May 2023 Provider News
Date: 05/31/23
In this issue:
- Quality - Medicaid: ADHD Follow up, Asthma and 90-day Refills, Breast Cancer Screening, Telehealth, Antidepressant Medication Management, Wellcare: COVID-19 Public Health Emergency Updates to Coverage for COVID-19 Tests, Mental Health Awareness Month, AANHPI Heritage Month
- Tribal - Updated Point of Contact for IHCPs, Referring Members for Out of State Services, Medicaid Credentialing Reminder
- Clinical Policy & Payment Integrity Updates - Interventional Pain Management, Monthly Updates, Optum’s Comprehensive Payment Integrity (CPI) Prepayment Claims Review Program
- Pharmacy Updates - July 1, 2023 Preferred Drug List Changes
- Wellcare - Prior Authorization Change Summary - eff 07/01/2023, Medicare Part B Drug List - eff 07/01/2023
- Apple Health Core Connections - EPSDT Requirements and CHET for Youth Entering Foster Care
- Training/Education - Building a Trauma Informed Resilient Focused Community, Pediatric Mental Health Conference, Equitable Care Webinar: Rebuilding Trust in Medicine, 2023 Washington Behavioral Healthcare Conference, Examining the Complexities of REL Data Webinar
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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.
Telehealth
Telehealth increases access to physicians and specialists to help patients receive the right care, at the right place, at the right time.
Telehealth for Providers: What You Need to Know
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
The Federal COVID-19 Public Health Emergency (PHE) will end on May 11, 2023. Most Covid tools such as vaccines, treatments and testing will remain available. The Center for Disease Control and Prevention’s (CDC) ability to collect and share certain data will change and its guidance for Americans will be updated to align with data changes.
Updates to Coverage for COVID-19 Tests
What you need to know:
The COVID-19 Public Health Emergency is set to end on May 11, 2023. The ending of the Public Health Emergency may impact an individual’s coverage of COVID-19 tests. We encourage you to learn about these changes and share the New Consumer Fact Sheet on COVID-19 tests.
Consumer Fact Sheets:
After May 11, 2023 educate Medicare members:
Laboratory tests for COVID-19 that are ordered by provider will still be covered with no out-of-pocket costs for people with Medicare. Over-the-counter tests will still be available, but there may be out-of-pocket costs. Coverage of over-the-counter tests may vary by insurance type, as described below.
What does this mean for Medicare Beneficiaries?
Generally, Medicare doesn’t cover or pay for over-the counter products. The demonstration that has allowed us to offer coverage for COVID-19 over-the-counter tests at no cost ends on May 11, 2023. However, if you are enrolled in Medicare Part B, you will continue to have coverage with no out-of-pocket costs for appropriate laboratory-based COVID-19 PCR and antigen tests when a provider orders them (such as drive-through PCR and antigen testing or testing in a provider’s office). If you are enrolled in a Medicare Advantage plan, you may have more access to tests depending on your benefits. Check with your plan.
What does this mean for people with Medicaid or Children’s Health Insurance Program?
If you have coverage through Medicaid or the Children’s Health Insurance Program, you will have access to COVID-19 over-the-counter and laboratory testing through September 30, 2024. After that date, coverage of testing may vary by state.
What does this mean for people with Private Insurance?
If you have private insurance, coverage will vary depending on your health plan. However, private plans won’t be required by federal law to cover over-the counter and laboratory-based COVID-19 tests after May 11, 2023.
If your insurance chooses to cover COVID-19 testing, they may require cost sharing, prior authorization, or other forms of medical management.
May 2023 Mental Health Awareness Month: Recommend Medicare Preventive Services
20% of Americans experience mental illness each year and it disproportionately affects racial and ethnic minority groups (see CDC). This National Mental Health Awareness month, the Centers for Medicare and Medicaid recommend Providers suggest appropriate preventive services, including:
- Depression Screening (telehealth eligible)
- Annual Wellness Visit telehealth eligible)
- Initial Preventive Physical Exam
- Alcohol Misuse Screening & Counseling (telehealth eligible)
Medicare covers preventive services, and your patients pay nothing.
The Centers for Disease Control and Prevention (CDC) suggest healthy ways to cope with stress by:
- Taking breaks from news stories and social media. It’s good to have information but negative events can be upsetting.
- Take care of your body: staying physically healthy helps a persons’ emotional well-being. This includes eating healthy, getting adequate sleep, increasing your physical activity, limiting alcohol intake, avoiding all forms of smoking, illegal drugs or taking prescription pill of another person or not in the way ordered by your Provider.
- Make time to unwind, connect with others and continue regular health appointments, tests, health screenings and vaccinations recommended by your health Provider.
The 988 Suicide & Crisis Lifeline
The 988 Suicide & Crisis Lifeline is a national network of local crisis centers that provides free and confidential emotional support to people in suicidal crisis or emotional distress 24 hours a day, 7 days a week in the United States. The 988 Suicide & Crisis Lifeline is committed to improving crisis services and advancing suicide prevention by empowering individuals, advancing professional best practices, and building awareness.
Additional tools and resources for Mental Health from the CDC can be found here.
Asian American Native Hawaiian & Pacific Islander (AANHPI) Heritage Month
AANHPI is celebrated in May because two significant events occurred. The first Japanese immigrants came to the US in May of 1843; and the transcontinental railroad was completed on May 10, 1869, where the majority of workers who laid the tracks were Chinese immigrants. In 2008, the U.S Census Bureau estimated that by 2050, AANHPI persons will make up 9.7% of the total US population—over 40 million people. AANHPIs represent over 30 countries and ethnic groups that speak over 100 different languages.
According to the National Institute on Minority Health and Health Disparities, Asian American Native Hawaiian & Pacific Islanders face health disparities in chronic diseases of heart disease, hypertension, diabetes, and mental health, in addition to the highest incidence and mortality rates of liver and stomach cancers. Overall, Asian Americans have the most difficulty understanding instructions from a doctor’s office, are the least satisfied with care coordination, and experience unique health disparities from other ethnic populations.
It is estimated more than half of Asian Americans with diabetes don’t know they have the disease, and they are more likely to develop type-2 diabetes compared to other ethnicities despite having lower body weight and body mass index (BMI). Unique risk factors for diabetes among Asian Americans include insulin resistance, differential body fat distribution, genetics and emerging risks, such as metabolic syndrome, acculturation and a traditional diet high in sodium and carbohydrates.
Mental health issues, especially related to depression, is just one area of understudied disparities among elderly Asian Americans. Others include limited access to culturally/linguistically appropriate health care, Alzheimer’s disease, and burden of family members as caregivers, self-management of chronic conditions, and lack of medication adherence.
Potential ways to address these challenges for your patients:
- Assess each AANHPI patient’s English proficiency, provide information in their preferred language.
- Allow AANHPI members to have a caregiver/family member/support person present for visits if indicated that is the member’s wish. AANHPI support people can reinforce importance of preventative screenings, medication adherence and diminish potential anxiety or hesitance toward medical providers/treatment recommendations.
- Provide culturally-tailored messages to AANHPI patients, observe body language/non-verbal cues that might indicate AANHPI patients’ dissatisfaction, misunderstandings or hesitancy/mistrust.
We encourage you to find your own ways to address these and any other health disparities you have noted in the AANHPI community and to celebrate, commemorate, acknowledge AANHPI members and their contributions to our communities.
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Tribal
Updated IHCP point of contact for all lines of business (Medicaid, Marketplace and Wellcare)
All Washington State Indian Health Care Providers now have a designated contact person—Carin Moritz. Please feel free to reach out for any questions, trainings, or just to say hello! Carin.Moritz@coordinatedcarehealth.com
Referring members for services out of Washington State (Medicaid)
Are you sending members on our plan out of the clinic for services? If yes, please reach out to the member's insurer before placing the member in an out of state facility to ensure appropriate care coordination between the insurer, the Tribe, and the out of state facility. The member’s insurers must be billed first and Tribes are intended to be the payer of last resort.
Helpful hints:
- Send a copy of the member’s ID card to the facility
- Inform the facility of the Insurance payer so claim submission and reimbursement is not delayed
- Use your health plan resources for any questions
Credentialing: (Medicaid)
- IHCP's are not required to go through the Credentialing process with Coordinated Care. Practitioners associated with an IHCP are enrolled via claims data received. Please reach out to Carin Moritz at carin.moritz@coordinatedcarehealth.com if you have any questions or concerns regarding IHCP credentialing issues such as received claim denials or letters indicating you are up for re-credentialing.
- If you are working with a 3rd party credentialing group, please let them know that as an IHCP, credentialing is not required for the Medicaid line of business.
- If your IHCP facility chose to contract with us, you are able to submit rosters as desired to keep our systems up to date with your practitioner updates.
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Clinical Policy & Payment Integrity Updates
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 |
Complex Radiology
Effective June 1, 2023, the Heart MRI policy used by National Imaging Associates, Inc. (NIA) to determine if the services are medically necessary and covered under Coordinated Care health plans is updated to fully reflect the Health Technology Assessment used by the Health Care Authority for Apple Health members. 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.028 | Heart MRI | Apple Health |
Monthly Updates:
The below clinical policies received updates as part of our regular monthly review in May. These policy changes are effective June 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.513 | Cardiac Stents | Apple Health |
| WA.CP.MP.504 | Elective Delivery Prior to 39 Weeks | Apple Health |
| WA.CP.MP.27 | Hyperbaric Oxygen Therapy | Apple Health |
| CP.MP.160 | Implantable Wireless Pulmonary Artery Pressure Monitoring | Apple Health & Ambetter |
| CP.MP.243 | Implantable Loop Recorder (Implantable Cardiac Monitor) | Apple Health & Ambetter |
| CP.MP.24 | Multiple Sleep Latency Testing | Apple Health & Ambetter |
| CP.MP.91 | Obstetrical Home Health Care Programs | Ambetter |
| WA.CP.MP.507 | Oral Enteral Nutrition | Apple Health |
| WA.CP.BH.506 | Psychological Testing | Apple Health |
| CP.MP.163 | Total Parenteral Nutrition and Intradialytic Parenteral Nutrition | Apple Health & Ambetter |
| WA.CP.MP.185 | Skin and Soft Tissue Substitutes for Chronic Wounds | Apple Health |
| CP.MP.185 | Skin and Soft Tissue Substitutes for Chronic Wounds | Ambetter |
The below policy was updated as part of our regular monthly review in May. The policy changes are effective July 1, 2023. You will find the policy, including a description of the revisions, posted on the policy site.
| Policy Number | Policy Title | Line of Business |
|---|---|---|
WA.CP.MP.37 | Bariatric Surgery | Apple Health |
The below policies were updated as part of our regular monthly review in May. The policy changes are effective September 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.BH.201 | Deep Transcranial Magnetic Stimulation for Treatment of Obsessive Compulsive Disorder | Ambetter |
| CP.MP.146 | Sclerotherapy and Chemical Endovenous Ablation of Varicose Veins and Other Symptomatic Venous Disorders | Ambetter |
| CP.BH.200 | Transcranial Magnetic Stimulation for Treatment Resistant Major Depression | Apple Health & Ambetter |
| WA.CP.MP.522 | Varicose Vein Treatment | Apple Health |
The below policy is new effective June 1. It will replace WA.CP.MP.248 – Sleep Apnea Diagnosis and Treatment. You will find the policy posted on the policy site.
| Policy Number | Policy Title | Line of Business |
|---|---|---|
CP.MP.248 | PSG and Split-Night in a Sleep Center | Apple Health & Ambetter |
The below genetic testing policies were updated as part of our regular monthly review in May. The policy changes are effective September 1, 2023. You will find the policies, including a description of the revisions, 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 | Apple Health & 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 |
The below policy will be archived effective June 1, 2023. The policy will be replaced with CP.MP.248, PSG and Split-Night in a Sleep Center which is available on the policy site.
| Policy Number | Policy Title | Line of Business |
|---|---|---|
WA.CP.MP.248 | Sleep Apnea Diagnosis and Treatment | 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.104 | Applied Behavior Analysis | Apple Health |
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.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 |
| CP.MP.100 | Allergy Testing and Therapy | 7/1/23 | Apple Health & Ambetter |
| CP.MP.108 | Allogenic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia | 7/1/23 | Apple Health & Ambetter |
| CP.MP.101 | Donor lymphocyte infusion | 7/1/23 | Apple Health & Ambetter |
| WA.CP.MP.36 | Experimental Technologies | 7/1/23 | Apple Health |
| CP.MP.36 | Experimental Technologies | 7/1/23 | Ambetter |
| CP.MP.40 | Gastric Electrical Stimulation | 7/1/23 | Apple Health & Ambetter |
| CP.MP.132 | Heart-Lung Transplant | 7/1/23 | Apple Health & Ambetter |
| CP.MP.86 | Neonatal Abstinence Syndrome Guidelines | 7/1/23 | Apple Health & Ambetter |
| CP.MP.102 | Pancreas Transplantation | 7/1/23 | Apple Health & Ambetter |
| CP.MP.120 | Pediatric Liver Transplant | 7/1/23 | Apple Health & Ambetter |
| CP.MP.162 | Tandem Transplant | 7/1/23 | Apple Health & Ambetter |
Payment Integrity Updates
Coordinated Care is committed to continuously evaluating and improving overall Payment Integrity solutions as required by state and federal governing entities. As a notification that we have partnered with Optum who is supporting us in performing prepayment claim auditing using Optum’s Comprehensive Payment Integrity (CPI) tool. The purpose of our review is to verify the extent and nature of the services rendered for the patient’s condition and that the claim is coded correctly for the services billed.
For claims received on or after 9/1/2023, providers may experience a slight increase in written requests for medical record submission prior to payment, based on the areas outlined below. These requests will come from Optum and will contain instructions for providing the documentation. Should the requested documents not be returned, the claim(s) will be denied. Providers will have the ability to dispute findings through Optum directly in the event of a disagreement.
| Editing Area | Description | Lines of Business |
|---|---|---|
High Dollar IV Hydration | Requesting medical records to determine if documentation supports services billed and that those services were in accordance with policies and regulations related to IV hydration therapy. | Medicaid, Marketplace |
| Custom Fitted or Custom Fabricated Prosthetics or Orthotics | Requesting medical records to verify documentation supports high-dollar custom DME codes billed by the provider | Medicaid, 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.
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Pharmacy Updates
Effective July 1, 2023, the following drugs will need to be billed to the Health Care Authority (HCA). For drugs that currently require prior authorization (PA), please submit PA requests to the HCA on or after July 1, 2023. For more information, please contact the HCA at 800-562-3022.
- Ganaxolone (Ztalmy®)
- Caplacizumab-Yhdp (Cablivi®)
- Beremagene Geperpavec (VyjuvekTM)
- Concizumab (NN7415)
- Delandistrogene Moxeparvovec (SRP-9001)
- Efanesoctocog Alfa (BIVV001)
- Exagamglogene Autotemcel (EXA-CEL)
- Leniolisib (Joenja®)
- Lifileucel (LN-144)
- Nedosiran (DCR-PHXC)
- Palovarotene (Palovarotene)
- Pegunigalsidase Alfa (PRX-102)
- Tofersen (QalsodyTM)
- Trofinetide (DaybueTM)
- Velmanase Alfa (Lamzede®)
Effective July 1, 2023, the following medication will no longer be preferred.
| Effective Date | Drug Name | Potential Alternatives |
|---|---|---|
07/01/2023 | Salicylic Acid Gel 6% | Salicylic Acid Foam 6% or Podofilox Solution 0.5% |
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Wellcare
Medicare Prior Authorization - List effective 7/1/2023
Wellcare requires prior authorization (PA) as a condition of payment for many services. This notice contains information regarding such prior authorization requirements and is applicable to all Medicare products offered by Wellcare.
Wellcare is committed to delivering cost effective quality care to our members. This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice. Prior authorization is a process initiated by the physician in which we verify the medical necessity of a treatment in advance using independent objective medical criteria and/or in network utilization, where applicable.
It is the ordering/prescribing provider’s responsibility to determine which specific codes require prior authorization.
Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered. NON-PAR PROVIDERS & FACILITIES REQUIRE AUTHORIZATION FOR ALL HMO SERVICES EXCEPT WHERE INDICATED.
For complete CPT/HCPCS code listing, please see Online Prior Authorization Tool on our website.
Effective July 1st, 2023, the following are changes to prior authorization requirements:
| Service Category | PA Rule | Services | Procedure Codes |
|---|---|---|---|
Observation | No PA Required | Observation services | Rev code: 762 |
| Surgical procedures | No PA Required | Subcutaneous hormone pellet implantation | 11980 |
| Injectable medications | Step therapy | Injectables | J0587, J0588, J1437, J1439, J1443, J1444, J1445, J1449, J1460, J1560, Q0138, Q0139, Q5126, Q5127, Q5128, Q5129, Q5130 |
| Injectable medications | PA Required - No Step Therapy | Injection, onabotulinumotxinA, 1 unit | J0585 |
| Injectable medications | No PA Required | Injectables | J0897, J1750, J1756, J2916, Q0221 |
See as bulletin posting on Wellcare website
Part B Drug List Updates - Effective July 1, 2023
The following drugs require utilization review:
| Procedure | Description | Step Therapy |
|---|---|---|
J0585 | INJECTION, ONABOTULINUMOTXINA, 1 UNIT | |
| J0587 | INJECTION, RIMABOTULINUMTOXINB, 100 UNITS | STEP THERAPY |
| J0588 | INJECTION, INCOBOTULINUMTOXIN A, 1 UNIT | STEP THERAPY |
| J1437 | INJECTION, FERRIC DERISOMALTOSE, 10 MG | STEP THERAPY |
| J1439 | INJECTION, FERRIC CARBOXYMALTOSE, 1 MG | STEP THERAPY |
| J1443 | INJECTION, FERRIC PYROPHOSPHATE CITRATE SOLUTION (TRIFERIC), 0.1 MG OF IRON | STEP THERAPY |
| J1444 | INJECTION, FERRIC PYROPHOSPHATE CITRATE POWDER, 0.1 MG OF IRON | STEP THERAPY |
| J1445 | INJECTION, FERRIC PYROPHOSPHATE CITRATE SOLUTION (TRIFERIC AVNU), 0.1 MG OF IRON | STEP THERAPY |
| J1449 | INJECTION, EFLAPEGRASTIM-XNST (ROLVEDON), 0.1 MG | STEP THERAPY |
| J1460 | INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 1 CC | STEP THERAPY |
| J1560 | INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, OVER 10 CC | STEP THERAPY |
| Q0138 | INJECTION, FERUMOXYTOL, FOR TREATMENT OF IRON DEFICIENCY ANEMIA, 1MG (NON-ESRD USE) | STEP THERAPY |
| Q0139 | INJECTION, FERUMOXYTOL, FOR TREATMENT OF IRON DEFICIENCY ANEMIA, 1MG (FOR ESRD ON DIALYSIS) | STEP THERAPY |
| Q5126 | INJECTION, BEVACIZUMAB-MALY, BIOSIMILAR, (ALYMSYS), 10 MG | STEP THERAPY |
| Q5127 | INJECTION, PEGFILGRASTIM-FPGK (STIMUFEND), BIOSIMILAR, 0.5 MG | STEP THERAPY |
| Q5128 | INJECTION, RANIBIZUMAB-EQRN (CIMERLI), BIOSIMIAR, 0.1 MG | STEP THERAPY |
| Q5129 | INJECTION, BEVACIZUMAB-ADCD (VEGZELMA), BIOSIMILAR, 10 MG | STEP THERAPY |
| Q5130 | INJECTION, PEGFILGRASTIM-PBBK (FYLNETRA), BIOSIMILAR, 0.5 MG | STEP THERAPY |
See as bulletin posting on Wellcare website.
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Apple Health Core Connections
EPSDT and CHET for Youth Entering Foster Care
The day that a youth is removed from their home can be one of the most traumatic in their lives. Pediatricians and family practice providers can play a key role in helping to minimize trauma by knowing about the medical appointments required for a youth entering foster care.
The Apple Health Core Connections Operations team can work with clinics and health systems to explain these requirements and help make your process for working with these youth and their caregivers and caseworkers as smooth as possible. Contact your Provider Engagement Administrator, or Senior Liaison Jen Estroff (jestroff@coordinatedcarehealth.com) for more information.
Requirements for Foster Care EPSDT within 30 days
When youth are removed from their home into shelter care (the first step to becoming a dependent of the state or of a Tribe), they need to have an EPSDT exam scheduled right away.
- The EPSDT appointment and documentation must be completed within the 30 days
- The appointment must be billed as an EPSDT exam, not as establishing care or office visit
- Coordinated Care has NO benefit maximum on EPSDT exams. If asked to schedule an EPSDT, please set the appointment even if the patient has had an EPSDT recently.
- Payment for the EPSDT will be made even if the provider is not the assigned PCP.
- An EPSDT exam may also be needed after a child changes placement (moves from one caregiving home to another)
EPSDT and CHET
The Department of Children, Youth, and Families (DCYF) has a team of Child Health Education and Tracking (CHET) Screeners in every region. The CHET Screeners are social workers authorized to collect health information for the CHET report.
Due 30 days from the day a youth enters foster care, the CHET report must include the record from the EPSDT well-child exam. -
- Exam must be billed only as EPSDT to meet the legal requirements
CHET Screeners will send a fax or email request noting WAC 182-502-0020 – Health Care Record Requirements, authorizing them to receive records.
- It’s critical to send the EPSDT record as soon as possible; please consider an office process and a single point of contact to ensure copies are sent promptly for youth in foster care.
A complete EPSDT record that fulfills the state requirement must include:
- Vitals
- Review of symptoms
- Include any abnormal findings - Recommendations/Referrals
- Including anticipatory guidance
- Make sure all referrals are in Coordinated Care's network
Please note that most Tribes do not use the CHET process
Reminder for Billing Teams: please use the TJ modifier for youth in foster care to receive the increased rate for EPSDT visits.
Washington State Health Care Authority (HCA)
EPSDT Fee Schedule
Effective July 1, 2022
For all other payable procedure codes, refer to the Physician-Related Services Fee Schedule.
For all payable drugs and biologicals, refer to the Professional Administered Drugs Fee Schedule.
| Code Status Indicator | Code | Modifier | Maximum Allowable NFS Fee | Maximum Allowable FS Fee | Foster Care Clients - Must use Mod TJ |
|---|---|---|---|---|---|
R | 99381 | $80.60 | $54.71 | $120.00 | |
| R | 99382 | $84.27 | $58.13 | $120.00 | |
| R | 99383 | $87.44 | $61.80 | $120.00 | |
| R | 99384 | $97.94 | $72.54 | $120.00 | |
| R | 99385 | $95.26 | $69.61 | $120.00 | |
| R | 99391 | $72.54 | $49.58 | $120.00 | |
| R | 99392 | $77.43 | $54.71 | $120.00 | |
| R | 99393 | $77.18 | $54.71 | $120.00 | |
| R | 99394 | $84.27 | $61.80 | $120.00 | |
| R | 99395 | $85.98 | $63.51 | $120.00 |
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 program. Coordinated Care’s program is named “Apple Health Core Connections.” For questions or care coordination referrals you can reach us at 1-844-354-9876 or AHCCTeam@coordinatedcarehealth.com .
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Training/Education
Building a trauma informed resilient focused community - This presentation will describe trauma's impact on communities and compelling reasons a community, and its prevention workforce, needs to become trauma informed and resilient focused. June 1st 9:00 – 10:30 AM Register Here.
Pediatric Mental Health Conference- hosted by the Partnership Access Line at Seattle Children’s. Free, virtual conference with CME available for primary care providers. Topics include: Being solution-focused: a transdiagnostic approach to developing treatment in primary care, Postpartum Psychosis, & Psychiatric Management of Child and Adolescent Anxiety. June 3rd 8:00 – 12:30 PM Register here.
Equitable Care Webinar: Rebuilding Trust in Medicine - Join us for Rebuilding Trust in Medicine through Courageous Conversations, with Dr. Cora Breuner and parent advocate Shayla Collins. June 28th 7:00 AM Register Here.
2023 Washington Behavioral Healthcare Conference: Reconnect and Recharge. Join us for 35 workshops, with tracks focusing on recovery & resiliency, race and equity in behavioral health, children, youth & families, corrections & mental health, and more. Kennewick, WA June 15-16, 2023. Register here.
Foundation for Health Equity presents: Examining the Complexities of REL Data Webinar. Health In this webinar, speakers will discuss the ethical and pragmatic challenges to collecting data on Race, Equity, and Language (REL); data storage and prep for analysis; and how data may be used to inform actions to advance equity. June 1st 12:00-1:30 PM. Register here.
ARTICLES & RESOURCES:
June is Pride Month. Providers interested in learning more about supporting the LGBTQ+ community can access recorded and live webinars with CEC’s available through the LGBTQ+ Behavioral Health Equity Center of Excellence.
On July 11 at 2-3 p.m. ET, ACU is planning to offer a national Suicide Safer Care webinar intended to support newly practicing clinicians and clinicians in training with practical tools/tips for suicide prevention.
The registration link is live and can be shared now with your network providers.
OHS Facilities Program
Behavioral Health Profession Licensure Requirements
The Department of Health (DOH) is hosting four virtual Listening Sessions in June. We want to learn about barriers to getting credentialed as a behavioral health professional in Washington State. All sessions will have the same content. Pick the session that works best for you or attend all sessions. You can register for the webinars at the links below. We will open the meetings for you to join 15 minutes prior to the start time listed below:
- June 6, 2023: 10:30am – 12pm
- June 7, 2023: 1:30pm - 3pm
- June 12, 2023: 5pm – 6:30pm
- June 15, 2023: 5pm – 6:30pm
If you cannot make it to the virtual listening sessions, we would still like to hear from you. You can send comments to Cori Tarzwell, Strategic Policy Manager, at cori.tarzwell@doh.wa.gov.
Why is DOH doing listening sessions?
2SSB 1724 passed the Washington State Legislature in 2023. Section 5 of the bill requires DOH to identify changes to statutes and rules that would remove unnecessary barriers to entering or remaining in the behavioral health workforce. The workforce is defined in the bill as advanced social workers, independent clinical social workers, marriage and family therapists, mental health counselors, substance use disorder professionals, and psychologists.
What are the listening sessions for?
These listening sessions will help DOH learn from providers, employers, and communities about barriers to entering and remaining in the behavioral health workforce. They will help us shape future rulemaking on licensing requirements and inform our recommendations to the legislature starting this November. Our goal is to have licensure requirements for the behavioral health workforce that are equitable, allow for timely credentialing, protect the safety of patients, and promote access to care.
What questions will DOH ask at the listening sessions?
These are the questions we will be asking:
- What licensing or credentialing barriers exist that prevent providers from entering or staying in the behavioral health workforce?
- What licensing or credentialing barriers exist that place an unfair burden on applicants from disadvantaged communities?
- What licensing or credentialing barriers exist that cause delays in applying for and receiving a credential from the department?
- What other licensing or credentialing related barriers does the department need to be aware of and consider?
Accessibility
Virtual listening sessions will have American Sign Language, Spanish interpreters, CART, and auto-generated Closed Captioning. If you would like to request accommodations, contact Cori Tarzwell, Strategic Policy Manager, at cori.tarzwell@doh.wa.gov.
We ask that any requests for additional interpreters be made at least two weeks in advance. This is to give us the time needed to secure the requested service. We will make every effort to secure services but may not be able to because of availability.
Help us get the word out
Help us get the word out about the listening sessions. Please share this event with your community.
For questions or comments, email Cori Tarzwell, Strategic Policy Manager, at cori.tarzwell@doh.wa.gov.
Requisitos de autorización para profesionales de la salud conductual
El Departamento de Salud (DOH, por su sigla en inglés) organizará cuatro sesiones de escucha virtuales en junio. Queremos informarnos sobre los obstáculos que existen a la hora de obtener una credencial como profesional de la salud conductual en el Estado de Washington. En todas estas sesiones se presentará el mismo contenido, por lo que puede elegir la que más le convenga o asistir a todas ellas. Encontrará los enlaces para inscribirse en los seminarios web a continuación. Abriremos las reuniones 15 minutos antes de la hora de inicio que se indica a continuación:
- 6 de junio de 2023: de 10:30 a. m. a 12:00 p. m.
- 7 de junio de 2023: de 1:30 p. m. a 3:00 p. m.
- 12 de junio de 2023: de 5:00 p. m. a 6:30 p. m.
- 15 de junio de 2023: de 5:00 p. m. a 6:30 p. m.
Si no puede participar de las sesiones de escucha virtuales, igualmente nos gustaría conocer su opinión. Puede enviarle sus comentarios por correo electrónico a Cori Tarzwell, gerenta de Políticas Estratégicas, a cori.tarzwell@doh.wa.gov.
¿Por qué organizará estas sesiones el DOH?
La asamblea legislativa del estado de Washington aprobó el proyecto de ley 2SSB 1724 (en inglés) en 2023. Según el artículo 5 del proyecto de ley, el Departamento de Salud debe identificar qué cambios en los estatutos y las normas eliminarían los obstáculos innecesarios a la hora de incorporarse a la fuerza laboral de salud conductual o permanecer en ella. En el proyecto de ley se define a la fuerza laboral como trabajadores sociales avanzados, trabajadores sociales clínicos independientes, terapeutas de pareja y familia, consejeros de salud mental, profesionales de trastornos por consumo de sustancias y psicólogos.
¿Para qué sirven estas sesiones?
Las sesiones de escucha permitirán que los proveedores, los empleados y las comunidades informen al DOH sobre los obstáculos con los que se enfrentan a la hora de formar parte de la fuerza laboral de salud conductual y permanecer en ella. Nos ayudarán a estructurar el futuro proceso de reglamentación de los requisitos para obtener autorización y a fundamentar nuestras recomendaciones a la asamblea legislativa a partir del próximo mes de noviembre. Nuestro objetivo es contar con requisitos de autorización para la fuerza laboral de salud conductual que sean equitativos, permitan obtener la autorización de forma oportuna, protejan la seguridad de los pacientes y promuevan el acceso a la atención.
¿Qué preguntas hará el DOH durante las sesiones?
Estas serán las preguntas:
- A la hora de obtener autorización o credenciales, ¿qué obstáculos impiden que los proveedores se sumen a la fuerza laboral de salud conductual o permanezcan en ella?
- A la hora de obtener autorización o credenciales, ¿qué obstáculos representan una carga injusta para los solicitantes que vienen de comunidades desfavorecidas?
- A la hora de obtener autorización o credenciales, ¿qué obstáculos causan retrasos en el proceso de solicitar y recibir credenciales del departamento?
- ¿Qué otros obstáculos debe tener en cuenta o considerar el departamento acerca de la obtención de autorización o credenciales?
Accesibilidad
Las sesiones de escucha virtuales tendrán intérpretes de lengua de señas estadounidense y español, además de subtítulos generados automáticamente y CART (por su sigla en inglés, subtitulado en tiempo real asistido por computadora). Si desea solicitar adaptaciones, envíele un correo electrónico a Cori Tarzwell, gerenta de Políticas Estratégicas, a cori.tarzwell@doh.wa.gov.
Todas las solicitudes de intérpretes adicionales deben hacerse al menos dos semanas antes para que tengamos el tiempo suficiente para obtener estos servicios. Haremos todo lo posible para que los reciba, pero no podemos garantizarlo debido a que quedamos sujetos a su disponibilidad.
Ayúdenos a correr la voz
Ayúdenos a correr la voz sobre las sesiones de escucha. Comparta este evento con su comunidad.
Si tiene comentarios o dudas, envíele un correo electrónico a Cori Tarzwell, gerenta de Políticas Estratégicas, a cori.tarzwell@doh.wa.gov