apple Health & Ambetter |
| CP.MP.162 | Tandem Transplant | Apple Health & Ambetter |
The below policies will be archived effective April 1, 2023.
| Policy Number | Policy Title | Line of Business |
|---|---|---|
CP.MP.34 | Hyperemesis Gravidarum Treatment | Apple Health & Ambetter |
| CP.MP.187 | Radiofrequency Ablation of Uterine Fibroids | Apple Health & Ambetter |
The below policy was previously announced as archived effective June 1, 2023. The policy will be replaced with a version of the policy with the same name but labeled CP.BH.104 which is available on the policy site.
| Policy Number | Policy Title | Line of Business |
|---|---|---|
WA.CP.MP.BH.104 | Applied Behavior Analysis | Apple Health |
The below new policy was previously announced effective on the date noted. 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 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.MP.107 | Durable Medical Equipment (DME) and Orthotics and Prosthetics Guidelines | 5/1/23 | Apple Health & Ambetter |
| CP.BH.104 | Applied Behavior Analysis | 6/1/23 | Apple Health & Ambetter |
| CP.BH.200 | Transcranial Magnetic Stimulation for Treatment Resistant Major Depression | 6/1/23 | Apple Health & Ambetter |
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Wellcare Updates
Reminder of CMS Lab Ordering Guidelines
We understand that timely claim payments to our lab and provider partners are important, so we would like to help you avoid unnecessary delays, rejections, or denials when possible. It is important to adhere to all CMS Billing Guidelines (PDF) which outlines regulatory guidance, as well as required information and details that must be included when ordering patient labs to aid in timely processing and payment. Specifically, it is imperative that providers turn on the medical necessity flag on the ordering provider’s EMR software. Departure from these guidelines and omission of required information are among the most common reasons that lab claims are delayed, rejected, or denied.
The CMS Lab Billing Guidelines cover the following topics:
- Insufficient Documentation
- Documentation Requirements
- Medicare Signature Requirements
- Ordering or Referring Services
Thank you for your continued participation in our network and products. If you have any questions, please do not hesitate to contact your Provider Representative.
Medicaid Redetermination Resumes Soon and Will Impact Medicare Benefits for Some of Your Patients
TALK TO YOUR D-SNP PATIENTS ABOUT ANNUAL MEDICAID ELIGIBILITY RENEWAL. If they no longer are eligible for Medicaid, let them know they have options.
Patients that are enrolled in a Dual Eligible Special Needs Plan (D-SNP) where they receive both Medicaid and Medicare benefits, must verify their Medicaid eligibility to continue dual coverage. Let your patients know:
- A letter will be sent a few months before their Medicaid anniversary date with instructions for verifying their eligibility.
- Their dual Medicare benefits are dependent on their Medicaid eligibility.
- If their eligibility is confirmed, they can continue their existing coverage.
- If they are no longer eligible for Medicaid, they can explore our Marketplace and Medicare options.
Download our Medicaid Redetermination flyer (PDF)
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.
Prior authorization can be requested by:
- Visiting NCH’s web portal
- Calling 1-888-999-7713, Option 1 Monday through Friday, from 5 a.m. to 5 p.m., Pacific time.
NCH uses clinical criteria based on nationally recognized guidelines to promote evidence-based guidelines. When using NCH’s web portal, you will be able to:
- Obtain real-time approvals when selecting evidence-based NCH treatment care pathways.
- Determine what clinical documentation is needed for medical necessity review.
- View all submitted requests in one location.
- Request to speak with a cardiologist to discuss treatment options.
Wellcare is proud to be your healthcare partner. If you frequently prescribe cardiology services and are new to this process, an NCH representative will contact you soon to schedule an introductory meeting and training. If you are new to NCH, portal login credentials will be securely emailed to you after your meeting and before July 1, 2023. If you need access to NCH’s portal and have not received a call from NCH, or if you have any questions beforehand, please email providertraining@newcenturyhealth.com or call NCH at 1-888-999-7713, Option 6. You may also call Wellcare directly at 1-855-538-0454 or visit wellcare.com. Just choose your state from the drop-down menu and click on “Providers.”
We look forward to working with you.
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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.
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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.
Foundation for Health Equity presents Our Climate's Impact on Health: Acting Now for a Resilient Future. During the webinar, we will learn about health issues related to our changing climate, current initiatives among Washington state health agencies to address these impacts and identify action steps our healthcare ecosystem can take to promote climate resilience and health equity. April 12, 2023 12-1:30pm. Register here.
New Journeys virtual gathering. This two-day virtual event will focus on education and awareness of first episode psychosis and is free to attend. April 25 and May 2, 2023, 8:30am-12:30pm both days. Register here.
Behavioral Health Institute at Harborview presents TeleBehavioral Health Summit (TeleBH Summit). A free two-day, CME-accredited virtual conference, solely focused on today’s emerging topics in digital and TeleBehavioral Health care. May 9-10, 2023, 10am-3:30pm both days. Register here.
2023 Washington Behavioral Healthcare Conference: Reconnect and Recharge. Registration opens April 1, 2023. Kennewick, WA June 14-16, 2023. Learn more here.