December 2023 Provider News
Date: 12/28/23
In this issue:
- General Updates - Tacoma Office Address Change, Key Benefit Changes, Pediatric Screening
- Quality - Youth Mental Health Access Community Project, New Medicare Approved Policies
- Tribal - Single Point of Contact
- Clinical & Payment Policies - Monthly updates
- Wellcare - Quick Reference Guide, Step Therapy Part B Drug List
- Apple Health Core Connections - Benefits Refresher: Providing Care to Children in Foster Care
- Training/Education - New Provider Orientation, CLAS Standards e-Learning Modules/Resources, Health Equity
- Pharmacy Updates - Pharmacy Claim Processing Change, Drugs Prescribed for Weight Loss
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General Updates
Tacoma Office Address Change
Please note – Coordinated Care of Washington, Inc. offices has a NEW suite number effective immediately. Updated address:
Coordinated Care
1145 Broadway, Suite 700
Tacoma, WA 98402
Key Benefit Changes to ALL Ambetter Plans: Ambetter Core Non-standard, Cascade Standard, Cascade Select Public Option – Effective 1/1/2024
- SB 5396: Supplemental breast examinations received from a par provider are covered at $0 member cost share
- SB 5242: Abortion services and any ancillary services related to an abortion received from a par or non-par provider are covered at $0 member cost share
- Ancillary services: 59840, 59841, 59850, 59851, 59852, 59855, 59856, 59857, 59870, S0190, S0191, S0199, S2260, S2265, S2266, S2267
- Prior Authorization Requirements: In-network does not require an authorization, but Out-of-network does requires an authorization
- HB 1357: Carrier response turnaround times were updated for non-electronic and electronic prior authorization requests
- Express Scripts to replace CVS as PBM
- Newly excluded services:
- Assertive Community Treatment (ACT)
- Adult Routine Vision (i.e. Adult Vision Buy-Up Benefits)
- Added clarification to excluded weight loss programs, gym memberships, exercise equipment or meal preparation programs
- Condoms – removed the 60 per month quantitative limit
- Prostate specific antigen test – updated eligibility guidelines to reflect current recommendation (average risk factors 50+; high risk factors 40-49)
- OBGYN care from a par provider does not require prior authorization – clarifying language added in EOC
- “Virtual 24/7 Care” terminology replaces “Ambetter Telehealth”
Cost Share Changes
- Cascade (Standard) and Cascade Select (Public Option):
- Bronze and Silver plans:
- $1 copay for 1st two PCP and 1st two BH visits
- Bronze and Silver plans:
- Gold plans:
- drug deductible now integrated with medical deductible
- Ambetter Core (Non-Standard) plans:
- new Generic Drug tier at $3 copay
- Tier 1a = Selected Generics $3
- Tier 1b = Generic
- new Generic Drug tier at $3 copay
Updated 2024 Service Encounter Reporting Instructions (SERI) are available
Follow-up to the October publication of the Service Encounter Reporting Instructions (SERI) - SERIv2024. Since the October publication, HCA found it necessary to update the Service Encounter Reporting Instructions and republish. The expected implementation of the changes in SERI remains January 1, 2024.
To see what changed please ensure to review the Summary of Changes Section at the end of the document, specifically the subsection entitled “post 10/02/2023 release changes.”
Provider Portal Enhancement: Configurable Provider Analytics Link in Useful Links
We are pleased to introduce an improvement to the Provider Landing Page – the Configurable Provider Analytics Link, now featured in the Useful Links section. Please see image below.
PT/OT/ST Prior Authorization Requirements
All PT/OT/ST PA requirements have been removed for Medicaid and Foster Care members 20 and under. Effective date was 8/1/2023.
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 Connections (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: coordinatedcarehealth.com
Pediatric Screen Survey
The Health Care Authority (HCA) is distributing a new survey for Apple Health (Medicaid) pediatric providers to better understand current pediatric screening and coding practices during well-child checkups.
This project is in partnership with the University of Washington and is administered by a Doctor of Nursing Practice (DNP) candidate and HCA. The results will be used to provide recommendations on actions to increase screening rates among pediatric providers and provide equal access to care for pediatric patients.
Pediatric screening survey, click here for survey
Time to complete: 10-15 minutes
Survey close date: Saturday, January 20
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Quality
Medicaid Quality
Fluoride
Dental cavities are the most chronic disease of childhood. When it occurs, several resources are needed to treat, it is costly, and if left untreated can lead to unnecessary pain and discomfort.
Click here for a resource to address fluoride hesitancy (PDF).
Youth Mental Health Access Community Project Request for Applications (RFA)
Application Title: Youth Mental Health Access (YHMA) Community Project
Funding: $30,000
Expected Number of Awards: Two (2)
| Description | Date |
|---|---|
| This schedule is subject to change. The Washington State Department of Health (DOH) must have all required documents by due dates. YMHA Community Project Announcement & Promotion | 12/4/2023 |
| Application Due Date | 1/26/2024 |
| Notification of Awards | 2/19-2/23/2024 |
| YMHA Community Project Start Date | April 2024 |
Application can be found at YMHA Community Project WA Portal (available after December 11, 2023)
Application Technical Assistance 1/9/2024 12:00PM, link to join meeting (MS Teams):
FAQs (Frequently Asked Questions) & Answers Available after December 11, 2023.
Additional questions not in FAQs, contact Keith Zang.
Visit the Youth Mental Health Access Community Project for more information.
Medicare Quality
Medicare Policies
The following policies have been created to comply with the CMS Final Rule 2024 and will be the only Centene clinical policies applicable to Medicare effective January 1st, 2024. The policies are available on the clinical policy SharePoint under the Jan 2024 Medicare Policies folder (here) and the MC.CP.MP.## policies will be live as custom content in InterQual (CCO) in January.
**PLEASE NOTE THAT ALL POLICIES APPLICABLE TO AND APPROVED FOR MEDICARE BEGIN WITH MC.CP.MP. OR V2.2023, EXCEPT FOR CC.PP.206.**
New Medicare-Approved Policies:
| Policy Number | Policy Title |
|---|---|
CC.PP.206 | Skilled Nursing Facility Leveling (placed on payment policy template to reflect that it is payment rule-based but will be used by SNF leveling team and vendors as the CP.MP.206 version was) |
MC.CP.MP.170 | Peripheral Nerve Blocks |
MC.CP.MP.22 | Stereotactic Body Radiation Therapy |
MC.CP.MP.69 | Intensity-Modulated Radiotherapy |
MC.CP.MP.246 | Pediatric Kidney Transplant |
MC.CP.MP.57 | Lung Transplantation |
MC.CP.MP.101 | Donor Lymphocyte Infusion |
MC.CP.MP.108 | Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-thalassemia |
MC.CP.MP.182 | Short Inpatient Stay |
MC.CP.MP.106 | Endometrial Ablation |
MC.CP.MP.160 | Wireless pulmonary artery monitoring |
MC.CP.MP.248 | Facility-Based Sleep Studies for Obstructive Sleep Apnea |
V2.2023 | Concert Genetics Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS, or PUBS) and Pregnancy Loss |
V2.2023 | Concert Genetics Genetic Testing: Aortopathies and Connective Tissue Disorders |
V2.2023 | Concert Genetics Genetic Testing: Cardiac Disorders |
V2.2023 | Concert Genetics Genetic Testing: Dermatologic Conditions |
V2.2023 | Concert Genetics Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Disorders |
V2.2023 | Concert Genetics Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Disorders |
V2.2023 | CG Exome and genome Sequencing for the DX 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 and Molecular Testing |
V2.2023 | Concert Genetics Genetic Testing: Hearing Loss |
V2.2023 | Concert Genetics Genetic Testing: Hematologic Conditions (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 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 Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies |
V2.2023 | Concert Genetics Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) |
V2.2023 | Concert Genetics Oncology: Algorithmic Testing |
V2.2023 | Concert Genetics Oncology: Cancer Screening |
V2.2023 | Concert Genetics Oncology: Cytogenetic Testing |
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: Skeletal Dysplasia and Rare Bone Disorders |
Fight the Flu Toolkit for Health Care Providers
Healthcare providers play a significant role in educating and protecting their patients against the flu. Influenza education and recommendation are important elements in protecting patients and accepting the flu vaccine. Fight the Flu Toolkit.
RSV
High rates of RSV combined with the regular flu season and on-going COVID-19 is creating a crisis of care in our community.
At highest risk for RSV are infants/young children, including, premature and Infants <6 months, children <2 years old w/chronic lung disease/congenital heart disease or with suppressed immune systems or with neuromuscular disorders/difficulty in swallowing and clearing mucus. A prophylaxis may be considered for high-risk infants and young children (per the CDC and the American Academy of Pediatrics).
Adults at high risk for RSV include adults>65 years old or those with chronic heart, lung conditions or with weaken immune systems. RSV can exacerbate existing conditions such as with asthma, COPD, and CHF.
For more information on RSV symptoms, lab testing, and treatment refer to the CDC site link RSV – extracted 20221216.
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Tribal Updates
Single point of Contact for IHCPs
IHCPs can contact Carin Moritz for claims for All Lines of Business.
Carin Moritz, the dedicated representative to Indian Health Care Providers, is available to help with claims from any of our line of business – Medicaid, Medicaid DSNP, WellCare, Ambetter, Cascade Care, including any of our third-party vendors, i.e. Envolve, etc.
Contact Carin directly at IndianHealthCareProviderAssistance@coordinatedcarehealth.com
Indian Health Care Providers should be aware that only Medicaid claims are handled locally. Carin can navigate our corporate teams to help reduce IHCP’s administrative burden.
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Clinical Policy Updates
National Imaging Associates, Inc. (NIA)
There are two announcements regarding prior authorization vendor NIA::
1) The following NIA policies have been updated with changes that will be effective January 1, 2024. The policies are available on the NIA site; a link is available from the Pre-Auth Check section of our provider web page.
| Policy Number | Policy Title |
|---|---|
NIA_CG_001 | NIA - Brain (Head) MRI Brain (Head) MRI with IAC (Internal Auditory Canal) |
NIA_CG_002 | NIA - Brain (Head) CT |
NIA_CG_003 | NIA - Brain (Head) MRS |
NIA_CG_004-1 | NIA - Brain (Head) CTA |
NIA_CG_004-2 | NIA - Brain (Head) MRA/MRV |
NIA_CG_006-1 | NIA - Temporal Bone, Mastoid, Orbits, Sella, Internal Auditory Canal CT |
NIA_CG_007 | NIA - Temporomandibular Joint (TMJ) MRI |
NIA_CG_008-1 | NIA - Neck CT (soft tissue) |
NIA_CG_009 | NIA - Sinus & Maxillofacial CT Limited or Localized follow up Sinus CT - CCW version |
NIA_CG_012-1 | NIA - Neck CTA |
NIA_CG_012-2 | NIA - Neck MRA/MRV |
NIA_CG_013 | NIA - Functional Brain MRI |
NIA_CG_014 | NIA - Orbit, Face, Neck, Sinus MRI - CCW version |
NIA_CG_015 | NIA - Cerebral Perfusion CT |
NIA_CG_020 | NIA - Chest (Thorax) CT |
NIA_CG_020-1 | NIA - Low Dose CT for Lung Cancer Screening |
NIA_CG_021 | NIA - Chest (Thorax) MRI |
NIA_CG_022-1 | NIA - Chest CTA |
NIA_CG_022-2 | NIA - Chest MRA/MRV |
NIA_CG_023 | NIA - Breast MRI |
NIA_CG_024 | NIA - Myocardial Perfusion Imaging (aka Nuclear Cardiac Imaging Study) |
NIA_CG_025 | NIA - CT Heart |
NIA_CG_026 | NIA - Stress Echocardiography |
NIA_CG_027 | NIA - MUGA (Multiple Gated Acquisition) Scan |
NIA_CG_028 | NIA - Heart MRI |
NIA_CG_029 | NIA - Coronary Calcification (EBCT) |
NIA_CG_030 | NIA - Abdomen CT |
NIA_CG_031 | NIA - Abdomen MRI MRCP |
NIA_CG_033-1 | NIA - CT (Virtual) Colonoscopy Diagnostic |
NIA_CG_033-2 | NIA - CT (Virtual) Colonoscopy Screening |
NIA_CG_034-1 | NIA - Abdomen CTAngiography |
NIA_CG_034-2 | NIA - Abdomen MRA (Angiography) |
NIA_CG_035 | NIA - CTA Aortogram with Runoff |
NIA_CG_036 | NIA - Pelvis CT |
NIA_CG_037 | NIA - Pelvis MRI |
NIA_CG_038 | NIA - Pelvis CT Angiography |
NIA_CG_039 | NIA - Pelvis MRA MRV |
NIA_CG_040 | NIA - Cervical Spine MRI |
NIA_CG_041 | NIA - Cervical Spine CT |
NIA_CG_042 | NIA - Thoracic Spine MRI |
NIA_CG_043 | NIA - Thoracic Spine CT |
NIA_CG_044 | NIA - Lumbar Spine MRI |
NIA_CG_045 | NIA - Lumbar Spine CT |
NIA_CG_046 | NIA - Spinal Canal MRA |
NIA_CG_057-1 | NIA - Upper Extremity CT (Hand, Wrist, Arm, Elbow, Long bone or Shoulder CT) |
NIA_CG_057-2 | NIA - Lower Extremity CT (Foot, Ankle, Knee, Leg or Hip CT) |
NIA_CG_057-3 | NIA - Upper Extremity MRI (Hand, Wrist, Arm, Elbow, Long bone or Shoulder MRI) |
NIA_CG_057-4 | NIA - Lower Extremity MRI (Foot, Ankle, Knee, Leg or Hip MRI) |
NIA_CG_058-1 | NIA - Lower extremity MRA/MRV |
NIA_CG_058-2 | NIA - Upper Extremity MRA/MRV |
NIA_CG_059 | NIA - Bone Marrow MRI |
NIA_CG_060-2 | NIA - CT Bone Density Study |
NIA_CG_061-1 | NIA - Lower Extremity CTA/CTV |
NIA_CG_061-2 | NIA - Upper Extemity CTA/CTV |
NIA_CG_062 | NIA - CT Coronary Angiography (CCTA) |
NIA_CG_063 | NIA - Unlisted Study |
NIA_CG_064 | NIA - Low Field MRI |
NIA_CG_066 | NIA - Transesophageal Echo (TEE) |
NIA_CG_067 | NIA - Transthoracic Echo (TTE) |
NIA_CG_068 | NIA - Abdomen/Pelvis CT Combo |
NIA_CG_069 | NIA - Abdomen/Pelvis CTA |
NIA_CG_070-1 | NIA - PET SCANS |
NIA_CG_070-2 | NIA - Tumor Imaging PET - Any Site (Unlisted PET) |
NIA_CG_070-3 | NIA - Tumor Imaging PET - Any Site (Unlisted PET) |
NIA_CG_070-4 | NIA - Tumor Imaging PET - Any Site (Unlisted PET) |
NIA_CG_071 | NIA - Brain PET SCAN |
NIA_CG_072 | NIA - Heart (Cardiac) PET |
NIA_CG_079 | NIA - Heart (Cardiac) PET with CT for Attenuation |
NIA_CG_100 | NIA - Urgent/Emergent Criteria |
NIA_CG_104 | NIA - 3D Rendering (CT Multiplanar Reconstruction) |
NIA_CG_105 | NIA - CT/MRI Guidance for Needle Placement CT Guidance for Radiation Fields |
NIA_CG_110 | NIA- Fetal MRI |
NIA_CG_300 | NIA - Epidural Spine Injections |
NIA_CG_301 | NIA - Paravertebral Facet Point Injections or Blocks |
NIA_CG_302 | NIA - Paravertebral Facet Joint Denervation (Radiofrequency Neurolysis) |
NIA_CG_305 | NIA - Sacroiliac Joint Injections |
NIA_CG_404 | NIA - Sympathetic Nerve Blocks |
NIA_CG_408 | NIA - Epidural Spine Injections & Single Injection Trials for Intrathecal Pumps |
2) 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 and for a link to NIA’s site from which you can view the policies.
| 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 November. These policy changes are effective January 1, 2024. 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.527 | Vitamin D Testing | Apple Health & Ambetter |
| CP.MP.31 | Cosmetic and Reconstructive Procedures | Apple Health & Ambetter |
| CP.MP.61 | IV Moderate Sedation, IV Deep Sedation and General Anesthesia for Dental Procedures | Ambetter |
| CP.MP.101 | Donor lymphocyte infusion | Apple Health & Ambetter |
| CP.MP.108 | Allogenic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia | Apple Health & Ambetter |
| CP.MP.109 | Panniculectomy | Apple Health & Ambetter |
| CP.MP.138 | Pediatric Heart Transplant | Apple Health & Ambetter |
| CP.MP.150 | Phototherapy for Neonatal Hyperbilirubinemia | Apple Health & Ambetter |
| CP.MP.202 | Orthognathic Surgery | Apple Health & Ambetter |
The below genetic testing clinical policies received updates as part of our twice yearly review. These policy changes are effective January 1, 2024. You will find the policies, including a description of the revisions, posted on the policy site.
| Policy Number | Policy Title | Line of Business |
|---|---|---|
V1.2024 | CG Aortopathies and Connective Tissue Disorders | Apple Health & Ambetter |
V1.2024 | CG Cardiac Disorders | Apple Health & Ambetter |
V1.2024 | CG Dermatologic Conditions | Apple Health & Ambetter |
V1.2024 | CG Epilepsy Neurodegenerative and Neuromuscular Conditions | Apple Health & Ambetter |
V1.2024 | CG Exome and Genome Sequencing for DX of Genetic Disorders | Apple Health & Ambetter |
V1.2024 | CG Eye Disorders | Apple Health & Ambetter |
V1.2024 | CG Gastroenterologic Disorders Non-cancerous | Apple Health & Ambetter |
V1.2024 | CG General Approach to Genetic Testing | Apple Health & Ambetter |
V1.2024 | CG Hearing Loss | Apple Health & Ambetter |
V1.2024 | CG Hematologic Conditions Non-cancerous | Apple Health & Ambetter |
V1.2024 | CG Hereditary Cancer Susceptibility | Apple Health & Ambetter |
V1.2024 | CG Immune Autoimmune and Rheumatoid Disorders | Apple Health & Ambetter |
V1.2024 | CG Kidney Disorders | Apple Health & Ambetter |
V1.2024 | CG Lung Disorders | Apple Health & Ambetter |
V1.2024 | CG Metabolic Endocrine Mitochondrial Disorders | Apple Health & Ambetter |
V1.2024 | CG Multisystem Inherited Disorders, Intellectual Disability and Developmental Delay | Ambetter |
WA.CP.MP.230 | Genetic Testing Multisystem Inherited Disorders, Intellectual Disability and Developmental Delay | Apple Health |
V1.2024 | CG Non-Invasive Prenatal Screening | Ambetter |
WA.CP.MP.231 | Genetic Testing Non-Invasive Prenatal Screening (NIPS) | Apple Health |
V1.2024 | CG Oncology Algorithmic Testing | Apple Health & Ambetter |
V1.2024 | CG Oncology Cancer Screening | Apple Health & Ambetter |
V1.2024 | CG Oncology Circulating Tumor DNA Tumor Cells Liquid Biopsy | Apple Health & Ambetter |
V1.2024 | CG Oncology Cytogenetic Testing | Apple Health & Ambetter |
V1.2024 | CG Oncology Molecular Analysis Solid Tumors & Hematolgic Malignancies | Apple Health & Ambetter |
V1.2024 | CG Pharmacogenetics | Apple Health & Ambetter |
V1.2024 | CG Preimplantation Genetic Testing | Apple Health & Ambetter |
V1.2024 | CG Prenatal and Preconception Carrier Screening | Apple Health & Ambetter |
V1.2024 | CG Prenatal Diagnosis Pregnancy Loss | Apple Health & Ambetter |
V1.2024 | CG Skeletal Dysplasia Rare Bone Disorders | Apple Health & Ambetter |
The below policies were previously announced as revised on the date noted. You will find the policies posted on the policy site.
| Policy Number | Policy Title | Effective Date | Line of Business |
|---|---|---|---|
CP.MP.50 | Drugs of Abuse: Definitive Testing | 1/1/24 | Ambetter |
CP.BH.124 | ADHD Assessment and Treatment | 1/1/24 | Apple Health |
CP.MP.123 | Laser Therapy for Skin Conditions | 1/1/24 | Apple Health |
CP.MP.246 | Pediatric Kidney Transplants | 1/1/24 | Apple Health & Ambetter |
CP.MP.181 | Polymerase Chain Reaction Respiratory Viral Panel | 1/1/24 | Apple Health |
CP.MP.98 | Urodynamic Testing | 1/1/24 | Apple Health |
CP.MP.101 | Donor Lymphocyte Infusion | 1/1/24 | Apple Health & Ambetter |
CP.MP.209 | GI Pathogen Nucleic Acid Detection Panel Testing | 1/1/24 | Apple Health |
CP.MP.57 | Lung Transplantation | 1/1/24 | Apple Health & Ambetter |
CP.MP.107 | Durable Medical Equipment (DME) and Orthotics and Prosthetics Guidelines | 3/1/24 | Apple Health & Ambetter |
The below new policy was previously announced effective 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.250 | Lantidra (donislecel): Allogeneic pancreatic islet cellular therapy | 1/1/24 | Apple Health & Ambetter |
Payment Policy Updates
Optum CPI AMISYS Phase 5
Coordinated Care is committed to continuously evaluating and improving overall Payment Integrity solutions as required by State and Federal governing entities. As a reminder, we have partnered with Optum who is supporting us in performing prepayment claim auditing. 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 10/17/2023, 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 | Line of Business |
|---|---|---|
Critical Care Coding | Medical record review to determine if critical care CPT codes are properly supported based on diagnosis codes and documentation. | Medicaid, Medicare, Marketplace |
Tongue-Tie & Frenulum Procedures | Medical record review to determine if the proper coding of tongue-tie and frenulum procedures are utilized based on correct coding guidelines. | Medicaid, Medicare, Marketplace |
Adjacent Tissue Transfer | When billing for adjacent tissue transfer services, providers must take great care to follow the coding guidelines, since this area presents very complex billing rules that need to be followed. Medical record review will be performed to determine if an adjacent tissue transfer was performed and if the reported defect size is supported by documentation. | Medicaid, Medicare, Marketplace |
| Associated EX Code for EOP | Description |
|---|---|
EXbo | DENY: MEDICAL RECORDS AND/OR OTHER SERVICE DOCUMENTATION REQUIRED |
Optum CPI C0037 and C0038
For claims received on or after 1/2/2024, 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 | Line of Business |
|---|---|---|
NCCI Modifier Override – Procedure Overlap (Professional) | This review seeks to prevent overpayment of inappropriately unbundled procedures per the NCCI coding guidelines. | Medicaid, Medicare, Marketplace |
NCCI Modifier Override – Misuse of Column Two Code with Column One Code (Professional) | The review ensures that procedures are reported with the most comprehensive CPT that describes the services performed. | Medicaid, Medicare, Marketplace |
| Associated EX Code for EOP | Description |
|---|---|
EXbo | DENY: MEDICAL RECORDS AND/OR OTHER SERVICE DOCUMENTATION REQUIRED |
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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Wellcare
Quick Reference Guide
WellCare’s Quick Reference Guide has been updated for January 2024.
Medicare's Step Therapy Part B Drug List
Step Therapy Part B Drug List, effective January 1, 2024.
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Apple Health Core Connections (AHCC)
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. Our program, Apple Health Core Connections, 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. For questions or care coordination referrals you can reach us at 1-844-354-9876 or AHCCTeam@coordinatedcarehealth.com.
There are many program benefits available to your practice to guide your care for AHCC members. These include:
Additional Early Periodic Screening, Diagnosis and Treatment program (EPSDT) well-child visits as required by the Department of Children, Youth and Families. AHCC will support provider recommendations identified as a result of the EPSDT. Coordinated Care will pay claims for as many EPSDT well-child visits as an AHCC member needs, at the state approved higher reimbursement rate using the TJ modifier for children in foster care.
Support in establishing a medical home with an assigned primary care provider for children and youth. The AHCC team is here to support your clinical recommendations including finding services, making appointments, and providing education.
Uninterrupted health care as children and youth move from placements and caregivers.
Our Secure Provider Portal enabling clinics to share health information securely as children move between placements and medical professionals.
The Coordinated Care Community Education Team offers no-cost training on topics such as Adoption Success, Trauma Informed Care, ACEs, Resilience, and Secondary Trauma and Self Care. To request more information or to schedule a no-cost training, please contact the Coordinated Care Community Education team.
Providers and members can reach us at 1-844-354-9876 or AHCCTeam@coordinatedcarehealth.com.
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Training/Education
New Provider Orientation
To attend an upcoming New Provider Orientation or request a one-on-one refresher session online or in person, reach out to your Provider Engagement Representative for assistance.
CLAS Standards E-Learning Modules and Resources
The Health Equity Governor’s Interagency Council partnered with the Washington State Department of Health to develop CLAS e-Learning modules to help provide quick access to culturally and linguistically appropriate health information and services. Each module takes about 30 minutes to complete. Visit the CLAS Standards Training and Resources page for access to the CLAS Standards resources and e-learning modules.
Free Continuing Education Opportunities
Centene Institute is offering the following virtual courses:
- Cultural Humility and Unconscious Bias in Healthcare
- Health Equity Essentials: Fundamentals for Transforming Health
- Creating Trauma-Informed Healthcare
- Vaccine Hesitancy: How to Identify and Approach the “Movable Middle”
View course description and registration information by clicking on the course titles above.
Please note, you must sign up for an account in order to be able to enroll in the activity. Once you are signed in, you may click on the links and click “Enroll Now” to enroll in the activity.
For questions, please email Centene_Institute@centene.com.
Driven to transform the health of the community through education, the Centene Institute for Advanced Health Education®, LLC, (Centene Institute) provides interprofessional continuing education as empowering, research-informed educational activities that improve quality of care, performance of the healthcare team, and health outcomes.
Additional Centene Institute opportunities can be viewed in the Activity Catalog.
Provider Education Resources
- Coordinated Care providers have no-cost access to Centene’s Provider Training program.
- Coordinated Care encourages providers to visit the Association of WA Health Care Plans MCO Provider Resources.
Additional training resources
- Implicit Bias Training Course | National Institute of Health | 3 Modules for 50 min (will need to take an additional course to meet hour requirements) | Online
- Improving Cultural Competency for Behavioral Health Professionals | US Dept. of Health and Human Service | 4 Sessions for 4 – 5.5 hours | Online
- Racism, Bias, and Other Determinants of Health: Issues and Actions | Region IV Public Health Training Center | 2 Modules for 90mins | Online
- Tribal Sovereignty and the Indian Health Care System | American Indian/Alaska Native Providers | 5 Modules for 5 hours | Webinar Videos
- Who We Are: A Chronicle of Racism in American | Documentary by Jeffrey Robinson | 2 hours | Video
Look for additional education opportunities and resources in our monthly news blast.
To be removed from these fax notices or to request to be added to our email list for these notices, please reply to CoordinatedCareProvider@centene.com.
SOAR for Human Trafficking Screening for Child Welfare Professionals - The human trafficking screening process involves evaluating, through targeted inquiry, whether a child or youth may have experienced trafficking while missing from care. As a child welfare professional, timely screening is often the first step in identifying children or youth who have experienced or are at risk of trafficking. Access the Recording of this training.
Infant and Early Childhood Mental Health: Relational Foundations for Lifelong Health - Learn and apply an infant and early childhood mental health principles to promote, prevent risks, and intervene to support healthy early childhood development. Use Promo Code SAVE5 to access the course for FREE.
This course is organized in 5 modules:
- Introduction to Infant and Early Childhood Mental Health
- Attuned Interactions
- Promoting and Preventing Social-Emotional Development Risks
- Intervening When a Developmental Concern Is Identified
- Building an Infant and Early Childhood Mental Health-Informed Practice
Rural Responses to Opioid Use from a Nonprofit Perspective - Mainstream media portrayals of rural America tend to focus on themes of political conservatism, lack of resources, and exodus of younger adults. But these stereotypes miss innovative work happening in rural areas, and a long-standing capacity among community building and collaboration around important issues like public health. This presentation will provide examples of rural-based care and responses to the opioid crisis in Southeast Washington, from staff of an independent nonprofit. Public-private partnerships, state and federal grant funding, volunteerism, and mobile-based services will be examined for their utility across a few different models of care. January 10th at 12:00pm – 1:00pm - Register Here.
Health Equity Resources
At Coordinated Care, we understand that health equity can only exist when all people have access to the same opportunities to attain their full physical and behavioral health and well-being regardless of race, ethnicity, disability, gender identity, sexual orientation, socioeconomic status, geography, language, or any other social barriers. Our approach systematically identifies disparities, prioritizes projects and collaborates across communities in an effort to remove inequities targeting members, providers, and communities.
Our mission is at the center of everything we do, transforming the health of the communities we serve, one person at a time. Treating the whole patient is a major component of delivering quality healthcare and we recognize the importance of serving members in a culturally and linguistically appropriate manner.
Coordinated Care conducts a language assessment on an annual basis to determine the current language population within the service area. Cultural and linguistic availability of services is an important characteristic of the services Coordinated Care provides to our membership.
You are encouraged to reach out to your dedicated Provider Engagement Representative to learn more about how this information can be used to strengthen your relationship with your patients.
Provider Engagement Representatives by Region
Visit the Regional Reps Page for a list of Provider Engagement Representatives by region and their contact information.
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Pharmacy Updates
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.
Express Scripts Transition: Frequently Asked Questions
This FAQ provides additional information on the migration of our Pharmacy Benefit Manager (PBM) services from CVS® to Express Scripts®, effective January 1, 2024.
What is changing?
As of 01/1/2024, we will be moving to directly being contracted with Express Scripts (ESI) vs. CVS.
Who is Express Scripts?
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.
What is the rationale for changing PBM vendors?
Express Scripts as our PBM will bring increased levels of transparency and value, positioning us to provide the highest level of quality at the lowest possible cost to our members.
What PBM services will Express Scripts be providing?
Express Scripts will be the PBM of record providing pharmacy claims adjudication, pharmacy network administration and rebate administration on behalf of our health plan.
How will this PBM transition impact our members?
There will be no immediate change in service for our members, although they will receive new ID cards. We will continue to provide the same member-focused care and support as we do today.
Our highest priority continues to be serving all our members, and we remain committed to providing affordable quality healthcare services. Our team is working closely with both CVS and Express Scripts to ensure a seamless migration.
Will there be significant changes to the pharmacy network?
No. Minimal changes have been made to limit disruption. Any member affected by changes in the pharmacy network will receive a notification. Members may call member services or check our website if they have any questions or need assistance with finding an in-network pharmacy.
Is Amazon part of the Express Scripts Network?
Yes, Amazon is part of the Express Scripts network.
Can members still use CVS Caremark for their mail orders?
No, CVS Caremark Mail Service Pharmacy will be out of network, effective January 1, 2024. If members wish to continue using mail order in 2024, they must switch to Express Scripts Pharmacy.
Do members have a choice besides Express Scripts for mail order services?
Members have a choice to use other pharmacies that offer home delivery, but Express Scripts Pharmacy is the preferred mail order pharmacy for our health plan.
Are we communicating this mail order change to members?
Yes. Impacted Medicaid members will receive a Mail Order Change notification letter.
How will members get started with mail order at Express Scripts?
For existing mail order users:
- Most open prescription refills will be automatically transferred to Express Scripts
- Refills for controlled drugs, such as Alprazolam, Clonazepam, Pregabalin, Tramadol, Zolpidem, etc., will not automatically transfer to Express Scripts Pharmacy; members must request a new prescription from their provider
For new mail order prescriptions on or after January 1, 2024, members may do one of the following:
- Ask their provider to electronically submit or fax a new prescription to Express Scripts Pharmacy, as listed on their medical ID cards
- Visit express-scripts.com/rx to register or sign in, then follow the guided steps to request a prescription
- Call Express Scripts Pharmacy, who will contact their provider for a new prescription to be filled via mail order
- Mail a Home Delivery Order Form (available at express-scripts.com/rx) directly to Express Scripts Pharmacy
Does Express Scrips offer a mail order app?
Yes, members will be able to download the Express Scripts Pharmacy app, available on the App Store and Google Play. Members with a mail order benefit can order medications, track delivery and more.
Does this change where providers would submit PA requests for medications?
No, Prior Authorization will stay the same.
Drugs Prescribed for Weight Loss
As a reminder, per WAC 182-530-2100, medications that are prescribed for weight loss (i.e., GLP-1 Agonist) are not covered by Coordinated Care.