April 2023 Provider News
Date: 04/28/23
In this issue:
- General Updates - Inpatient Concurrent Review, Changes to Post-Acute Review Process, Hepatitis C, Evidence Based Best Practices, Correction from March Faxblast: FQHC Pay Class Changes, Changes to Inpatient NICU Review Process, Redetermination Webinar
- Quality - Medicaid: Postpartum/Newborn Visits, Lead Screening, Telehealth, Wellcare: National Minority Health Month, Updated Coverage to Care Resources, National Stress Awareness Month, Teladoc Mental Health
- Tribal - Payment Recoupment and Reconciliation FAQs
- Payment & Clinical Policy - Interventional Pain Management, April Updates
- Pharmacy Updates - 2023 March and April Preferred Drug List (PDL)
- Wellcare - Medicaid Redetermination
- Apple Health Core Connections - SCH Gender Clinic Mental Health Care Consult
- Training/Education - Social Media and Risky Behavior Among Adolescents, Examining the Complexities of REL Data Webinar, 2023 Washington Behavioral Healthcare Conference
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General Updates
Inpatient Concurrent Review
Coordinated Care will be making process changes to our Inpatient Concurrent Review process effective 7/1/23. These changes are designed to 1) increase process standardization across the Centene family of plans to improve operational efficiency and pave the way for increased use of process automation afforded by advances in technology and interoperability standards, and 2) provide continued support to our members through discharge.
The changes will be in three primary areas:
- Timing of authorizations: As of 7/1/23, IP reviews and authorization decisions will focus on a prospective approach.
- Length of authorizations:
- For facilities with a DRG based payment structure, when the clinical information supports medical necessity, initial authorization will be for 7 calendar days and subsequent authorizations up to 7 days
- For facilities with a per diem-based payment structure, authorization length will be based on member clinical acuity
- Monitoring of admissions through discharge to support transition planning: we will continue to monitor members even when they no longer meet acute care criteria through clinical records review and coordination with discharge planning teams. If a member’s clinical status changes and IP acute care criteria are again met, we will send notification of approval and continue concurrent reviews.
Discharge Needs:
We will continue to partner with our facilities on discharge planning, transition management, and coordination of post-acute care needs to enable a safe and timely discharge. Our Complex Discharge Planning team will continue to support members with complex needs.
For additional questions, please contact your Provider Engagement representative.
Changes to Post-Acute Review Process
Coordinated Care will be making process changes to our Post-Acute Review process effective 8/1/23. These changes are designed to 1) increase process standardization across the Centene family of plans to improve operational efficiency and pave the way for increased use of process automation afforded by advances in technology and interoperability standards, and 2) provide continued support to our members through discharge.
The changes will be in two primary areas:
1) Length of authorizations: When the clinical information supports medical necessity, initial authorization will be for 7 calendar days and subsequent authorizations up to 7 calendar days for skilled nursing facilities, inpatient rehabilitation units and long-term acute care hospitals stays.
2) If the member does not admit within 72 hours of the initial request, an additional review will be completed prior to transfer.
Discharge Needs:
We will continue to partner with our facilities on discharge planning, transition management, and coordination of the individual’s needs to enable a safe and timely discharge. Our Complex Discharge Planning team will continue to support members with complex needs.
For additional questions, please contact your Provider Engagement representative.
Hepatitis C
Our provider partners are a key stakeholder in the fight to eliminate Hepatitis C in our state!
Coordinated Care would like to remind you that:
- Anti-viral MAVYRET can cure Hepatitis C. These daily pills are typically dispensed from a pharmacy in 4-week intervals at a time.
- CDC recommends that all adults 18 years and older be screened for Hep C at least once, as well as pregnant women during each pregnancy.
- Injection drug use is the primary risk for Hepatitis C. Any person requesting HCV screening should receive it.
- Treatment is not approved for children under 3 at this time, but children should be monitored.
- Patients who have certain liver problems or are taking medicines (atazanavir or rifampin) are not eligible to take MAVYRET.
- Anti-Viral MAVYRET medication is fully covered and does not require prior authorization (PA). Other anti-viral medications will require review and be approved only if Mavyret is not clinically appropriate.
- Anyone licensed to prescribe direct acting anti-viral medications is allowed to screen and treat Apple Health members, including primary care doctors and pharmacists.
- Find providers in your area who have prescribed Mayvret.
Members can be referred to Care Management for assistance with member needs, connection to care, and adherence support through our toll-free customer service number: 1-888-982-7618, option 1 or caremanagement@coordinatedcarehealth.com.
Learn more at:
- Eliminating Hepatitis C | Washington State Health Care Authority
- Eliminating Hepatitis C | Washington State Department of Health
Evidence Based Practices
Coordinated Care would like to remind you that providers who deliver Children’s Mental Health Evidence Based Practices to clients under age 18 should include the appropriate SERI code for mental health providers. Coordinated Care is required by law to track and report to HCA quarterly all children’s mental health visits and how many of these visits were billed as an Evidence Based Practice. Billing correctly helps Coordinated Care to be able to refer new clients to you for Evidence Based Practices.
The utilization of EBP codes does not impact payment of your claims. Coordinated Care will not deny any claims due to EBP code utilization.
Please reach out to your Provider Engagement Administrator if you have any questions/concerns.
FQHC Pay Class Changes
Last month we reported that the following FQHC pay class changes were applicable to Medicaid. That was incorrect. The following language is pertaining to our Ambetter/Marketplace plans:
Please be advised of upcoming Marketplace FQHC pay class changes.
Encounters:
- Must be billed with one of these revenue codes: "521", "522", "524", "525", "527", "528", "519", "900"
- And one of these HCPCS: "G0466", "G0467", "G0468", "G0469", "G0470", "G0511", "G0512"
- Must be billed on a UB04
Non-Encounters (adjunct codes):
- Must be billed on a HCFA 1500
Apologies for any confusion this caused with you and your teams. Please reach out to your Provider Engagement Administrator if you have any questions/concerns.
Changes to Inpatient NICU Review Process
Coordinated Care of WA will be making process changes to our Inpatient NICU Review process effective 7/1/23. These changes are designed to 1) increase process standardization across the Centene family of plans to improve operational efficiency and pave the way for increased use of process automation afforded by advances in technology and interoperability standards, and 2) provide continued to support our members through discharge.
For baby less than 32 weeks - can approve up to 7 calendar days (max) → 31 weeks and 6/7 days or less
- Babies under 32 weeks are not realistically close to discharging home
- Improvement is slow but consistent
For 32 weeks and greater - can approve up to 5 calendar days (max) → 32 weeks and 0/7 days or greater
- Babies 32 weeks and over are expected to begin improving at a faster rate and are nearing their discharge date
- Review more often to assess for any changes and all discharge needs as their discharge date approaches
Coordinated Care is proud to announce the next installment in our Lunch and Learn Series!
Apple Health Redetermination Overview Webinar – Tuesday, May 23rd, at Noon
This webinar will cover the following topics:
- What is Redetermination?
- Coordinated Care’s action plan
- HCA and HBE information
- Partnership Opportunities
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Quality
Medicaid Quality
Postpartum/Newborn Visits
When scheduling Postpartum and Newborn visits, it is helpful to combine or make concurrent visits. This can be beneficial in making sure mom is taking care of herself as well as her newborn. Taking every opportunity to ensure mom’s recovery outcome is healthy will benefit both mom and baby.
CMS Blood Lead Testing Mandate - Lead Screening
Did you know federal law mandates testing for all children covered by Medicaid? Completion of risk assessment questionnaire does not meet the Medicaid requirement and all children enrolled in Medicaid are required to receive blood lead screening test at ages 12 months and 24 months.
Telehealth
By increasing access to physicians and specialists, telehealth helps ensure patients receive the right care, at the right place, at the right time.
Telehealth for Providers: What You Need to Know
Wellcare Quality
National Minority Health Month (NMHM)
April is a time to raise awareness about the importance of improving the health of racial and ethnic minority communities and reducing health disparities.
The origin of National Minority Health Month was initially the establishment of National Negro Health Week by Booker T. Washington in 1915. In 2002, U.S. Congress recognized with a concurrent resolution (H. Con. Res. 388) that “a National Minority Health and Health Disparities Month should be established to promote educational efforts on the health problems currently facing minorities and other health disparity populations.” The resolution encouraged “all health organizations and Americans to conduct appropriate programs and activities to promote healthfulness in minority and other health disparity communities.”
The 2023 NMHM theme is Better Health Through Better Understanding. The National Institute of Health (NIH), and the Office of Minority Health (OMH) partnered to share resources to address health literacy, language access, and more. Health and Human Services (HHS) estimates that only 14% of the US population has proficient health literacy and nearly 20% of people in the US speak another language other than English at home. Additionally, it is estimated that over 60% of racial and ethnic minority patients who are 18 years old or older believe it is somewhat important to have health care providers who share or understand their culture.
A couple of ways providers can participate this year are to:
- Encourage patients to make the most of their health coverage to live a long, healthy life by encouraging action through health education, early detection, and control of disease complications.
- Build awareness about the disproportionate burden of premature death and illness in people from racial and ethnic minority groups by talking with patients about the importance of preventive care and recommend appropriate Medicare-covered preventive services.
CMS offers health equity technical assistance (https://www.cms.gov/about-cms/agency-information/omh/health-equity-programs/health-equity-technical-assistance) to help address health disparities. The program offers help with developing a language access plan, personalized coaching, additional resources, and data collection/analyses.
Additionally, Medicare covers preventive services, and generally, your patients pay nothing if you the provider, accept assignment. This six-page reference tool will help you find out when your patient is eligible for services. If you need additional help, you can contact your eligibility service provider.
Coverage to Care (C2C) is an initiative, developed by the Centers for Medicare & Medicaid Services, to provide help to understand health coverage and connect to primary care and preventive services that are right for each person. CMS recognizes that understanding health insurance can be overwhelming and confusing for those persons eligible for services.
Updated Coverage to Care Resources are Now Available
Coverage to Care has released newly updated resources to help those served by CMS understand their health coverage and get health care services they need. Updated resources include Roadmap to Better Care, Roadmap to Behavioral Health, Prevention Flyers, and more. These updated materials are available in both English and Spanish. Additional languages will be made available soon.
Think Cultural Health
This is an OMH initiative that provides health and health care professionals with information, continuing education opportunities, and resources to learn about and implement CLAS and the National CLAS Standards.
E-Learning Programs
Culturally and Linguistically Appropriate Services (CLAS)
Through the Think Cultural Health website, OMH offers free, accredited online educational programs tailored for a variety of health care professionals, including physicians; nurses; oral health, maternal health, and behavioral health providers; disaster and emergency management personnel; and community health workers/promotores(as) de salud. Each e-learning program is designed to build knowledge, skills, and awareness of cultural and linguistic competency and CLAS as a way to improve quality of care.
CLAS are services that are respectful of and responsive to the culture, health beliefs, practices, and needs of diverse patients. CLAS is offered to improve the quality of services provided to all individuals, which will ultimately help reduce health disparities and achieve health equity.
National CLAS Standards
Office of Minority Health (OMH) developed the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care, also known as the National CLAS Standards, to advance health equity, improve quality of services, and help eliminate disparities.
The National CLAS Standards are a comprehensive set of 15 action steps that provide a blueprint for individuals and health and health care organizations to provide CLAS. To learn more about the National CLAS Standards, visit this webpage, which also offers a National CLAS Standards Implementation Checklist.
This Behavioral Health Implementation Guide
This guide underscores the ways in which the National CLAS Standards can improve access to behavioral health care, promote quality behavioral health programs and practices, and ultimately reduce persistent disparities in mental health and substance use treatment for underserved minority communities.
National Stress Awareness Month
April is also National Stress Awareness Month. Mental health can positively or negatively impact your physical health and risk factors for heart disease and stroke, according to “Psychological Health, Well-Being, and the Mind-Heart-Body Connection,” a scientific statement in the American Heart Association Journal Circulation. The National Institutes of Health (NIH) know it’s critical for people to recognize what stress and anxiety look like and to offer resources to obtain help. A stress screener tool can be found here (https://mhanational.org/get-involved/stress-screener) and the NIH encourages visiting the CDC website that offers strategies for stress management.
Stress may contribute to poor health behaviors linked to increased risk for heart disease and stroke, such as:
- Smoking
- Overeating
- Lack of physical activity
- Unhealthy diet
- Being overweight
- Not taking medications as prescribed
Additional resources from the NIH to help mitigate the effects of stress on all Americans are listed below:
- Wellness @NIH
- Helpful Practices to Manage Stress and Anxiety (NIMH)
- So Stressed Out Fact Sheet (NIMH)
- Stress (NCCIH)
Teladoc Mental Health
Healthcare and medical advice by phone, video or app | Teladoc Health®
Your Centene health plan gives you 24/7 access to virtual care by U.S. board-certified providers
Teladoc Mental Health gives Medicare members access to licensed therapists and psychiatrists by phone or video to help with sleep, depression, anxiety, etc. at no cost to the member. The member flyer to promote the program will be mailed by Teladoc in Q2. To find a therapist, members can download the Teladoc app or call 1-800-835-2362 TTY: 711; or visit the webpage.
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Tribal
Payment Recoupment and Reconciliation FAQs
During the April 2023 HCA Rapid Response call, Coordinated Care shared resources to help IHCP’s better understand the Medicaid and Marketplace recoupment process and how to reconcile these types of payments. Resources provided include:
- Recoupment FAQ
- Reconciliation FAQ
- Recovery Letter Example
- Negative Balance Report details
We encourage you to review these resources and keep them as tools for training and reference guides when you come across a payment with a recoupment listed. Please feel free to reach out to Carin Moritz at Carin.Moritz@coordinatedcarehealth.com for any questions related to these resources, obtain a copy of the resources or to request 1:1 training.
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Payment & Clinical Policy
Clinical Policy
Vendor Reminders and Updates:
Interventional Pain Management
Effective June 1, 2023, interventional pain management services will be reviewed by National Imaging Associates, Inc. (NIA) to determine if the services are medically necessary and covered under Coordinated Care health plans. You will find the policies on the NIA Website. A link is available under “provider resources” on CoordinatedCareHealth.com. Policy names are listed below.
Policy Number | Policy Title | Line of Business |
|---|---|---|
| NIA.CG.300 | Epidural Spine Injections | Apple Health & Ambetter |
| NIA.CG.301 | Facet Joint Injections | Apple Health & Ambetter |
| NIA.CG.302 | Facet Joint Denervation | Apple Health & Ambetter |
| NIA.CG.305 | Sacroiliac Join Injection | Apple Health & Ambetter |
CPT codes considered interventional pain management and addressed in the above policies are: 0213T-0218T, 0228T-0231T, G0260, 27096, 62320-62323, 64479, 64480, 64483, 64484, 64490-64495, 64633-64636. All these codes currently require prior authorization, but effective 6/1/23, authorization will be provided by NIA.
The below policies will be archived effective June 1, 2023. The policies will be replaced with NIA versions of the policies described above.
| Policy Number | Policy Title | Line of Business |
|---|---|---|
CP.MP.164 | Caudal or Interlaminar Epidural Steroid Injections for Pain Management | Apple Health & Ambetter |
| CP.MP.171 | Facet Joint Interventions for Pain Management | Ambetter |
| WA.CP.MP.171 | Facet Joint Interventions for Pain Management | Apple Health |
| CP.MP.166 | Sacroiliac Joint Interventions for Pain Management | Apple Health & Ambetter |
| CP.MP.165 | Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management | Apple Health & Ambetter |
Monthly Updates:
The below clinical policies received updates as part of our regular monthly review in April. These policy changes are effective May 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.520 | Tympanostomy Tubes in Children | Apple Health |
| WA.CP.MP.505 | Microprocessor Controlled Lower Limb Prosthetics | Apple Health |
| WA.CP.MP.517 | Testosterone Testing | Apple Health |
| WA.CP.MP.37 | Bariatric Surgery | Apple Health |
| CP.MP.106 | Endometrial ablation | Apple Health & Ambetter |
| CP.MP.110 | Bronchial Thermoplasty | Ambetter |
| CP.MP.121 | Homocysteine Testing | Apple Health & Ambetter |
| CP.MP.139 | Low-Frequency Ultrasound and Noncontact Normothermic Wound Therapy | Ambetter |
| CP.MP.242 | Pulmonary Function Testing | 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 new policy was previously announced effective on the dates noted. You will find the policy posted on the policy site.
| Policy Number | Policy Title | Effective Date | Line of Business |
|---|---|---|---|
CP.MP.247 | Transplant Service Documentation Requirements | 5/1/23 | Apple Health & Ambetter |
The below policies were previously announced as revised on the dates noted. You will find the policies posted on the policy site.
| Policy Number | Policy Title | Effective Date | Line of Business |
|---|---|---|---|
CP.MP.107 | Durable Medical Equipment (DME) and Orthotics and Prosthetics Guidelines | 5/1/23 | Apple Health & Ambetter |
| CP.BH.104 | Applied Behavior Analysis | 6/1/23 | Apple Health & Ambetter |
| CP.BH.200 | Transcranial Magnetic Stimulation for Treatment Resistant Major Depression | 6/1/23 | Apple Health & Ambetter |
| 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 & Ambetter |
| 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 |
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Pharmacy Updates
All Stimulant Claims Require an ADHD Diagnosis for Members 18 Years of Age and Older
Effective April 1, 2023, a prior authorization will be required for members 18 years and older for short and long-acting stimulants unless the member has a diagnosis of ADHD. If member has an ADHD diagnosis, please indicate on the prescription.
Effective March 31, 2023, the following medications will no longer be preferred.
| Effective Date | Drug Name | Potential Alternatives |
|---|---|---|
03/31/2023 | Lantus (Brand) | Insulin Glargine (Generic for Lantus) or Levemir |
| 03/31/2023 | Lantus Solostar (Brand) | Insulin Glargine Solostar (Generic for Lantus Solostar), Levemir Flextouch Solution Pen-Injector, or Levemir Flexpen |
| 03/31/2023 | Basaglar Kwikpen (Brand) and Basaglar Tempo Pen | Insulin Glargine Solution Pen-Injector (Generic for Basaglar Kwikpen), Levemir Flextouch Solution Pen-Injector, or Levemir Flexpen |
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Wellcare
Check the Provider News section of the WellCare website to refer to previous notices and review the Quarterly Provider Newsletter.
REMINDER
Medicaid Redetermination resumes soon and will impact Medicare Benefits for some patients. Please view the flyer below for more information.
Download the Wellcare Medicaid Redetermination flyer (PDF)
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Apple Health Core Connections
Seattle Children’s Gender Clinic – Gender Affirming Mental Health Care Consult Group
LGBTQIA+ youth are overrepresented in child welfare and may have unique care needs. The Coordinated Care Apple Health Core Connections Care Management and Operations teams are committed to supporting providers who serve these youth with information, consultation, and resources.
This month, we are highlighting the Seattle Children’s Gender Clinic Mental Health Care Consult Group. Use the QR code above or click here for the form to sign up to receive information.
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.”
Providers can reach us at 1-844-354-9876 or AHCCTeam@coordinatedcarehealth.com for referrals, trauma-informed care training, and consultations to better serve LGBTQIA+ youth in care.
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Training/Education
Social media and risky behavior among adolescents - Dr. Dana Litt, an expert on adolescent and young adult risk behavior, will guide attendees through an overview of the current state of the field as it pertains to social media and risky behavior among adolescents and young adults and present some of her own research findings May 10, 2023 12:00 PM Register Here.
Examining the Complexities of REL Data Webinar - Washington Health Alliance and Comagine 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 1, 2023 12:00 PM Register Here.
2023 WASHINGTON BEHAVIORAL HEALTHCARE CONFERENCE - The Washington Council for Behavioral Health. As we emerge from these difficult years, we also see promising signs of hope, recovery, and resiliency. There is unprecedented support and recognition of the need for expanded access to behavioral health care, including community-based treatment and peer support services. There is long overdue attention and growing momentum to address structural racism throughout our communities and institutions. June 15-16, 2023 Register here.