November 2022 Provider News
Date: 11/30/22
In this issue:
- General Updates - Mental Health EBP Reporting for Behavioral Health Providers, Surge in Pediatric Respiratory Virus Cases, HB 1860
- Quality - Influenza Vaccine, Well Child Visits, NCQA Notification
- Billing - ER Leveling Policy Retired
- Tribal - Native American Heritage Month
- Prior Authorization - Updates
- Clinical & Payment Policies - Monthly Updates
- Apple Health Core Connections - TF-CBT Training March 22-23, 2023
- Training/Education - Centene’s Clinical Provider Training, Opioid Prescribing in Older Adults, Beyond Clean Needles: How Peers Talk About Harm Reduction.
- Pharmacy Updates - 2022/2023 Synagis Season, January 1, 2023 Preferred Drug List changes, and February medical code changes
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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.
| Codes | Description |
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 Number | Policy Title | Line of Business |
CP.MP.108 | Allogenic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia | Apple Health & Ambetter |
| CP.MP.31 | Cosmetic and Reconstructive Procedures | Apple Health & Ambetter |
| CP.MP.101 | Donor Lymphocyte Infusion | Apple Health & Ambetter |
| WA.CP.MP.50 | Drugs of Abuse: Definitive Testing | Apple Health |
| CP.MP.50 | Drugs of Abuse: Definitive Testing | Ambetter |
| CP.MP.109 | Panniculectomy | Apple Health & Ambetter |
| CP.MP.127 | Total Artificial Heart | Apple Health & Ambetter |
| WA.CP.MP.185 | Skin Substitutes for Chronic Wounds | Apple Health |
| CP.MP.185 | Skin Substitutes for Chronic Wounds | Ambetter |
| WA.CP.MP.527 | Vitamin D Testing | Apple 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 Number | Policy Title | Line of Business | Line of Business |
CP.MP.202 | Orthognathic Surgery | 3/1/23 | Apple Health & Ambetter |
| CP.MP.150 | Phototherapy for Neonatal Hyperbilirubinemia (formerly Home Phototherapy) | 3/1/23 | Apple Health & Ambetter |
| CP.MP.61 | IV Moderate Sedation, IV Deep Sedation and General Anesthesia for Dental Procedures (formerly Dental Anesthesia) | 3/1/23 | Ambetter |
Reminders:
| Policy Number | Policy Title | Line of Business | Line of Business |
CP.MP.246 | Pediatriac Kidney Transplant | 2/1/23 | Apple Health & Ambetter |
| WA.CP.MP.117 | Percutaneous Electrical and Peripheral Nerve Stimulation | 2/1/23 | Apple Health & Ambetter |
| CP.MP.242 | Pulmonary Function Testing | 2/1/23 | Apple 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 |