ConnectiCare | Office Visit - July 2017
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New oncology management program for members ages 18 and older
We're launching a new oncology management program to streamline preauthorization. We will phase it in as follows:
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All commercial plans went into effect July 1, 2017.
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All Medicare Advantage plans will go into effect Aug. 1, 2017.
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The program, to be managed by New Century Health (NCH), will give providers access to medical oncologists for peer-to-peer discussions and help your staff deliver quality care to your patients.
We will continue to require preauthorization of all oncology-related chemotherapeutic drugs and supportive agents administered in a physician’s office, outpatient or ambulatory setting. Preauthorization requests, however, will have to be submitted to NCH after July 1, 2017, for your commercial patients, and after Aug. 1, 2017, for your Medicare patients.
Continue to submit preauthorization requests for pediatric patients to ConnectiCare.
By working with NCH, you will get:
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A team approach in delivering quality patient care.
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Access to peer-to-peer discussions with medical oncologists who understand treatment regimens.
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A quick turnaround on authorization requests.
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Telephone support from 8 a.m. to 8 p.m. Monday through Friday at 1-888-999-7713, option 1.
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A secure web portal that provides real-time authorizations, reduced documentation requirements and eligibility verification.
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How the preauthorization process will work through NCH
You can submit preauthorization requests:
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through the NCH secure website at my.newcenturyhealth.com (log in required), or
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by calling NCH's Utilization Management Intake department at 1-888-999-7713, option 1, between 8 a.m. and 8 p.m. (ET) Monday through Friday.
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NCH will review requests using ConnectiCare's medical criteria. NCH will also use clinical guidelines based on nationally recognized, evidence-based criteria for determining medical necessity in cancer care.
Authorizations issued before the effective dates listed above will remain valid as written until they expire. Once those authorizations expire, preauthorization requests will need to be submitted to NCH for review.
Please refer to this frequently-asked-questions document for more details. To schedule an in-service training for your staff, call NCH at 1-888-999-7713 and choose option 6.
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Coding edits, effective Aug. 29, 2017
The following coding edits will go into effect Aug. 29, 2017, for both commercial and Medicare Advantage plans, unless otherwise noted:
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24-Hour EEG monitoring: We recognize NGS Medicare LCD L33399 for commercial and Medicare claims. CPT codes 95950, 95951, 95953 or 95956 (24-Hour EEG Monitoring) will be reimbursed when billed with a requisite diagnosis in accordance with the LCD criteria.
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Ambulance transport and mileage: We follow the Centers for Medicare & Medicaid Services (CMS) policy that states mileage codes must be billed for the same date of service as ambulance services (A0380, A0390, A0425, A0435 or A0436) and/or transport codes (A0225, A0426-A0434, S9960 or S9961), when covered.
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Anatomical modifiers: Procedure codes that involve a specific body site require an applicable anatomical modifier, which are:
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E1-E4 (eyelids)
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FA-F9 (fingers)
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TA-T9 (toes)
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LC (left circumflex, coronary artery)
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LD (left anterior descending coronary artery)
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LM (left main coronary artery)
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RC (right coronary artery)
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RI (ramus intermedius)
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LT (left side)
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RT (right side)
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50 (bilateral side)
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Consultation services: Consultation services have specific reporting and documentation criteria to be able to be reported based on American Medical Association (AMA) and AMA CPT Assistant guidelines.
If a provider of the same primary specialty and same group tax ID has billed any other evaluation and management service in any place of service in the previous 12 months, outpatient/office consultation services 99241-99245 will be denied and may be reconsidered upon submission of the clinical documentation.
Alternatively, an office visit 99201-99215 may be submitted on a corrected claim. An exception is made to this policy for consultations performed for the purpose of pre-operative evaluations (ICD-10 codes Z01.810, Z01.811, Z01.818).
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Duplicate drug claims: We will not reimburse more than one professional provider for the same drug code and unit count billed on a different claim by any other professional provider for the same member and date of service.
This edit will only go into effect on Aug. 29 for commercial plans. An existing edit is already in place for Medicare Advantage plans.
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Emergency ambulance destination modifiers: We recognize the CMS policy for emergency (ground) ambulance services (A0427, A0429 or A0433) are payable only for the destination of hospital (Modifier H), site of transfer (Modifier I), or intermediate stop at physician’s office on way to hospital (Modifier X).
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You can now check for patients' Passage referrals online
We have upgraded our secure provider website, Provider Connections, so Passage PCPs and specialists can view referrals.
Passage plans, which went into effect Jan. 1, 2017 for some commercial and Medicare Advantage plans, require members to get primary care provider (PCP) referrals to see any specialists in our network. This is indicated on members' ID cards.
Now specialists can log into Provider Connections and go to the referral section to make sure patients have valid referrals before their appointments. Without referrals, we will deny claims for specialists' consultation services and tell members they are responsible for the costs.
If a referral's end date needs to be extended, only the patient's Passage PCP can make the edit online.
As a reminder, referrals are not required when Passage members need hospital and/or ancillary care services, such as radiology and lab work.
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Epidural codes will not require preauthorization
The new 2017 epidural codes of 62320, 62321, 62322, 62323, 62324, 62325, 62326 and 62327 will not require preauthorization. This applies to both commercial and Medicare plans. This policy supersedes a February 2017 provider notification.
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Medicare news: Organization determination requests for non-covered services
Providers who want to order services that are not covered under ConnectiCare Medicare Advantage plans should follow a process known as "organization determination."
To obtain an organization determination from ConnectiCare, providers can:
Call: 1-800-508-6157
Fax: 1-866-706-6929
Write: ConnectiCare
ATTN: Medicare Utilization
P.O. Box 4050
Farmington, CT 06034-4050
If we deny a provider's organization determination request, we will issue an integrated denial notice (IDN) to both provider and member. The IDN will include information on how to appeal.
ConnectiCare will not pay for – and the provider cannot bill the member for – any non-covered service if the organization determination process isn't followed.
If ConnectiCare issues an IDN, however, the provider may hold the member responsible for the cost of a service.
For more information, or answers to your questions, please contact Medicare provider services at 1-877-224-8230.
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There's no place like home: Summer promotion through Aug. 6
There's no place like Connecticut. It's our home. And to celebrate, we're giving away $50 gift cards to your favorite local experiences, places like The Mystic Aquarium, The Hartford Yard Goats and the Warner Theater. This summer promotion runs until August 6.
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