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November 2022 Provider News

Date: 11/30/22

In this issue: 

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General Updates

Mental Health EBP Reporting for Behavioral Health Providers

Coordinated Care would like to remind all clinics and providers who deliver Children’s Mental Health Evidence Based Practices (EBPs) to clients under age 18 that they should include the appropriate SERI code for Mental Health providers when billing for these services. EBP codes are specially designated identifiers on a claim or encounter that are used to report specific research- or evidence-based practices for children’s public mental health care provided by licensed or certified mental health providers to children and youth under 18 in Washington State. Coordinated Care is required by law to track and report quarterly to HCA, all children’s mental health visits and how many of these visits were billed as an Evidence Based Practice. EBP codes and all associated history and criteria can be found in the Evidence-Based Practices Reporting Guide.

The utilization of EBP codes does not impact payment of your claims. Coordinated Care will not deny any claims due to EBP code utilization. Additionally, please know that billing correctly also helps Coordinated Care to be able to refer new clients to you for Evidence Based Practices.

Please reach out to your Provider Network Specialist if you have any questions/concerns about billing with EBP codes.

Surge in Pediatric Respiratory Virus Cases

Due to the recent surge of respiratory virus cases in our pediatric members, healthcare systems have been overwhelmed with calls from parents and caregivers. Many of the calls we receive are questions regarding the appropriate level of care for those experiencing symptoms, as well as symptom management.

To support the statewide response in addressing the surge in respiratory virus cases, we have information posted on our member-facing website about RSV, what it is, signs and symptoms and actions parents should take.   We also offer a triage hotline available to Medicaid members which can help answer questions and potentially mitigate the calls that outpatient clinics are receiving.

HB 1860: Inpatient Behavioral Health Discharges for those with Homelessness and Housing Instability (Effective January 1, 2023)

On January 1, 2023, HB 1860 goes into effect with new requirements for managed care organizations (MCOs) and inpatient behavioral health providers. This legislative requirement requires notification and coordination for individuals discharging from inpatient behavioral health settings to support discharge to stable housing.

Coordinated Care of Washington agrees with the new legislative requirements below:

  • Inpatient behavioral health providers and MCOs are required to collaborate on housing-related care coordination for discharge planning purposes for individuals in inpatient behavioral health settings,
  • Inpatient behavioral health providers are required to notify a patient’s MCO at least 24 hours prior to discharge, or on the day of discharge for patients leaving against medical advice. Notification must include housing instability or homelessness risk.

Providers will:

  • Begin Identify housing status and assessing risk for housing instability at admission and determine needs prior to discharge.  
  • Include housing status/needs in admission notification and/or continued stay requests submitted to the MCOs.
  • Will notify and collaborate with MCOs when additional assistance is needed with discharge planning and housing-related discharge needs.
  • Ensure individuals discharging from inpatient behavioral health settings are set up with safe and stable housing.

MCOs will:

  • Through the UM process, MCO’s will screen all Inpatient hospitalizations for housing status, risk of housing instability and potential housing needs as identified by providers during course of treatment.
  • Will collaborate with inpatient providers on discharge planning and housing-related discharge needs as requested by provider or identified through the UM process.
  • Ensure that individuals discharging from the inpatient setting are provided the resources and assistance required to apply and secure safe and stable housing.

Provider Overview Dates:

December 15, 2022 – 11:00 am – 11:30 am, via Zoom
January 11, 2023-12:00 pm -12:30 pm, via Zoom

For more information, please reach out to your Provider Relations representative. Thank you for your continued service to our Coordinated Care MCO members.

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Quality

Influenza Vaccine Recommendation

It is important to remind members to get vaccinated and follow up to ensure it has been received.  Repeat recommendations for those who are unvaccinated and answer any questions they may have.  Strong professional recommendation plays a critical role in our members receiving their vaccination.

https://www.cdc.gov/flu/professionals/vaccination/flu-vaccine-recommendation.htm

Well Child Visits

Educate parents on the importance of getting their children up to date on well child visits and routine vaccinations.  Well child check ups are essential for their children’s growth and development and vaccines help protect their child’s health.

https://www.cdc.gov/vaccines/partners/childhood/stayingontrack.html#resources-partners

2022 Ambetter Provider NCQA Notification

Helping you care for your patients is our top priority.  Strong communication and trust between you and your patients will help ensure they’re satisfied and have good outcomes. You can rely on Ambetter from Coordinated Care for information and support to help you keep those patient relationships strong.

  • Annual CAHPS Survey
    The Consumer Assessment of Healthcare Providers and Systems (CAHPS) Health Plan Survey is an opportunity for your patients to share their healthcare experiences with you as their provider and with their health plan. Your patients are asked specific questions, which include how well their doctor communicates, if they felt their doctor listened to them, and if their doctor explained things in a way that was easy to understand. Also included are questions on how well different healthcare providers are communicating about care coordination and a (0-10) rating of the patient’s overall satisfaction with their healthcare, personal doctor and specialists.
  • Annual Provider Satisfaction Survey
    You are essential to providing the highest quality healthcare possible for our members, and your satisfaction is very important to us, too. We assess your experience with the health plan through an annual Provider Satisfaction Survey and use the results to guide operational improvement activities.

Your Ambetter from Coordinated Care Support Doesn’t Stop There.  Our provider website contains essential information, including your rights and other sources of support for you. Read more about our Quality Programs now: https://ambetter.coordinatedcarehealth.com/qi-program.html.  If you have additional questions or need specific support, call Provider Services at 1-877-687-1197 (TTY/TDD 1-877-941-9238).

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Billing Updates

ER Leveling

The payment policy, Leveling of ER Services (CC.PP.053), was archived as of 11/10/22.  Down-coding will no longer occur under this policy for the Medicaid or Marketplace lines of business.

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Tribal

Native American Heritage Month

November is national Native American Heritage Month or as it is commonly referred to, American Indian and Alaska Native Heritage Month. This is the time for Coordinated Care to acknowledge the important contributions of Native people and to celebrate their rich and diverse cultures, traditions, and histories.

We appreciate the work of Indian Health Care Providers in supporting the wellbeing of American Indians and Alaska Natives. Every Coordinated Care employee receives annual Tribal training to increase our awareness of Tribal sovereignty and the Indian Health Care delivery system. We are learning the importance of heritage, culture, traditions, and history in improving health outcomes for Native people.

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Prior Authorization

The following services, addressed under clinical policy CP.MP.202, Orthognathic Surgery, will require prior authorization for all providers treating Apple Health members starting March 1, 2023. Facial bone osteoplasty codes 21208 and 21209 have always required prior authorization and are not changing.

CodesDescription

21110

Application of interdental fixation device for conditions other than fracture or dislocation, includes removal

21125

Augmentation, mandibular body or angle; prosthetic material

21127

Augmentation, mandibular body or angle; prosthetic; with bone graft, onlay or interpositional includes obtaining autograft)

21141

Reconstruction midface, LeFort I; single piece, segment movement in any direction (eg, for Long Face Syndrome), without bone graft

21142

Reconstruction midface, LeFort I; two pieces, segment movement in any direction, without bone graft

21143

Reconstruction midface, LeFort I; three or more pieces, segment movement in any direction, without bone graft

21145

Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts)

21146

Reconstruction midface, LeFort I; two pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (e,g., ungrafted unilateral alveolar cleft)

21147

Reconstruction midface, LeFort I; three or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (e.g., ungrafted bilateral alveolar cleft or multiple osteotomies)

21150

Reconstruction midface, LeFort II; anterior intrusion (eg, Treacher-Collins Syndrome)

21151

Reconstruction midface, LeFort II; any direction, requiring bone grafts (includes obtaining autografts)

21154

Reconstruction midface, LeFort III; (extracranial), any type, requiring bone grafts (includes obtaining autografts); without LeFort I

21155

Reconstruction midface, LeFort III; (extracranial), any type, requiring bone grafts

(includes obtaining autografts); with LeFort I

21188

Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts)

21193

Reconstruction of mandibular rami, horizontal vertical, C”, or “L” osteotomy; without bone graft

21194

Reconstruction of mandibular rami, horizontal vertical, “C”, or “L” osteotomy; with bone graft (includes obtaining graft)

21195

Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation

21196

Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation

21198

Osteotomy, mandible, segmental

21199

Osteotomy, mandible, segmental; with genioglossus advancement

21206

Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)

21208

Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant)

21209

Osteoplasty, facial bones; reduction

21210

Graft, bone; nasal, maxillary or malar areas (include obtaining graft)

21215

Graft, bone; mandible (includes obtaining graft)

21244

Reconstruction of mandible, extraoral, with transosteal bone plate (e.g., mandibular staple bone plate)

21245

Reconstruction of mandible or maxilla, superiosteal implant; partial

21246  

Reconstruction of mandible or maxilla, superiosteal implant; complete

21247

Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (e.g., for hemifacial microsomia)

21248

Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder);partial

21249

Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); complete

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Clinical and Payment Policies

Payment Policy Updates

The payment policy, Leveling of ER Services (CC.PP.053), was archived as of 11/10/22.  Down-coding will no longer occur under this policy for the Medicaid or Marketplace lines of business.

Clinical Policy Updates

Monthly Updates:

The below clinical policies received updates as part of our regular monthly review in November. These policy changes are effective December 1, 2022. You will find the policies, including a description of the revisions, posted on the policy site.

Policy NumberPolicy TitleLine of Business

CP.MP.108

Allogenic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia

Apple Health & Ambetter
CP.MP.31Cosmetic and Reconstructive ProceduresApple Health & Ambetter
CP.MP.101Donor Lymphocyte InfusionApple Health & Ambetter
WA.CP.MP.50Drugs of Abuse: Definitive TestingApple Health
CP.MP.50Drugs of Abuse: Definitive TestingAmbetter
CP.MP.109PanniculectomyApple Health & Ambetter
CP.MP.127Total Artificial HeartApple Health & Ambetter
WA.CP.MP.185Skin Substitutes for Chronic WoundsApple Health
CP.MP.185Skin Substitutes for Chronic WoundsAmbetter
WA.CP.MP.527Vitamin D TestingApple Health & Ambetter

The below policies were updated as part of our regular monthly review in November. These policy changes are effective March 1, 2023. You will find the policies, including a description of the revisions, posted on the policy site.

Policy NumberPolicy TitleLine of BusinessLine of Business

CP.MP.202

Orthognathic Surgery

3/1/23Apple Health & Ambetter
CP.MP.150Phototherapy for Neonatal Hyperbilirubinemia (formerly Home Phototherapy)3/1/23Apple Health & Ambetter
CP.MP.61IV Moderate Sedation, IV Deep Sedation and General Anesthesia for Dental Procedures (formerly Dental Anesthesia)3/1/23Ambetter

Reminders:

Policy NumberPolicy TitleLine of BusinessLine of Business

CP.MP.246

Pediatriac Kidney Transplant

2/1/23Apple Health & Ambetter
WA.CP.MP.117Percutaneous Electrical and Peripheral Nerve Stimulation2/1/23Apple Health & Ambetter
CP.MP.242Pulmonary Function Testing2/1/23Apple Health & Ambetter

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Apple Health Core Connections

Coordinated Care is the single managed care organization to administer the Integrated Managed Care Apple Health Foster Care program in collaboration with the Health Care Authority and Department of Children Youth and Families. This program serves children and youth in foster care, adoption support, alumni of foster care (ages 18-26), and children reunified with their parents. Coordinated Care’s program is named “Apple Health Core Connections.” You can reach us at 1-844-354-9876 or AHCCTeam@coordinatedcarehealth.com.

The Coordinated Care Community Education Team serves providers and their staff with training to support the needs of the Medicaid population. The CE Team can offer training on topics such as SBIRT, Adoption Success, Trauma Informed Care, ACEs, Resilience, and Secondary Trauma and Self Care. To request more information or to schedule no-cost training please email: communityeducation@coordinatedcarehealth.com.

Trauma Focused Cognitive Behavioral Training

Save the date! Coordinated Care is hosting a no-cost TF-CBT training for mental health clinicians that treat youth in foster care on March 22-23, 2023, in Wenatchee, WA. Registration information will be available soon. If you are interested in learning more about this opportunity email Lindsey.C.Greene@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 Care Quality. Bree Recommendation Spotlight: Opioid Prescribing in Older Adults. During the webinar, a few of our dedicated workgroup members will speak about the unique challenges of prescribing opioids for an older population, the Bree's recommendations for improving pain management and patient outcomes, and how members of our health ecosystem, like health delivery sites and health plans, can utilize the document to enact change. December 7, 2022 12-1pm. Register here.

Northwest ATTC Webinar: Beyond Clean Needles: How Peers Talk About Harm Reduction.  Harm reduction for opioids, heroin, meth, alcohol, benzos and beyond will be covered in this course as will the techniques and approaches to have a trauma informed conversation to let the people we serve know that their lives matter. December 14, 2022 12-1pm. Register here.

RESOURCES:

Center for Health Care Strategies (Oct. 2022). Words Matter: Strategies to Reduce Bias in Electronic Health Records. Download the tool here.

 

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Pharmacy Updates

2022/2023 Synagis Season

The Health Care Authority and Managed Care Organizations (MCOs) have updated the 2022/2023 Synagis Season to allow a total of five (5) doses between October 15, 2022 and April 30, 2023.

For Synagis coverage Criteria, please see https://www.coordinatedcarehealth.com/providers/pharmacy/rsv-synagis-season.html.

For questions, please call 1-877-644-4613.

January 1, 2023 Preferred Drug List Changes 

Effective January 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 January 1, 2023. For more information, please contact the HCA at 800-562-3022.

  • Pyrimethamine (Daraprim)       
  • Pyrimethamine (Pyrimethamine) 
  • Teduglutide (RDNA) (Gattex)         
  • Pegloticase (Krystexxa)   
  • Eliglustat Tartrate (Cerdelga)  
  • Imiglucerase (Cerezyme)    
  • Taliglucerase Alfa (Elelyso)  
  • Miglustat (Miglustat)         
  • Velaglucerase Alfa (Vpriv)   
  • Miglustat (Zavesca)   
  • Pegzilarginase (AEB1102)   
  • Etranacogene Dezaparvovec (AMT-061)   
  • Lecanemab (BAN2401)            
  • Copper Histidinate (CUTX-101) 
  • Donanemab (Donanemab)    
  • Olipudase Alfa-RPCP (Xenpozyme)  
  • Olipudase Alfa (GZ402665)
  • Bulevirtide (Myrcludex B)
  • Omaveloxolone (Omav)
  • Teplizumab (PRV-031)
  • Vamorolone (VBP15)
  • Efgartigimod Alfa-FCAB (Vyvgart)   
  • Sipuleucel-T (Provenge)      
  • Ibalizumab-Uiyk (Trogarzo)
  • Enfuvirtide (Fuzeon)
  • Zidovudine (Retrovir IV Infusion)
  • Cabotegravir (Apretude)
  • Cabotegravir & Rilpivirine (Cabenuva)     

February 1, 2023 Medical Code Changes

Effective February 1, 2023 the following codes for Apple Health (Medicaid) will be updated to the following:

Add Prior Authorization for All Providers

 

 

Brand Name

Generic Name

J-Code

Aranesp

Darbepoetin alfa

J0882

Epogen/Procrit

Epoetin alfa

Q4081

Epogen/Procrit

Epoetin alfa

J0885

Injectafer

Ferric carboxymaltose

J1439

 

Remove Prior Authorization for Non-Participating Providers

 

Generic Name

J-Code

Iron Sucrose

J1756

Sodium Ferric Gluconate

J2916

inj iron dextran

J1750

injection iron sucrose

J1756

inj sodim ferric gluconate

J2916

inj dexmethoson sodim phoshate

J1100

inj ondansetron hcl

J2405

fosaprepitant inj

J1453

inj palonosetron hcl

J2469

methotrexate sodium

J9250

methotrexate sodium

J9260

inj leucovorin calcium

J0640

inj hydralazine hcl

J0360

atropine sulfate inj

J0461

inj baclofen intrathecal trial

J0476

peng benzathine/procaine inj

J0558

inj bivalirudin

J0583

injection caspofungin acetate

J0637

inj morphine pf epid ithc

J2274

inj linezolid

J2020

inj dihydroergotamine mesylate

J1110

inj mepivacaine hcl

J0670

ins clonidine hydrochloride

J0735

inj ampicillin

J0290

inj azithromycin

J0456

levetiracetam injection

J1953

inj methylergonovine maleate

J2210

milrinone lactate

J2260

inj orphenadrine

J2360

inj neostigmine methylsulfate

J2710

inj protamine sulfate

J2720

inj methocarbamol

J2800

inj diazepam

J3360

infusion normal saline solution

J7030

5% dextrose/normal saline

J7042

5% dextrose/water

J7060

infusion d5w

J7070

albuterol

J7611

albuterol

J7620

ipratropium bromide

J7644

inj vitamin b-12 cyanocobalamin

J3420

dexamethasone oral 0.25 mg

J8540

inj droperidol

J1790

inj methylprednisolone sodium succinate

J2920

inj promethazine hcl

J2550

inj phytonadione (vit k)

J3430

inj pantoprazole sodium

C9113

inj thiamine hcl

J3411

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