Effective October 21, 2024- Blue Cross and Blue Shield of Texas will further enhance claim processing for Employee Retirement System of Texas participants by adding more enhancements. Along with the current post-payment audits, BCBSTX will further enhance the facility billing and payment accuracy by adding pre-payment reviews.

This new process will help provide more accurate payment with less administrative complexity for ERS participants while providing ease of the billing/claims process.

These BCBSTX pre-payment reviews will be performed by CERIS, a subsidiary of CorVel Health Corporation. Currently, CERIS serves as a post-pay auditor on behalf of the ERS plan participants. In the new process, claims will be reviewed prior to payment. This would imply fewer requests for refund post-claim since discrepancies in the billing could have been found out in advance.

An FAQ regarding this new pre-pay review process will soon be available via the ERS Tools page with more details to assist ERS plan participants and their healthcare providers.

Additional documentation may be needed for this pre-pay review by CERIS to allow the claims to pass correctly, it means keeping a record of all the necessary documentation on the part of the providers. Furthermore, providers must send these documents directly to CERIS at the address shown on the request and not to BCBSTX.

CERIS is a third-party contractor and is not an affiliate of BCBSTX. BCBSTX does not endorse the services or products of CERIS or any other third-party vendor.

BCBSTX will release more detailed information about these enhancements on their official website. So, keep an eye out and contact your service representative for more clarity. For additional support with navigating these changes, Capline is here to assist you every step of the way.

UnitedHealthcare has recently updated its Medicare Advantage Medical Policy, focusing on wound treatments and skin substitutes. The update contains the most recent coverage and vital guidance for providers on implementing these policies.

They've updated the headline and article to reflect current medical policy better. In addition, added a link to frequently asked questions about the details of the update.

This policy update applies to UnitedHealthcare Medicare Advantage plans and follows CMS Local Coverage Determinations (LCDs) and Local Coverage Articles (LCAs), where applicable.

When no specific LCDs or LCAs are available, it is suggested that providers consult the UnitedHealthcare Commercial and Individual Exchange Medical Policy on Skin and Soft Tissue Substitutes.

In case you require more details, providers may find the frequently asked questions on skin substitutes and wound treatments.

For additional information, providers can direct to the updated frequently asked questions.

This policy update reaffirms UnitedHealthcare's dedication to adhering align with the most current guidelines available while aiding in making certain that Medicare Advantage members receive effective and relevant care.

Effective December 1, 2024, UnitedHealthcare Community Plan (Medicaid) members in Maryland will be required to obtain prior authorization for certain specialty medications. This new requirement aims to ensure that members receive the most appropriate and effective treatments while managing healthcare costs.

How to Submit a Request: You can submit a prior authorization request through the UnitedHealthcare Provider Portal:

• Visit UHCprovider.com and click "Sign In" at the top-right corner.
• Enter your One Healthcare ID and password.
• If you're a new user without a One Healthcare ID, go to UHCprovider.com/access to create one.
• From the menu, select "Prior Authorizations."
• Scroll down to "Create a new notification or prior authorization request" and click "Create New Submissions."
• Fill in the necessary details and submit your request.

Please Note: For the following cell and gene therapies, contact Optum Transplant Services at 888-805-1802 to submit your prior authorization request:

• Abecma
• Breyanzi
• Carvykti
• Tecartus
• Zynteglo

Services provided without prior authorization request made before the service date will not be paid for. In such circumstances, the provider will be banned from balance billing members; thus, the cost of the medication cannot be shifted to the patient. This policy is used to save the patients from any shock of being asked to contribute some amount of money and also to ensure that the insurance company complies with the set standards.

Providers are encouraged to submit prior authorization requests as early as possible about the planned service date to enable adequate time for processing the request. The following guidelines are important to follow so that the provider can guarantee that the patients get the right treatments without gaps or costs.

UnitedHealthcare will enforce a new GA modifier requirement for commercial plans when billing claims as part of the Charging Members for Non-Covered Services protocol starting on February 1, 2025. As the Administration continues working to increase price transparency in healthcare, this regulation will help alert patients upfront of their potential cost-sharing liabilities.

The New Requirement

However, in addition to the consent requirements as stated in the protocol, if the provider is aware or has reasons to believe that a commercial member's benefits do not entitle him or her to a certain service as provided in the protocol, the GA modifier has to be included with the claim to charge the member for such a service.

The GA modifier will also be used to report that the higher consent standards that were put in place have been fulfilled. The rationale for this requirement is to make the members aware of their possible exposure to risk before any procedure or billing is done. If all the consent requirements in the protocol are not met, then the GA modifier should not be submitted, and the member cannot be billed.

What Providers Need to Do Now!

Suppose written consent is obtained from a commercial member for a service known or suspected to be non-covered, and the consent meets all protocol requirements. In that case, the GA modifier must be included on the claim for the non-covered service. Including the GA modifier ensures the claim is adjudicated as member liability where appropriate. The 2025 Administrative Guide for Commercial Plans will also include this new requirement.

Healthfirst announced an increase in the reimbursement rates for the services provided. It will go into force from September 1, 2024. Medicaid, Child Health Plus, Qualified Health Plan (QHP)/Marketplace, and Essential Plans will all be affected by the fee adjustments.

The reimbursement rate increase comes on the heels of an extensive analysis regarding the costs associated with the treatment of Healthfirst members receiving services.

The fee increase applies to a wide range of dental procedures and codes, as outlined in the revised fee schedule.

Increase in the Medicaid Adult Plan

The increase in fees associated with different dental codes is presented below for better understanding.

Increase in the Medicaid Child Health Plus Plan

The increase in fees associated with different dental codes is presented below for better understanding.

Increase in the Healthfirst QHP/Marketplace/Essential Plans

The increase in fees associated with different dental codes is presented below for better understanding.

This step will surely mark a change in the face of health coverage. It will bring about serious changes that will influence the affordability and accessibility of healthcare for many in the long run.

Effective September 1, 2024, prior authorization will be needed for certain services provided in multidisciplinary offices and outpatient hospital settings. This doesn't apply to services provided at home. The services requiring prior authorization include:

• Physical therapy (PT)
• Occupational therapy (OT)
• Speech therapy (ST)
• Medicare-covered chiropractic services (when billed with the AT-modifier)

Multidisciplinary practices are places where you can get physical therapy, occupational therapy, speech therapy, and chiropractic care all in one office or facility. Sometimes, they can also be individual offices that specialize in just one of these areas.

Starting soon, certain services will need prior authorization if they happen in specific places, including:

• Office settings (code 11)
• Off-campus outpatient hospitals (code 19)
• On-campus outpatient hospitals (code 22)
• Ambulatory surgical centers (code 24)
• Independent clinics (code 49)
• Comprehensive outpatient rehabilitation facilities (code 62)

This rule applies to UnitedHealthcare® Medicare Advantage plans across the country, except for Dual Complete Special Needs Plans (SNP). The existing rules for prior authorization in Arkansas, Georgia, South Carolina, and New Jersey will stay the same, and now Medicare-covered chiropractic services will also need prior authorization.

Process

Before starting treatment, no prior authorization is needed for the initial evaluation, so it can be reimbursed. However, once the treatment plan is made, which includes the number of visits, a prior authorization is required. Healthcare providers must submit the initial evaluation results and the treatment plan using an outpatient assessment form. If more visits are needed after the initial treatment, providers must get another prior authorization.

When a prior authorization request is made, it will be reviewed to see if the treatment is medically necessary. This review is done by licensed medical professionals, including physical therapists, occupational therapists, and speech-language pathologists, using specific criteria. Both the provider and the patient will be informed about the decision.

Affected Procedures

The procedure codes that need prior authorization include:

• Outpatient therapies: 92507, 92508, 92526, 97012, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97150, 97164, 97168, 97530, 97533, 97535, 97537, 97542, 97545, 97546, 97750, 97755, 97760, 97761, 97799, G0283
• Chiropractic services (Medicare-covered): 98940, 98941, 98942 when billed with the AT-modifier

Plans Affected

This update affects these UnitedHealthcare Medicare Advantage plans:

• Medicare Individual plans (including Chronic SNPs)
• Medicare Group Retiree plans
• UHCWest Medicare plans in Nevada, Oregon, Washington, and Texas
• UHCWest Medicare plans in Colorado starting January 1, 2025

Plans Not Affected

• UnitedHealthcare® Dual Complete plans
• UnitedHealthcare® Nursing Home and Assisted Living Plans
• Erickson Advantage
• Preferred Care Network and Preferred Care Partners of Florida
• UHCWest in California and Arizona
• OptumCare
• WellMed
• Peoples Health Plan
• Rocky Mountain Medicare Advantage plans

What You Need to Know

• Starting September 1, 2024, Optum Health Solutions will handle the approval process for outpatient therapy services.
• They will use specific rules to decide on these approvals.
• Initial evaluations don’t need prior approval.
• Services provided in the hospital or at home are not included in this change.

How to Submit a Request

• Go to UHCprovider.com and click "Sign In" at the top-right corner.
• Enter your One Healthcare ID and password.
• If you’re a new user without a One Healthcare ID, visit UHCprovider.com/access to get one.
• Select "Prior Authorizations" from the menu.
• Click "Create New Submissions" under “Create a new notification or prior authorization request.”
• Fill in the required information and submit.

If a prior authorization request is not received within 10 days after starting the service, the claim might be denied and you won't be able to charge the members extra.

Effective October 1, 2024, home- and community-based service (HCBS) providers in New Jersey will now have two options for filing claims. These claims include CPT® codes T1001 (evaluation) and T1001 with modifier 76 (re-evaluation).

These two methods are introduced to streamline the process and make the claim submission process faster.

Providers Will Now Have Two Options Mentioned Below:

• HHA eXchange (HHAx): An electronic visit verification system will allow you to enter a claim electronically.
• United Healthcare Provider Portal: It is an online portal designed for providers to send claims directly to the United Healthcare Community Plan of New Jersey.

With the help of online claim filing for nurses, the assessment will also aid Medicaid patients and HCBS providers. It will decrease the time and effort required to fill out claims by hand, allowing doctors to spend more time providing good care. Plus, electronic payments will be quicker and more accurate.

HCBS providers should check out the United Healthcare Community Plan of New Jersey information or contact their representative to learn more about the new online claim submission options and rules.

Please email and connect with the HCBS team at NJ_HCBS_PR@UHC.com.

As of October 1, 2024, CareFirst BCBS implemented a policy requiring prior authorization for a specific power wheelchair accessory. This policy change is specifically unique to the Healthcare Common Procedure Coding System HCPCS Code E2298, which denotes complex rehabilitative power wheelchair accessories; it represents the power seat elevation system.

This mandates health providers to get prior authorization for the accessory E2298 before it is delivered to the patient. This prior authorization process would help assure medical necessity and adherence to policy on the coverage as set out by CareFirst regarding the use of apparatuses of this nature. Providers must forward claims to CareFirst for review and approval before the provision of such accessories.

This newest requirement is part of CareFirst's ongoing efforts to contain healthcare costs, ensure that services and equipment provided to members are necessary, and ensure the appropriateness of services and equipment. Providers should be aware of the change and take all measures to prevent delays in patient care.

Additional information can be found on CareFirst's website for providers, with specific guidelines on the submission process and related training on the new process to facilitate the navigation of this change. Compliance would be crucial to this change to ensure no lapse in service delivery to the patients.

This kind of information should be communicated to relevant stakeholders, including patients who may be affected, to avoid any glitches in the smooth process of acquiring needed equipment. Health providers should be informed of such changes and should effect the right administrative changes.

CareFirst BlueCross BlueShield recently announced prior authorization changes for advanced imaging services in cardiology and radiology services, which will impact members enrolled with fully insured commercial coverage. This is an update stemming from the ongoing work between CareFirst and EviCore on enhancing the management of these services.

Effective August 2, 2024, the following identified advanced imaging procedures in cardiology and radiology will require prior authorization for the CareFirst commercial fully insured members on the Facets system. Providers have been able to submit prior authorization requests since July 15, 2024.

A provider must research three pieces of information to verify if prior authorization is required:

• Commercial Membership: The membership shall not be included in any of the following government programs, that are Federal Employee Program, FEP, Medicare Advantage, or CareFirst CHPMD. If participating in one of these, then they are not a commercial member, and prior authorization is not required for that member.
• Fully Insured Status: Providers must confirm the member is fully insured, or "RISK," with CareFirst. If the member is self-insured, or "NON-RISK," prior authorization is not required.
• Facets System Association: The member must be associated to the Facets source system. This can be confirmed on the CareFirst Direct Eligibility Summary screen.

Members meeting all three criteria would be required to have prior authorization for the imaging services identified. Providers can refer to a comprehensive list of codes requiring prior authorization on EviCore's Health Resource Page for CareFirst, under the 'Solutions Resources' tab.

CareFirst has several resources available to help providers navigate these changes. These include guides about the prior authorization request process via the EviCore portal and how to determine if an authorization is on file. Recordings of the live webinars held in July are also available for those who are unable to join.

This is an important update in that it makes all advanced imaging services management is preceded by necessary approvals, probably reducing unneeded procedures and enhancing coordination in care.

What could be a first-of-its-kind move to facilitate healthcare services and break down some of the administrative burdens, UnitedHealth Group announced its launch of the Gold Card program, effective August 1. The new initiative allows qualified medical practices to bypass the sometimes cumbersome prior authorization process for a variety of medical, behavioral, and mental health services.

The Gold Card program is a dramatic departure from how providers traditionally interact with insurance protocols, but one said to bring more efficiency and better delivery of care to the patient. Practices that successfully register for the gold card program will no longer have to worry about submitting prior authorization requests, a step that was historically known to be both time-consuming and bureaucratically challenging. It will save a lot of administrative workload for healthcare providers, who then get to focus much more on the care of patients.

Effective September 1, UnitedHealth Group will post a comprehensive list of services eligible under the Gold Card program. To this, UHG will release specific instructions as to how provider groups may assess their eligibility for Gold Card status. That is aimed at making practices informed about the standards and procedures for qualifying for gold card status, which helps them in necessary preparation and adjustment.

The program is scheduled to officially start this October 1, and qualified practices can look forward to a new beginning in health management. UHG strives to give birth to a more streamlined, healthcare-oriented system by easing and fast-tracking prior authorization initiatives, which shall allow providers to effectively deliver care on time, rather than getting held up by administrative red tape. Further updates will be published as UnitedHealth Group further rolls out this game-changing initiative.