January 2024 Provider News
Date: 01/29/24
In this issue:
- General Updates - 2024 Provider Manuals Published, Payspan, Mental Health EBP Reporting for Behavioral Health Providers, Coordination of Benefit (COB) Updates, Inpatient Voluntary and Inpatient Involuntary Requirements
- Quality - Cervical Cancer Awareness Month, 2024 New Year Screenings, 2024 Focus Areas, Asthma Medication Review, Managing Diabetes and Associated Conditions
- Tribal - CY 2024 IHS Encounter rates released
- Clinical Policy - National Imaging Associates, Inc. (NIA), Genetic Testing Policy Updates, Policy Updates
- Pharmacy Updates Specialty Pharmacy Program: AcariaHealth
- Wellcare - Roster Submissions, Epic Payer Platform, Reminder of Express Scripts and Medical Clinical Policy Updates
- Apple Health Core Connections - Requesting Care Coordination
- Training/Education - The Intersection of Transracial Adoption and Racial (in)Justice, The Impact of Social Media on the Mental Health of LGBTQ+ Youth, Trauma Responsive Interventions for Transgender and Nonbinary Individuals, Culturally Responsive Depression Screenings for LGBTQIA+ Communities
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General Updates
Provider Manuals Updated for 2024
All provider manuals have been updated for the 2024 plan year.
Coordinated Care – Foster Care/Medicaid (PDF)
Wellcare – Medicare (National version, not Washington specific)
Wellcare – Medicare Quick Reference Guide (Washington specific)
Payspan: Sign up to receive Electronic Fund Transfers (EFT) and Electronic Remittance Advices (ERA)
Our Partnership with Payspan offers access to EFT’s and ERA’s allowing you to receive payments and remits quickly, without mail delays or bank deposit preparation. Click the links below for more information or reach out to your Provider Network Specialist for assistance in enrollment:
Mental Health EBP Reporting for Behavioral Health Providers
Coordinated Care would like to remind all clinics and providers who deliver Children’s Mental Health Evidence Based Practices (EBPs) to clients under age 18 that they should include the appropriate SERI code for Mental Health providers when billing for these services. EBP codes are specially designated identifiers on a claim or encounter that are used to report specific research- or evidence-based practices for children’s public mental health care provided by licensed or certified mental health providers to children and youth under 18 in Washington State. Coordinated Care is required by law to track and report to HCA quarterly all children’s mental health visits and how many of these visits were billed as an Evidence Based Practice. EBP codes and all associated history and criteria can be found in the Evidence-Based Practices
The utilization of EBP codes does not impact payment of your claims. Coordinated Care will not deny any claims due to EBP code utilization. Additionally, please know that billing correctly also helps Coordinated Care to be able to refer new clients to you for Evidence Based Practices.
Please reach out to your Provider Network Specialist if you have any questions/concerns about billing with EBP codes.
Coordination of Benefit (COB) Updates
Members need to contact Coordinated Care Customer Service 1-877-644-4613 to update their Coordination of Benefits (COB). The Health Care Authority (HCA) does not facilitate these changes, but instead, they are made through Coordinated Care Customer Service.
Inpatient Voluntary and Inpatient Involuntary Requirements
If a member transitions from a voluntary behavioral health admission to an involuntary admission, providers need to notify the health plan that the member has discharged/transferred from voluntary to involuntary and submit a new request for authorization of the involuntary.
Similarly, when a member transitions from an involuntary behavioral health admission to an voluntary admission, providers need to notify the health plan that the member has discharged/transferred from involuntary to voluntary and submit a new request for authorization of the voluntary stay.
Why is the notification needed? Legal status for a member changes how authorizations are reviewed and determined, therefore the notifications will help to ensure the authorizations are accurately reviewed for the correct level of care.
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Quality
Medicaid Quality
January is Cervical Cancer Awareness Month - Cervical Cancer Screening (CCS)
The goal for CCS is to assess the following for your patients:
- Women 21 - 64 years of age who have had cervical cytology performed within last 3 yrs.
- Women 30 - 64 years of age who had cervical high risk human papillomavirus testing performed within the last 5 yrs.
- Women 30 - 64 years of age who had cervical/high risk human papillomavirus co-testing within the last 5 yrs.
Click here for HEDIS measure information.
2024 New Year Screenings
Lead Screening for Children (LSC)
Children 2 years of age who have had one or more capillary or venous lead blood tests for lead poisoning by their second birthday.
Click here for HEDIS measure information.
Well-Care Visits (WCV)
Child and Adolescent Well-Care Visits: Assesses children 3 - 21 years of age who received one or more well care visits from a primary care practitioner or OB/GYN practitioner during the measurement year.
Click here for HEDIS measure information.
2024 Focus Areas
FOLLOW UP AFTER EMERGENCY DEPARTMENT VISIT FOR SUBSTANCE USE (FUA)
The percentage of emergency department (ED) visits among members aged 13 years and older with a principal diagnosis of substance use disorder (SUD), or any diagnosis of drug overdose, for which there was follow-up. Two rates are reported:
- The percentage of ED visits for which the member received follow-up within 30 days of the ED visit (31 total days).
- The percentage of ED visits for which the member received follow-up within 7 days of the ED visit (8 total days).
The following mental health providers can perform the FUH/FUA: psychologist, psychiatrist, clinical social worker, mental health occupational therapist, psychiatric/mental health nurse practitioner/clinical nurse specialist, neuropsychologist, psychoanalyst, professional counselor, marriage and family therapist.
An example of some of the qualifying events with adequate documentation/billing to close the FUA gap are listed below:
- An outpatient visit
- A telephone visit
- An intensive outpatient encounter or partial hospitalization
- A non-residential substance abuse treatment facility visit
- A community mental health center visit
- A telehealth visit
- An observation visit
- A peer support service
- An opioid treatment service that bills monthly or weekly
- An e-visit or virtual check-in
- A behavioral health screening or assessment for SUD or mental health disorders
- A pharmacotherapy dispensing event
FOLLOW UP AFTER HOSPITALIZATION (FUH HEDIS MEASURE)
The percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness or intentional self-harm diagnoses and who had a follow-up visit with a mental health provider.
The percentage of discharges for which the member received follow-up within 30 days after discharge (excluding day of discharge).
The percentage of discharges for which the member received follow-up within 7 days after discharge (excluding day of discharge).
The following mental health providers can perform the FUH/FUA: psychologist, psychiatrist, clinical social worker, mental health occupational therapist, psychiatric/mental health nurse practitioner/clinical nurse specialist, neuropsychologist, psychoanalyst, professional counselor, marriage and family therapist.
An example of some of the qualifying events with adequate documentation/billing to close the FUH gap are listed below:
- A telephone visit with a mental health provider
- A visit in a behavioral healthcare setting
- A visit in a non-behavioral healthcare setting with a mental health provider
- An intensive outpatient encounter or partial hospitalization
- Electroconvulsive therapy with a mental health provider
- Outpatient visits with a mental health provider
- Psychiatric collaborative care management
- Telehealth visits with a mental health provider
- Transitional care management services with a mental health provider
Asthma Medication Review
Assesses adults and children 5–64 years of age who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.50 or greater during the measurement year.
Asthma is a treatable, manageable, condition that affects more than 25 million people in the United States. Managing this condition with appropriate medications could save the U.S. billions of dollars in medical costs.1 The prevalence and cost of asthma have increased over the past decade, demonstrating the need for better access to care and medication. Appropriate medication management for patients with asthma could reduce the need for rescue medication—as well as the costs associated with ER visits, inpatient admissions and missed days of work or school.
Wellcare Quality
Managing Diabetes and Associated Conditions
Risk of diabetic retinopathy increases the longer a person has been diagnosed with diabetes. Over time, more than half of people with diabetes will develop the early stages of diabetic retinopathy usually without symptoms. Some may experience changes in their vision, like trouble reading or seeing faraway objects.
In later stages of the disease, blood vessels in the retina can start to bleed into the gel-like fluid that fills the eye. If this happens, a person may see dark, floating spots or streaks that look like cobwebs. It’s important to assess and implement treatment right away.
Diabetic retinopathy can lead to other serious eye conditions:
- Diabetic macular edema (DME). Over time, about 1 in 15 people with diabetes will develop DME. DME happens when blood vessels in the retina leak fluid into the macula (a part of the retina needed for sharp, central vision). This causes blurry vision.
- Neovascular glaucoma. Diabetic retinopathy can cause abnormal blood vessels to grow out of the retina and block fluid from draining out of the eye. This causes a type of glaucoma (a group of eye diseases that can cause vision and blindness)
- Retinal detachment. Diabetic retinopathy can cause scars to form in the back of your eye. When the scars pull your retina away from the back of your eye, it’s called tractional retinal detachment.
- Cataracts. Having diabetes makes you 2 to 5 times more likely to develop cataracts. It also makes you more likely to get them at a younger age.
- Open-angle glaucoma. Having diabetes nearly doubles your risk of developing a type of glaucoma called open-angle glaucoma.
If you see patients with diabetes, it’s important they get regular eye exams, have management of their blood glucose levels in a healthy range and a healthy lifestyle.
Encourage your patients to attend their Annual Wellness Visit (AWV), get their A1C testing regularly, participate in a dilated Diabetic eye exam and have a healthy lifestyle that manages any associated condition with their diabetes diabetic retinopathy.
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Tribal Updates
CY 2024 IHS Encounter Rates released (Medicaid only)
The 2024 IHS Encounter rates have been released and are effective 1/1/24. The Coordinated Care system has been updated to reflect the new rates; if you have claims processing for 2024 dates of service not reimbursing correctly, please contact Indianhealthcareproviders@coordinatedcarehealth.com for assistance.
Below are the rates:
- Medical, Dental and Mental Health encounters: $719.00 rate
- SUD:
- SUD services for IHS eligible AI/AN clients have the $719.00 rate.
- SUD services for non-AI/AN clients are:
- RAC 1201 and 1274 (T1015+SE) is $647.10 (90%)
- RAC 1217 (T1015+HB) is $647.10 (90%)
- all other non AI/AN with eligible RACs (T1015+HX) are $359.50 (50%)
Please note, the Residential Treatment Facilities that are cost based do not yet have the updated 2024 rates available from HCA. Once this is released, we will work to get our systems updated timely and reprocess claims as needed.
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Clinical Policy Updates
National Imaging Associates, Inc. (NIA)
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 Number | Policy Title |
|---|---|
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.
Genetic Testing Policy Updates
Updates to genetic testing clinical policies previously announced to be effective on January 1, 2024, have been postponed ensuring the most current criteria are used. Policies currently available on our policy website remain in effect.
Regular Monthly Updates
The below clinical policies received updates as part of our regular monthly review in December. These policy changes are effective February 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.PP.501 | Provider Preventable Readmission | Apple Health |
| WA.CP.MP.525 | Catheter Ablation for Supraventricular Tachyarrhythmia | Apple Health |
| WA.CP.MP.500 | Mandibular Advancement Devices | Apple Health |
| CP.MP.38 | Ultrasound in Pregnancy | Apple Health |
| WA.CP.MP.38 | Ultrasound in Pregnancy | Ambetter |
| CP.MP.70 | Proton and Neutron Beam Therapy | Apple Health & Ambetter |
| CP.MP.91 | Obstetrical Home Health Care Programs | Ambetter |
| CP.MP.142 | Urinary Incontinence Devices and Treatments | Apple Health & Ambetter |
| CP.MP.144 | Mechanical Stretching Devices | Ambetter |
| CP.MP.145 | Electric Tumor Treating Fields | Ambetter |
| CP.MP.168 | Biofeedback | Ambetter |
| CP.MP.181 | Polymerase Chain Reaction Respiratory Viral Panel Testing | Apple Health & Ambetter |
| CP.MP.247 | Transplant Service Documentation Requirements | Apple Health & Ambetter |
The below policies were updated as part of our regular monthly review in December. The policy changes are effective May 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 |
|---|---|---|
CP.MP.151 | Transcatheter Closure of Patent Foramen Ovale | Apple Health & Ambetter |
| CP.MP.180 | Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea | Apple Health & Ambetter |
| CP.MP.186 | Burn Surgery | Apple Health & Ambetter |
The below policy will be archived effective February 1, 2024. It will be replaced by a payment policy: CC.PP.206, Skilled Nursing Facility Leveling.
| Policy Number | Policy Title | Line of Business |
|---|---|---|
CP.MP.206 | Skilled Nursing Facility Leveling | Apple Health & 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.107 | Durable Medical Equipment (DME) and Orthotics and Prosthetics Guidelines | 3/1/24 | Apple Health & Ambetter |
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Pharmacy Updates
AcariaHealth
AcariaHealth is Coordinated Care's preferred specialty pharmacy vendor that can supply a number of products. Some products can be delivered directly to the provider’s location for office administration.
Visit AcariaHealth's website for a list of products AcariaHealth can provide to Coordinated Care members.
Providers can submit requests for specialty medications to Coordinated Care by filling out the General Specialty Medication PA Form (PDF) and faxing to Pharmacy Services.
Providers can submit requests to use their own stock of biopharmaceutical products by filling out the Buy and Bill Prior Authorization Form (PDF).
AcariaHealth General Customer Care
Phone: 1-800-511-5144
Fax: 1-877-541-1503
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Wellcare
As a best practice, and because of the large expansion of Wellcare now in 33 counties, please submit your rosters and any updates to both emails:
WAProviderservices@wellcare.com & CONTRACTINGB@coordinatedcarehealth.com
EPIC Payer Platform
November 6, 2023
We are pleased to be participating in Epic Payer Platform, a platform that enables more secure, efficient bi-directional data exchange between providers and health plans, as part of our broader interoperability strategy.
How does Epic Payer Platform benefit you?
Epic Payer Platform benefits providers by reducing friction, combining knowledge to improve care, and ultimately improving the patient experience. It is available for health systems and providers on Epic.
What are the features of Epic Payer Platform and how do they help?
- In our initial work with Payer Platform, we are live with clinical data exchange, which automatically releases appropriate clinical records to health plans. This helps reduce manual record requests, reducing administrative burden for providers.
- Following our initial work on risk adjustment, we intend to focus on HEDIS/Quality use, similarly, receiving information from Epic Payer Platform to improve the accuracy of quality measurement, also reducing manual records requests.
- We plan to develop additional features and continue to refine our roadmap:
- Actionable insights (such as our members’ gaps in care and historical conditions and diagnoses) can be provided at the point of care directly into a clinician’s existing workflow. This helps our provider-partners receive a more complete picture of their patients to help improve their quality of care.
- Plans to pilot prior authorization can help streamline the process and further reduce administrative frictions involved.
How do I learn more?
- For more information on risk adjustment use cases, please contact Jennifer Holman at Jennifer.l.holman@centene.com
Express Scripts
Reminder that Express Scripts begins Jan. 1, 2024
Medical Clinical Policy Updates
May 1, 2024:
- MC.CP.MP.248 Facility-based Sleep Studies for Obstructive Sleep Apnea
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 Betathalassemia
- 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
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Apple Health Core Connections
Apple Health Core Connections staff partner with caregivers, caseworkers, providers, Tribes, parents, and youth to ensure members get the care they need. Our care coordination team can support with:
- Referrals
- Plans for children/youth discharging from the ER or hospital
- Medication/pharmacy issues
- Support children/youth with multiple or complex needs
- Home Health care
- Support and education for health conditions (e.g., asthma, anxiety, diabetes)
- Accessing durable medical equipment and medical supplies
- Making connections to community resources and supports
- Suicide prevention and safety planning
- And more!
Call 1-844-354-9876, prompt “2” and ask for “Health Care Coordination” or email AHCCTeam@coordinatedcarehealth.com with the patient name, date of birth, Provider One or AHCC member number, and how we can help.
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.
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Training/Education
The Intersection of Transracial Adoption and Racial (in)Justice Transracial caregiving is a multifaceted journey for the entire family, but it is often the child who bears the brunt of navigating the complexity of the experience. It is critical that caregivers and parents understand the history of why children of color are over-represented in child-welfare in order to avoid perpetuating racism and to instead embrace an anti-racist outlook to support the health and wellbeing of transracial adoptees and/or transracial foster youth. This workshop will provide a window into the nuanced first-hand narratives of adoptees through videos, anonymized case studies and Angela’s personal stories. This interactive workshop will leave you thinking about the role transracial adoption plays in our quest for racial justice in America. February 1st - 4:00pm Register now.
Friend or Foe: The Impact of Social Media on the Mental Health of LGBTQ+ Youth & Implications for Practice Social media and online engagement have complex but significant impacts on the wellbeing of LGBTQ+ youth. Centering a trauma- informed and affirmative approach, this presentation will describe the benefits and challenges of these technologies on the mental health of these adolescents and early adults and highlights emerging research that centers the role of social media on the development of resilience. Specific strategies for the assessment and integration of social media use into practice will be offered. February 7th - 10am Register now.
Trauma Responsive Interventions for Transgender and Nonbinary Individuals: Clinical Considerations for Affirmative Implementation of EMDR Transgender and nonbinary (TNB) individuals experience disparate rates of rejection, discrimination, marginalization, and interpersonal violence. Gender dysphoria coupled with barriers to gender affirmation serve as additional sources of suffering for many TNB individuals. As a result of these experiences, many TNB youth and adults can benefit from trauma responsive interventions. Eye Movement Desensitization and Reprocessing (EMDR) is a highly recommended trauma treatment with a host of empirical evidence supporting its efficacy for PTSD and related mental health needs. Register now.
Culturally Responsive Depression Screenings for LGBTQIA+ Communities This webinar aims to increase the capacity of health centers to conduct culturally responsive depression and mental health screening and referral for LGBTQIA+ communities. This webinar will support health centers in population needs assessment and management, community needs and resource mapping, and clinical effectiveness of care for LGBTQIA+ patients, with an emphasis on social determinants of health. February 6th - 11am Register now.