October 2023 Provider News
Date: 10/27/23
In this issue:
- General Updates - Joint MCO Live Training Sessions for Apple Health (Medicaid) Providers, Home Health Care Services (HHCS) Electronic Visit Verification (EVV) guidelines, COVID-19 vaccines, Smoking & Tobacco Cessation, Annual CAHPS Survey, Important Pharmacy Claims Processing Change
- Quality - Medicaid: Breast Cancer Screening, Clinical Practice Guidelines Medicare: Flu season
- Clinical Policy - Monthly updates
- Wellcare - Pharmacy Claims Processing Change, Medical Clinical Policy Updates, Special Needs Plan Model of Care Training
- Apple Health Core Connections - HB 1227 - How the "Keeping Families Together Act" impacts providers, COVID Vaccination Update for Youth
- Training/Education - Strengthening Families Program 10-14 New Facilitator Training, Common Pediatric Hand Problems, Strengthening Families Conference, School-Based Training for Mental Health Professionals
______________________________________________________________________________________
General Updates
Joint MCO Live Training Sessions for Apple Health (Medicaid) Providers
Washington’s Managed Care Organizations (MCOs) request your participation in 2023 joint Apple Health Integrated Managed Care (IMC) & Medicare Advantage Provider Training. You will hear from Amerigroup, Community Health Plan of Washington, Coordinated Care of Washington, Inc., Molina Healthcare of Washington, and United Healthcare about this training.
Joining one of the training sessions will satisfy your annual attendance requirement under 42 CFR 438.608(a)(1)iv.
Who: Providers servicing Medicaid and Medicare enrollees.
What is Covered:
- Enrollee Rights & Responsibilities
- Advanced Directives
- Fraud, Waste and Abuse
- False Claims Act
- Cultural Awareness
Where: Webinar. To register, please use the date specific links below.
When: Please register for one of the below training sessions.
Date | Session | Time | Zoom Link |
Tuesday, November 7, 2023 | Session 4 | 10:00 AM | |
Wednesday, November 8, 2023 | Session 5 | 11:00 AM | |
Thursday, November 9, 2023 | Session 6 | 12:00 PM | |
**Tuesday, November 7, 2023 | Session 7 | 5:30 PM | |
**Wednesday, November 8, 2023 | Session 8 | 3:00 PM | |
**Thursday, November 9, 2023 | Session 9 | 7:00 AM |
**We heard you and added times that may be more convenient for attendees!
After the training, you will be asked to complete a short survey, which confirms your participation and provides an opportunity to submit feedback on this presentation.
Home Health Care Services (HHCS) Electronic Visit Verification (EVV) guidelines
Who do the EVV HHCS requirements not apply to?
HCA decided that EVV HHCS requirements do not apply to Medicare crossover claims. For reference, see the Frequently Asked Questions updated September 2023 on HCA’s website.
As a reminder, EVV HHCS requirements do not apply to Private Duty Nursing (PDN) services performed by and billed by individuals or agencies. PDN services do not fall under intermittent home health care services. For reference, see the Private Duty Nursing for Children Billing Guide, page 8, here.
Note: The Department of Social and Health Services (DSHS) has implemented EVV for personal care services and respite care services. The EVV requirements for these services are found on DSHS’ Electronic Visit Verification website.
Is there a period of technical assistance for reject/denial of claims?
Yes. On September 29, 2023, HCA sent a provider alert stating that due to implementation challenges, HCA determined that claims and encounters without the EVV HHCS data elements will not be rejected or denied for service dates of January 1, 2024, or later. Instead, HCA will enter a period of technical assistance to ensure home health providers are able to provide the necessary data elements and continue to serve the Medicaid population.
HCA extends this same period of technical assistance to the enrollment of individual home health servicing providers with HCA.
What is the status of the EVV rules?
On September 21, 2023, HCA sent out a rulemaking notice for proposed rulemaking and notice of public hearing related to EVV HHCS. See HCA’s Upcoming public hearings website for more information.
For more information
Additional information can be found on the EVV HHCS website. Please send questions or concerns to HCA via the EVV HHCS email box: HCAEVVHomeHealth@hca.wa.gov.
COVID-19 vaccines are no longer federally purchased
Retroactive to dates of service on and after September 11, 2023, the Health Care Authority (HCA) reimburses for only the COVID-19 vaccine and administration codes listed in the following table. The table also indicates the fee schedule where the information for each COVID-19 vaccine and administration code is found.
CPT® code | Short Description | Physician-related/ professional services fee schedule | Professional administered drug fee schedule | Outpatient hospital fee schedule |
91318 | SARSCOV2 VAC |
| X | X |
91319 | SARSCV2 VAC |
| X | X |
91320 | SARSCVB2 VAC |
| X | X |
91321 | SARSCOV2 VAC |
| X | X |
91322 | SARSCOV2 VAC |
| X | X |
91304 | SARSCOV2 VAC 5MCG/0.5 ML IM |
| X | X |
90480* | ADMIN SARCOV2 | X |
| X |
M0201 | Covid-19 vaccine |
| X | X |
* Previously there were vaccine-specific administration codes. This is now the only vaccine administration code in non-home settings.
HCA will revise the Apple Health (Medicaid) COVID-19 vaccine clinical policy shortly. See HCA’s Provider billing guides and fee schedules here, under COVID-19, Policies, and billing guidance.
Fee Schedules
HCA’s fee schedules are located on HCA’s Billers and Provider’s web page, Professional Billing Guides/Fee Schedules here under Outpatient Hospital, Physician-related/professional services, or Professional administered drugs.
Smoking and Tobacco Cessation
Coordinated Care has Smoking and Tobacco Cessation programs with health coaches to provide support for our Apple Health (Medicaid) and Apple Health Core Connects foster care members who are ready to quit.
We accept referrals from our members and providers via phone or email:
- Washington Apple Health (Medicaid):
- Toll-Free: 1-866-274-5791 / E-mail: caremanagement@coordinatedcarehealth.com
- Apple Health Core Connections (Foster Care):
- Toll-Free: 1-844-882-3827 / E-mail: ahccteam@coordinatedcarehealth.com
We also offer the Puff Free Pregnancy program.
Start Smart for Your Baby - Case management and support for your member’s pregnancy includes smoking cessation assistance.
- Toll-Free: 1-877-644-4613 (TTY: 711)
- E-mail: WASSFB@centene.com
- Visit: www.coordinatedcarehealth.com/benefits
Tobacco Cessation/Smoking Deterrent medications are outlined on Pages 162 and 163 of the Preferred Drug List.
Annual CAHPS Survey
Happening February through June
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 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. These results from the Provider Satisfaction Survey are key to helping us improve your experience, so please be sure to complete the survey if you receive one.
Our provider website contains essential information, including member surveys, health equity resources, language services and resources, provider credentialing rights, the utilization management process, how to access care management services and other sources of support for you. Read more now.
If you have additional questions or need specific support, call Provider Services at 1-877-644-4613.
Important Pharmacy Claims Processing Change, Effective January 1, 2024
We are pleased to announce that, effective January 1, 2024, Express Scripts® will begin processing pharmacy claims for our plan members.
Express Scripts is a pharmacy benefit management (PBM) company serving more than 100 million Americans. Express Scripts Pharmacy delivers specialized care that puts patients first through a smarter approach to pharmacy services.
Members have been notified in advance and will receive a new ID card with updated pharmacy information, so that they are prepared to begin having their prescriptions filled at participating network pharmacies when this change occurs.
Providers can direct members to call the Member Services phone number listed on their ID card should they have questions about this change.
Please contact your Provider Relations Representative with any additional questions.
Thank you for the care you provide to our members.
______________________________________________________________________________________
Quality
Medicaid Quality
Breast Cancer Screening
Does your patient have any of these risk factors? They may need to be assessed for early onset Breast Cancer:
- Thoracic radiation between ages 10 and 30
- Lobular carcinoma in situ or atypical hyperplasia
- Breast or ovarian cancer
CDC’s Breast cancer screening guidelines for women
Clinical Practice Guidelines
The following Practice Guidelines on the Provider Website have been updated:
- Osteoporosis
- Weight Management
- Anxiety Disorders
- Depressive Disorders
- Management of Substance Use Disorders
- Post Traumatic Stress Disorder and Acute Stress Disorder
- Suicidal Behavior
Medicare Quality
Flu season
Preventing Seasonal Flu
The flu vaccine has been shown to reduce flu related illnesses and the risk of serious flu complications that can result in hospitalization or even death. The CDC also recommends everyday preventative actions to help slow the spread of germs that cause respiratory illnesses, like flu. More information can be found here.
Portal features: Do you need a form?
There are many resources available to providers from the WellCare home page especially if you’re looking for a form.
Under the Provider dropdown menu, select forms under the Medicare section.
Once in the forms section, providers have access to dozens of PDF forms for disputes, reconsiderations and grievances, authorizations, behavioral health forms, claims, medical records, pharmacy, and other provider forms.
______________________________________________________________________________________
Payment & Clinical Policy
Clinical Policy Updates
Musculoskeletal Services
Effective February 1, 2024, musculoskeletal service prior authorization will transition from TurningPoint to National Imaging Associates, Inc. (NIA). NIA policies and the codes requiring Prior Authorization are noted below. Please check the Prior Authorization tool on our provider website for the most current information.
| Policy Title | Codes Requiring PA for Participating Providers |
|---|---|
NIA - Cervical Spine Surgery | 22548, 22551, 22552, 22554, 22590, 22595, 22600, 22614, 22856, 22858, 22861, 22864, 63001, 63015, 63020, 63040, 63045, 63050, 63051, 63075 |
| NIA - Hip Arthroplasty | 27130, 27132, 27134, 27137, 27138 |
| NIA - Hip Arthroscopy | 29860-29863, 29914-29916 |
| NIA - Hip Resurface | S2118 |
| NIA - Knee Arthroplasty | 27438, 27446, 27447, 27486, 27487 |
| NIA - Knee Arthroscopy | 27332, 27333, 27403, 27405, 27407, 27409, 27412, 27415, 27416, 27418, 27420, 27422, 27424, 27425, 27427-27429, 27570, 29866-29868, 29870, 29873-29877, 29879, 29880-29889, G0289 |
| NIA - Lumbar Artificial Disc Replacement | 22857, 22860, 22862, 22865, 0164T, 0165T |
| NIA - Lumbar Spine Surgery | 22533, 22558, 22612, 22614, 22630, 22633, 62380, 63005, 63012, 63017, 63030, 63042, 63047, 63056 |
| NIA - Sacroiliac Joint Fusion | 27279 |
| NIA - Shoulder Arthroplasty | 23470, 23472-23474 |
| NIA - Shoulder Arthroscopy | 23120, 23125, 23130, 23405, 23410, 23412, 23415, 23420, 23430, 23450, 23455, 23460, 23462, 23465, 23466, 23700, 29805-29807, 29819, 29820-29828 |
You will find the policies on the NIA website. A link is available under “provider resources” on CoordinatedCareHealth.com.
Monthly Updates
The below clinical policies received updates as part of our regular monthly review in August. These policy changes are effective November 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 |
| CP.MP.100 | Allergy Testing and Therapy | Apple Health |
| CP.MP.156 | Cardiac Biomarker Testing | Apple Health & Ambetter |
| CP.MP.105 | Digital EEG Spike Analysis | Apple Health & Ambetter |
| CP.MP.155 | EEG in the Evaluation of Headache | Apple Health & Ambetter |
| CP.MP.134 | Evoked Potential Testing | Apple Health & Ambetter |
| CP.MP.153 | Helicobacter Pylori Serology Testing | Apple Health & Ambetter |
| CP.MP.113 | Holter Monitors | Apple Health & Ambetter |
| CP.MP.102 | Pancreas Transplantation | Apple Health & Ambetter |
| CP.MP.146 | Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Venous Disorders | Ambetter |
| CP.MP.154 | Thyroid Hormones and Insulin Testing in Pediatrics | Apple Health & Ambetter |
| WA.CP.MP.38 | Ultrasound in Pregnancy | Ambetter |
| CP.MP.143 | Wireless Motility Capsule | Ambetter |
The below policy was previously announced as revised 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.129 | Fetal Surgery in Utero for Prenatally Diagnosed Malformations | 12/1/23 | Apple Health & Ambetter |
______________________________________________________________________________________
Wellcare
Important Pharmacy Claims Processing Change, Effective January 1, 2024
We are pleased to announce that effective January 1, 2024, Express Scripts® will begin processing pharmacy claims for our plan members.
Express Scripts is a pharmacy benefit management (PBM) company serving more than 100 million Americans. Express Scripts Pharmacy® delivers specialized care that puts patients first through a smarter approach to pharmacy services.
Members have been notified in advance and will receive a new ID card with updated pharmacy information, so they are prepared to begin having their prescriptions filled at participating network pharmacies when this change occurs.
Providers can direct members to call the Member Services phone number listed on their ID card should they have questions about this change.
Please contact your Provider Relations Representative with any additional questions.
Thank you for the care you provide to our members.
Medical Clinical Policy Updates
The following Medicare Clinical Policies contain changes to their previous versions, have been approved for use by Medicare QIC and will be effective January 1, 2024:
- MC.CP.MP.22 Stereotactic Body Radiation Therapy
- MC.CP.MP.57 Lung Transplantation
- MC.CP.MP.69 Intensity-Modulated Radiotherapy
- MC.CP.MP.101 Donor Lymphocyte Infusion
- MC.CP.MP.106 Endometrial Ablation
- MC.CP.MP.108 Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-thalassemia
- MC.CP.MP.160 Wireless Pulmonary Artery Monitoring
- MC.CP.MP.170 Peripheral Nerve Blocks
- MC.CP.MP.182 Short Inpatient Stay
- CP.PP.206 Skilled Nursing Facility Leveling
- MC.CP.MP.246 Pediatric Kidney Transplantation
- V2.2023 Concert Genetics Oncology Algorithmic Testing
- V2.2023 Concert Genetics Genetic Testing Aortopathies and Connective Tissue Disorders
- V2.2023 Concert Genetics Genetic Testing Cardiac Disorders
- V2.2023 Concert Genetics Oncology Cancer Screening
- V2.2023 Concert Genetics Oncology Circulating Tumor DNA and Circulating Tumor Cells Liquid Biopsy
- V2.2023 Concert Genetics Oncology Cytogenetic Testing
- V2.2023 Concert Genetics Genetic Testing Dermatologic Conditions
- V2.2023 Concert Genetics Genetic Testing Epilepsy, Neurodegenerative, and Neuromuscular Conditions
- V2.2023 Concert Genetics Genetic Testing Exome and Genome Sequencing for the Diagnosis of Genetic Disorders
- V2.2023 Concert Genetics Genetic Testing Eye Disorders
- V2.2023 Concert Genetics Genetic Testing Gastroenterologic Disorders (non-cancerous)
- V2.2023 Concert Genetics Genetic Testing General Approach to Genetic Testing
- V2.2023 Concert Genetics Genetic Testing Hearing Loss
- V2.2023 Concert Genetics Genetic Testing Hematologic Condition (non-cancerous)
- V2.2023 Concert Genetics Genetic Testing Hereditary Cancer Susceptibility
- V2.2023 Concert Genetics Genetic Testing Immune, Autoimmune, and Rheumatoid Disorders
- V2.2023 Concert Genetics Genetic Testing Kidney Disorders
- V2.2023 Concert Genetics Genetic Testing Lung Disorders
- V2.2023 Concert Genetics Oncology Molecular Analysis of Solid Tumors and Hematologic Malignancies
- V2.2023 Concert Genetics Genetic Testing Metabolic, Endocrine, and Mitochondrial Disorders
- V2.2023 Concert Genetics Genetic Testing Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay
- V2.2023 Concert Genetics Genetic Testing Non-Invasive Prenatal Screening (NIPS)
- V2.2023 Concert Genetics Genetic Testing Pharmacogenetics
- V2.2023 Concert Genetics Genetic Testing Preimplantation Genetic Testing
- V2.2023 Concert Genetics Genetic Testing Prenatal and Preconception Carrier Screening
- V2.2023 Concert Genetics Genetic Testing Prenatal Diagnosis via Amniocentesis, CVS or PUBS and Pregnancy Loss
- V2.2023 Concert Genetics Genetic Testing Skeletal Dysplasia and Rare Bone Disorders
Click here for more details and for Policies Retired for Medicare.
Special Needs Plan Model of Care (MOC) Training
The Centers for Medicare & Medicaid Services (CMS) requires health plans to provide annual education and training on Wellcare’s Model of Care to providers who treat our Special Needs Plan (SNP) members. This applies to our Dual Eligible Special Needs Plan (D-SNP) members, who are eligible for both Medicare and Medicaid, and our Chronic Condition Special Needs Plan (C-SNP) members, who have one or more qualifying conditions.
As stated in the Provider Manual, all providers who treat SNP members must complete Wellcare’s Model of Care training. The annually updated training is available for download and self-study at: https://www.wellcare.com/providers/model-of-care-training.
We appreciate the quality care you provide to our members and your support of our efforts to meet CMS regulations.
For additional information on how to work with our health plan to manage SNP members, please visit your state's provider Overview & Resources page. This site has links to the Provider Manual, Quick Reference Guides, Clinical Practice Guidelines, and more.
______________________________________________________________________________________
Apple Health Core Connections
Keeping Families Together Act – HB 1227
On July 1, the “Keeping Families Together Act” went into effect. There are three main changes to be aware of:
- The legal standard for child removal has been raised such that children and parents should not be separated unless there is “imminent physical harm…which outweighs the harms of removal.”
- When children are removed from home, the State must prioritize placement with relatives or suitable other persons and demonstrate why placement in a licensed foster care home is needed.
- This new legislation requires the State to actively engage parents in scheduling and participating in health appointments whenever possible.
What does this mean for providers?
- There has been a statewide decrease of children entering foster care and an increase in acuity of physical harm for youth entering the system.
- You may begin interacting more with parents of children involved with the child welfare system. They may be attending Initial Health Screens (IHS) and EPSDTs along with caregivers, during which time the trauma of family separation may present itself. Providers are asked to prioritize the right of parents to be in the room during examination, which may look like having a caregiver step out and/or having separate conversations with parents and caregivers at appointments to ease potential tension and anxiety.
- There may be an increase of in-home dependencies, during which parents are solely responsible for getting their child(ren) to their Initial Health Screen and EPSDTs.
- Please contact the child’s DCYF caseworker if a child misses their scheduled IHS or EPSDT and their parent or caregiver has not contacted your office to reschedule.
Click here for more information about the Keeping Families Together Act, or contact AHCC Operations Manager, Katie Ferguson at her email: Katherine.Ferguson@coordinatedcarehealth.com or phone number (206) 514-1181.
COVID Vaccination Update
The Centers for Disease Control and Prevention recommends the updated 2023-2024 COVID-19 vaccine for everyone ages 6 months and over. Read more on the Department of Health’s Vaccinating Youth webpage.
______________________________________________________________________________________
Training/Education
Strengthening Families Program 10-14 New Facilitator Training (In-Person): This training will be in-person and is for SFP 10-14 new facilitators who will be working in a team of three to deliver the evidence-based prevention program to families in their local communities. November 15-17, 2024. Register here.
Common Pediatric Hand Problems: Yours, Mine, Ours: Seattle Children’s Physician Relations invites you to attend this virtual Category II CME event to learn more about common pediatric hand problems and how we can work together to treat them. November 8, 2024. Register here.
Strengthening Families Conference: This conference provides an opportunity to discover the latest research, best practices and tools for parents, kinship and foster caregivers, early childhood, home visiting, family support and other human service professionals. November 3, 2024. Register here.
School-Based Training for Mental Health Professionals: Free web-based training for school counselors, social workers, psychologists, school-based therapists, administrators, and other professionals. The training helps address the complex mental health and developmental needs of students experiencing adoption, foster care, or kinship care. Learn more.