February 2025 Provider News
Date: 02/28/25
In this issue:
- General Updates - DOH Licensure Number on Claims, Routine Foot Care
- Quality - ADHD Medication Adherence, Annual Wellness Visits, Asthma and 90 Day Medication Refills, Wellcare Annual Wellness Visits
- Tribal - Resource for Assistance
- Pharmacy Updates - Medical Oncology Updates, April 1, 2025 Preferred Drug List (PDL) Changes, Significant Change to the Preferred Products in the Cytokine and CAM Antagonist Drug Class
- Wellcare - Link to Medical Clinical Policy Updates
- Apple Health Core Connections - DOH Youth-Friendly Care Certification
- Training/Education - Upcoming Training Opportunities
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General Updates
DOH Licensure Number on Claims
Starting in April 2017, it has been a requirement of behavioral health agencies (BHAs) to report the specific site ID of the agency where a service was performed in their claims and encounters. Reporting requirements that were implemented to support institutions for mental diseases (IMD) reporting requirements in [CFR 438.3(e)(2)] in addition to the CMS regulations regarding enrollee encounter data [42 CFR 438.242(c).].
This reporting requirement has not changed; however, instead of reporting the site-specific ID, BHAs must report the site-specific Department of Health (DOH) licensure number instead. This number is searchable on the Facility Search page of the DOH website.
IMPORTANT: Due to this requirement, starting March 1, 2025, claims will be subject to denial if the DOH Certification number is omitted. Should you experience a denial for omitting the DOH certification number, you can submit a corrected claim within timely filing limits.
The DOH license number must be reported as follows:
Loop 2310C, REF*G2 Segment for 837P
Loop 2420C, REF*G2 Segment for 837P
Loop 2310E, REF*G2 Segment for 837I
If paper claim, Box 19 on CMS 1500 is used to provide additional information.
Additional Resources:
The Behavioral Health Data System Guide (BHDG), also known as the Behavioral Health Supplemental Transaction Data Guide, refers to this field in "Appendix F: Instructions for Submitting License Number in P1." It advises users to refer to the State of Washington 837 Professional and Institutional Encounter Data Companion Guide. Note that the BHDG is specifically for supplemental data within the Behavioral Health Data System (BHDS) and should not be used as a reference for submitting encounter data.
Furthermore, the 837 Professional and Institutional Encounter Data Companion Guide details this field in section “3 Transaction Specifications,” covering loops 2310C and 2420C.
WAC 246-341-0300, concerning agency licensure and certification, provides guidance on the process of obtaining a license number through the Department of Health (DOH).
For any questions, please contact your Provider Engagement Administrator.
Routine Foot Care
Ambetter reimburses for routine foot care in accordance with state mandates and CMS guidelines. Routine Foot Care services are not restricted to podiatrists. These services may be used by any certified physician or non-physician (NPP) specialty. Based on CMS guide for routine foot care modifiers Q7, Q8 and Q9 are being added to further ensure Ambetter benefit(s) are applying routine foot care cost share for routine foot care services.
All other services will apply Surgical/Specialist/Doctor/Facility cost share depending on provider billing.
Effective 1/1/2025 routine foot care benefit(s) will be updated to align with the CMS guidance provided here.
Prior authorization may be required. Pre-Auth Check here.
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Quality
Medicaid Quality
ADHD Medication Adherence
HEDIS includes a measure to assess adherence to best-practice protocols regarding follow-up care for children prescribed ADHD medication. The measure includes:
- Initiation phase: Members ages 6 to 12 years old who were dispensed an ADHD medication, and who had a follow-up visit with a practitioner with prescribing authority during the 30-day initiation phase and had a negative medication history for a period of 120 days.
- Continuation and maintenance phase: Members ages 6 to 12 years old who were dispensed an ADHD medication and who remained on the medication for at least 210 days and who, in addition to the visit in the initiation phase, had at least two follow-up visits with a practitioner within 270 days (nine months) after the initiation phase ended.
Provider tips
- Screen for ADHD by specifically asking questions about the major symptom domains of ADHD and asking whether such symptoms cause impairment.
- Complete a comprehensive medical and psychiatric exam, including rating scales from parents and teachers, before diagnosing and prescribing.
- Screen for coexisting issues that may be impacting the child.
- Limit the first prescription of ADHD medication to a 28- to 30-day supply and schedule follow-up before the family leaves the office.
- Refer the patient to a behavioral health provider for psychosocial support and skill building.
- Re-evaluate medication effectiveness no more than 30 days after initiation via telehealth when available and regularly monitor medication effects thereafter.
- Discuss parent and child questions and concerns and highlight the child’s strengths and come to a joint agreement on the treatment plan.
- Partner with the health plan, address barriers and coordinate care with other providers.
- Use telehealth and submit the correct Current Procedural Terminology (CPT) claim codes.
- Periodically review the ongoing need for continued medication therapy.
- Refer the patient to a behavioral health provider for psychosocial support and skill building.
Sources
1 American Academy of Child & Adolescent Psychiatry - ADHD Resource Center (aacap.org) https://www.aacap.org/AACAP/Families_Youth/Resource_Centers/ADHD_Resource_Center/AACAP/Families_and_Youth/Resource_Centers/ADHD_Resource_Center/Home.aspx?hkey=263af418-94e9-4c33-a6c7-e058f81a80e5#treatment and Practice Parameter for the Assessment and Treatment of Children and Adolescents With Attention-Deficit/Hyperactivity Disorder (jaacap.org) https://www.jaacap.org/article/S0890-8567%2809%2962182-1/pdf
2 American Academy of Pediatrics - Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents | Pediatrics | American Academy of Pediatrics (aap.org) https://publications.aap.org/pediatrics/article/144/4/e20192528/81590/Clinical-Practice-Guideline-for-the-Diagnosis?autologincheck=redirected
Annual Wellness Visits
Annual Wellness Visits (AWV) are an opportunity to close clinical HEDIS measure gaps, establish or strengthen your Provider/Patient rapport and most importantly provide quality health care including early detection to save lives. The AWV helps develop or update a Personalized Prevention Plan (PPP) and perform a Health Risk Assessment (HRA).
Resources for Annual Wellness Visits: helpful resource tools for the AWV can be found here.
CMS website Medicare Learning Network documents 12 defined components of the First Annual Wellness Visit and subsequent Annual Wellness Visits having 11 components. Preparing eligible Patients for the AWV can include encouraging them to bring to their appointment at a minimum:
- Medical records, including immunization records
- Detailed family health history
- Full list of medications and supplements, including calcium and vitamins, and how often and how much of each they take
- Full list of current providers and suppliers involved in their care, including community-based providers (for example, personal care, adult day care, and home-delivered meals), and behavioral health specialists
Asthma and 90 Day Medication Refills
Moving members with asthma prescriptions to 90-day medication refills may increase their maintenance medication adherence.
Educate parents on the importance of getting their children up to date on well child visits and routine vaccinations. Well child checkups are essential for their children’s growth and development and vaccines help protect their child’s health.
Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC)
The percentage of members 3-17 years of age who had an outpatient visit with a PCP or OB/GYN and had evidence of the following during the measurement year:
- BMI Percentile documentation*
- Counseling for Nutrition
- Counseling for Physical Activity
- Telehealth Flexibilities Extended until March 31
- Recent legislation extended the waiver of the geographic, site of service, and practitioner type restrictions. Medicare patients in non-rural areas and in their homes can continue to get telehealth services from this extended range of practitioners until March 31, 2025.
Topics to discuss during your patient’s (ages 20 and over) Annual Preventative Wellness Visit (APV) recommended yearly:
► Update patient’s medical record: including demographics, other treating providers and family history
► Conduct a Social Determinants of Health assessment
► Discuss Advanced Care planning
► Screen for cognitive impairment, including depression, mental wellness and emotional health
► Conduct medication reconciliation and extend day fill opportunities (mail order or 90 days at retail)
► Complete pain and functional assessments; including use of Durable Medical Equipment (DME)
► Assess bladder leakage and care options
► Create a preventative screening schedule and refer members for tests, labs, X-rays (eye exams, colonoscopy, mammograms), counseling and care programs
► Complete the health risk assessment, including functional abilities, ADLS, instrumental ADLs and create an action plan
► Create patient’s list of balance/fall risk factors and conditions; including interventions and treatment options
► Check routine measurements: height, weight, blood pressure, etc.
► Review current opioid prescription and screen for potential Substance Use Disorders (SUDs)
Wellcare Quality
Annual Wellness Visits
Annual Preventative Wellness Visits (APV) are an opportunity to close clinical HEDIS measure gaps, establish or strengthen your Provider/Patient rapport and most importantly provide quality health care including early detection to save lives. The AWV helps develop or update a Personalized Prevention Plan (PPP) and perform a Health Risk Assessment (HRA).
Resources for Annual Wellness Visits: helpful resource tools for the AWV can be found here.
CMS website Medicare Learning Network documents 12 defined components of the First Annual Wellness Visit and subsequent Annual Wellness Visits having 11 components. Preparing eligible Patients for the AWV can include encouraging them to bring to their appointment at a minimum:
- Medical records, including immunization records
- Detailed family health history
- Full list of medications and supplements, including calcium and vitamins, and how often and how much of each they take
- Full list of current providers and suppliers involved in their care, including community-based providers (for example, personal care, adult day care, and home-delivered meals), and behavioral health specialists
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Tribal
Resource for Assistance
IHCPs have access to a dedicated email inbox for inquires regarding all lines of business at Coordinated Care (Medicaid, Marketplace/Exchange, and Medicare Advantage). Please don’t hesitate to reach out to IndianHealthCareProviderAssistance@coordinatedcarehealth.com and the team monitoring the inbox will assist or connect you with the appropriate contacts to resolve your questions.
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Pharmacy
Medical Oncology Updates- Ambetter
Prior Authorization requests for the following HCPCS codes need to be verified by Evolent.
HCPCS | Generic Name | Brand Name | Medical PA | Pharmacy PA | Impact Description |
J9999 | DATOPOTAMAB DERUXTECAN-DLNK INJECTION | DATROWAY | Yes | Yes | Effective 7/1/25 |
J9999 | NIVOLUMAB AND HYALURONIDASENVHY | OPDIVO QVANTIG | Yes | Yes | Effective 7/1/25 |
Participating providers should submit oncology/supportive drug authorization for members through Evolent.
April 1, 2025 Preferred Drug List Changes- Medicaid
Effective April 1, 2025, the following drugs will be non-preferred. Suggested preferred alternatives are listed in the last column. Please note, impacted members will be notified prior to the change.
Drug Class | Drug Name | Preferred Alternative(s) |
ANTIDIABETICS : INSULIN - LONG ACTING | BASAGLAR KWIKPEN U-100 BASAGLAR TEMPO PEN U-100 | INSULIN GLARGINE-YFGN, LANTUS SOLOSTAR, OR SEMGLEE (YFGN) PEN |
ANTIDIABETICS : INSULIN - LONG ACTING | LEVEMIR | INSULIN GLARGINE-YFGN, LANTUS, OR SEMGLEE (YFGN) |
ANTIDIABETICS : INSULIN - LONG ACTING | LEVEMIR FLEXPEN | INSULIN GLARGINE-YFGN, LANTUS SOLOSTAR, OR SEMGLEE (YFGN) PEN |
ANTIDEPRESSANTS : TRICYCLIC AGENTS | AMOXAPINE TABLETS | AMITRIPTYLINE HCL TABLETS, CLOMIPRAMINE HCL CAPSULES, DESIPRAMINE HCL TABLETS, DOXEPIN CAPSULES, IMIPRAMINE HCL TABLETS, OR NORTRIPTYLINE HCL CAPSULES |
Significant Change to the Preferred Products in the Cytokine and CAM Antagonist Drug Class- Medicaid
Effective April 1, 2025 Washington Apple Health (Medicaid) will make a significant change to the preferred products in the Cytokine and CAM Antagonist drug class. Brand name Humira products will no longer be preferred. Select adalimumab biosimilars (see included list for specific products), Enbrel, Enbrel Sureclick and Spevigo will be the preferred products in this class.
This change will apply to all agency-contracted managed care organizations (MCOs) and the fee-for-service (FFS) program per the Apple Health PDL. For questions about the Apple Health PDL, please email applehealthpharmacypolicy@hca.wa.gov.
| Product ID | Label Name | Generic Name | Strength | Dosage Form |
|---|---|---|---|---|
| 72606002206 | ADALIMUMAB-AATY(CF) | ADALIMUMAB-AATY | 40MG/0.4ML | SYRINGEKIT |
| 72606004101 | ADALIMUMAB-AATY(CF) | ADALIMUMAB-AATY | 20MG/0.2ML | SYRINGEKIT |
| 72606002210 | ADALIMUMAB-AATY(CF) AUTOINJ(2) | ADALIMUMAB-AATY | 40MG/0.4ML | AUTOINJKIT |
| 72606002209 | ADALIMUMAB-AATY(CF) AUTOINJECT | ADALIMUMAB-AATY | 40MG/0.4ML | AUTOINJKIT |
| 72606004004 | ADALIMUMAB-AATY(CF) AUTOINJECT | ADALIMUMAB-AATY | 80MG/0.8ML | AUTOINJKIT |
| 61314032764 | ADALIMUMAB-ADAZ(CF) | ADALIMUMAB-ADAZ | 40MG/0.4ML | SYRINGE |
| 61314032720 | ADALIMUMAB-ADAZ(CF) PEN | ADALIMUMAB-ADAZ | 40MG/0.4ML | PEN INJCTR |
| 00597055580 | ADALIMUMAB-ADBM(CF) | ADALIMUMAB-ADBM | 20MG/0.4ML | SYRINGEKIT |
| 00597056520 | ADALIMUMAB-ADBM(CF) | ADALIMUMAB-ADBM | 40MG/0.4ML | SYRINGEKIT |
| 00597058589 | ADALIMUMAB-ADBM(CF) | ADALIMUMAB-ADBM | 10MG/0.2ML | SYRINGEKIT |
| 00597059520 | ADALIMUMAB-ADBM(CF) | ADALIMUMAB-ADBM | 40MG/0.8ML | SYRINGEKIT |
| 00597057550 | ADALIMUMAB-ADBM(CF) PEN | ADALIMUMAB-ADBM | 40MG/0.4ML | PEN IJ KIT |
| 00597054566 | ADALIMUMAB-ADBM(CF) PEN CROHNS | ADALIMUMAB-ADBM | 40MG/0.8ML | PEN IJ KIT |
| 00597057560 | ADALIMUMAB-ADBM(CF) PEN CROHNS | ADALIMUMAB-ADBM | 40MG/0.4ML | PEN IJ KIT |
| 00597054544 | ADALIMUMAB-ADBM(CF) PEN PS-UV | ADALIMUMAB-ADBM | 40MG/0.8ML | PEN IJ KIT |
| 00597057540 | ADALIMUMAB-ADBM(CF) PEN PS-UV | ADALIMUMAB-ADBM | 40MG/0.4ML | PEN IJ KIT |
| 00597054522 | ADALIMUMAB-ADBM(CF)PEN | ADALIMUMAB-ADBM | 40MG/0.8ML | PEN IJ KIT |
| 00597037082 | CYLTEZO(CF) | ADALIMUMAB-ADBM | 40MG/0.8ML | SYRINGEKIT |
| 00597040089 | CYLTEZO(CF) | ADALIMUMAB-ADBM | 10MG/0.2ML | SYRINGEKIT |
| 00597040580 | CYLTEZO(CF) | ADALIMUMAB-ADBM | 20MG/0.4ML | SYRINGEKIT |
| 00597048520 | CYLTEZO(CF) | ADALIMUMAB-ADBM | 40MG/0.4ML | SYRINGEKIT |
| 00597037597 | CYLTEZO(CF) PEN | ADALIMUMAB-ADBM | 40MG/0.8ML | PEN IJ KIT |
| 00597049550 | CYLTEZO(CF) PEN | ADALIMUMAB-ADBM | 40MG/0.4ML | PEN IJ KIT |
| 00597037516 | CYLTEZO(CF) PEN CROHN'S-UC-HS | ADALIMUMAB-ADBM | 40MG/0.8ML | PEN IJ KIT |
| 00597049560 | CYLTEZO(CF) PEN CROHN'S-UC-HS | ADALIMUMAB-ADBM | 40MG/0.4ML | PEN IJ KIT |
| 00597037523 | CYLTEZO(CF) PEN PSORIASIS-UV | ADALIMUMAB-ADBM | 40MG/0.8ML | PEN IJ KIT |
| 00597049540 | CYLTEZO(CF) PEN PSORIASIS-UV | ADALIMUMAB-ADBM | 40MG/0.4ML | PEN IJ KIT |
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Wellcare
Effective April 20,2025 there are several Medical Clinical Policy Updates
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Apple Health Core Connections (AHCC)
Washington State Department of Health (DOH) has developed a Youth-Friendly Care Certification for providers which will launch in June 2025. The certification will recognize and designate medical and behavioral health clinics or practices that promote youth-friendly care in alignment with the Department of Health’s criteria, which was created with youth voice.
DOH will be hosting four information and feedback sessions about the youth-defined criteria for youth-friendly care as well as the certification structure, eligibility requirements, and application process. Join any of the four sessions on:
- Wednesday, February 19 at 7am
- Wednesday February 19 at 12pm
- Wednesday, March 5 at 7am
- Wednesday, March 5 at 12pm
Use this Zoom link to join any session. No preregistration needed.
Learn more about Youth-Friendly Care Certification here.
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Training/Education
Supporting LGBTQIA+ Youth in Foster Care This curriculum was developed through Amara with input from Coordinated Care and guidance from many community organizations. This training is for caregivers and professionals who work in the child welfare setting. Mar 3, 2025 10:00 AM Register here.
Suicide Prevention Provides an overview of the topic of suicide, signs and symptoms, and how caregivers should respond in times of crisis. The training will dive into the rates of youth suicide, risk factors, and proactive steps to take for prevention. Mar 5, 2025 10:00 AM Register here.
Understanding Youth Substance Use Disorders Use Understanding Youth Substance Use explores the impact and rates of substance use among youth in foster care. It discusses risk factors and protective factors, how substance use effects the brain, different types of substances being used, and common warning signs of use or addiction. Caregivers will leave better able to start conversations with youth on substance use and addiction. Mar 6, 2025 10:00 AM Register here.
Commercial Sexual Exploitation of Children (CSEC 101) Responding to Sexual Exploitation and Trafficking of Youth was developed by Leslie Briner, MSW of Youth Care; This training will prepare caregivers and service providers to identify, engage and provide support to sexually exploited youth; Introductory topics include definitions, language, landscape of exploitation, identification including “red flags”, victim engagements and interventions. Mar 13, 2025 10:00 AM Register here.