ConnectiCare | Office Visit - May 2019
April 2019 Office Visit

May 2019 - In this issue

Check your taxonomy code in NPPES
Updated clinical practice guidelines for diabetes
Pharmacy updates
Medical record reviews to start this month
Claims edit goes into effect July 30, 2019
Modifier policy updated for commercial plans only
Need help understanding ERA codes?
ConnectiCare tools, resources and notifications
Has any of your information changed? Let us know.
Recent provider headlines

Check your taxonomy code in NPPES

Please make sure your taxonomy code in the National Plan and Provider Enumeration System (NPPES) database is accurate so you can prescribe controlled substances without problems. Taxonomy codes are administrative codes that identify your provider type and area of specialization. A taxonomy code is a unique 10-character, alphanumeric code that identifies your specialty at the claim level.

Express Scripts, our pharmacy benefit manger, will use the taxonomy code associated with the National Provider Identifier (NPI) number and in the NPPES to validate whether a provider has the authority to prescribe controlled substances. If the taxonomy code listed with the NPI is incorrect, your patients may not be able to fill prescriptions for controlled substances at the pharmacy.

This is being done to meet the requirements of the state prescriptive authority rules for our ConnectiCare Medicare Advantage members.

Here’s what you need to do:

1. Go to and look up your NPI.
2. Click on the NPI number to view the full record, including the provider taxonomy codes. If the taxonomy codes are accurate, you’re all set.
3. If the codes are incorrect, sign into to manage and update your NPI and taxonomy code. The taxonomy code should be updated automatically.

Updated clinical practice guidelines for diabetes

Once a year we review and update the clinical practice guidelines for some chronic conditions. We have updated our guidelines for diabetes based on the information the American Diabetes Association published in the Standards of Medical Care in Diabetes — 2019 report.*

Highlights of the changes are:

Based on new data, criteria for the diagnosis of diabetes was changed to include two abnormal test results from the same sample (i.e., fasting plasma glucose and A1C from same sample).
Because smoking may increase the risk of type 2 diabetes, a section on tobacco use and cessation was added. Discussion about e-cigarettes was expanded to include more on public perception and how their use to aid smoking cessation was not more effective than “usual care.”
Based on a new consensus report on diabetes and language, new text was added to help health care professionals communicate with people with diabetes and professional audiences in an informative, empowering and educational style.
A new table was added listing factors that increase risk of treatment-associated hypoglycemia.
The fatty liver disease section was revised to include updated text and a new recommendation regarding when to test for liver disease.
A recommendation was modified to encourage people with diabetes to decrease consumption of both sugar-sweetened and nonnutritive-sweetened beverages and use other alternatives, with an emphasis on water intake.
The sodium consumption recommendation was updated for those with both diabetes and hypertension. The guidelines do not recommend restricting sodium intake below 1,500 mg per day.
A recommendation was added to reevaluate glycemic targets over time to emphasize glycemic targets can change as diabetes progresses and patients age.
The recommendation to use self-monitoring of blood glucose in people who are not using insulin was changed because routine glucose monitoring has limited additional clinical benefit in this population.
To align with the ADA-EASD consensus report, the approach to injectable medication therapy was revised. A recommendation was made that, for most patients who need the greater efficacy of an injectable medication, a glucagon-like peptide 1 receptor agonist should be the first choice, ahead of insulin.
For the first time, the American College of Cardiology endorsed the section acknowledging heart failure is an important cardiovascular disease that needs to be considered when determining optimal diabetes care.
A discussion of the appropriate use of the ASCVD risk calculator was included, and recommendations were modified to include assessment of 10-year ASCVD risk as part of overall risk assessment and in determining optimal treatment approaches.
The recommendation and text regarding the use of aspirin in primary prevention was updated with new data.
Gabapentin was added to the list of agents to be considered for the treatment of neuropathic pain in people with diabetes based on data on efficacy and the potential for cost savings.
The recommendation for patients with diabetes to have their feet inspected at every visit was modified to only include those at high risk for ulceration. Annual examinations remain recommended for everyone.
Within the pharmacologic therapy discussion, deintensification of insulin regimes was introduced to help simplify insulin regimen to match individual’s self-management abilities. The report included new figures and table to help guide providers considering medication regimen simplification and deintensification/deprescribing in older adults with diabetes.
The discussion of type 2 diabetes in children and adolescents was significantly expanded, with new recommendations in several areas, including screening and diagnosis, lifestyle management, pharmacologic management and transition of care to adult providers.
Women with preexisting diabetes are now recommended to have their care managed in a multidisciplinary clinic to improve diabetes and pregnancy outcomes.
Greater emphasis has been placed on the use of insulin as the preferred medication for treating hyperglycemia in gestational diabetes mellitus as it does not cross the placenta to a measurable extent. It also notes how metformin and glyburide should not be used as first-line agents because both cross the placenta to the fetus.

*Source: American Diabetes Association. Standards of Medical Care in Diabetes — 2019 Standards of Medical Care in Diabetes — 2019. (last accessed 14 May 2019)

Pharmacy updates

We recently sent letters to some patients about coverage changes to drugs they may be taking. Here are the changes for ConnectiCare members with:

Medicare Advantage plans — We have removed Zytiga 250 MG tablet from our formulary and will no longer cover it. Please prescribe the preferred drug alternative of abiraterone acetate 250 mg tablet instead. This change was effective May 1, 2019.
Commercial plans — After July 1, 2019, the following specialty drugs will only be covered if they are filled through Accredo Specialty Pharmacy, our exclusive specialty provider:
o Granix
o Leukine
o Neulasta
o Neupogen
o Zarxio

Medical record reviews to start this month

Ciox Health and/or Optum may contact your office between now and the end of December to retrieve and review the medical records of your patients who have ConnectiCare Medicare Advantage plans.

Ciox Health and Optum will conduct chart reviews of 2018 and 2019 dates of services on ConnectiCare’s behalf. We are required to submit accurate and complete diagnosis data for each member to the Centers for Medicare & Medicaid Services (CMS).

As our partners and “Business Associates,” as defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Ciox Health and Optum are fully HIPAA-compliant and are required to protect, preserve and maintain the confidentiality of any protected health information (PHI) obtained from clinical records provided by medical practices.

We appreciate your help. If you have questions, please call ConnectiCare Medicare Provider Services at 877-224-8230.

Claims edit to go into effect July 30, 2019

The following claims edit will go into effect July 30, 2019:

Policy: Pilonidal cyst and pilonidal sinus procedures

Policy description: Incision and drainage of a pilonidal cyst (10080-10081) and excision of a pilonidal cyst or sinus (11770-11772) should only be reported with a diagnosis of pilonidal cyst or pilonidal sinus (ICD-10 codes L05-L05.92). These procedures will be denied when reported without an appropriate diagnosis.

Reference: AMA CPT Manual

Plans affected: ConnectiCare commercial and Medicare Advantage plans

Modifier policy updated for commercial plans only

We have included the modifier “QW” to our current modifier policy for commercial plans only. This modifier is used to identify Clinical Laboratory Improvement Amendment (CLIA)-waived test(s). If this modifier is used in claims submissions that are not CLIA-waived tests, those claims will be denied. Please note, claims for CLIA-waived tests need to include both the modifier and CLIA number.

Here’s the Modifier Reference Policy (Commercial) for more details.

Need help understanding ERA codes?

Have questions about an electronic remittance advice (ERA) code? Check this web page from the Centers for Medicare & Medicaid Services (CMS).

ERA codes, in general, explain the payment and adjustments made to any Medicare claims payment. They can also help providers identify if they need to take any additional steps related to a claim, such as resubmitting it with correct information, or whether the member can be billed.

Medicare providers should only bill Medicare members if the claims adjustment code lists “PR,” which stands for patient responsibility or the patient is financially liable. Medicare members should not be billed under the OA (other adjustment – no financial liability) or CO (contractual obligation – provider is financially liable) reason codes.

Check out our provider manual for more details on billing Medicare members.

ConnectiCare tools, resources and notifications

Every year, we let our providers know about the tools and resources that are available to you and our members and share information that is important for you to know.

Read more

Has any of your information changed? Let us know.

Check our provider directory to make sure we have the right information for you and your practice. Our members rely on our provider directory to find doctors like you quickly and easily.

Relevant changes include your:

Tax ID number
National provider identification (NPI)
Phone number
Office hours
Ability to accept new patients

Submit any changes by filling out our provider information update form and sending it back to us as noted on the form.

Recent provider headlines

Check out the latest Provider News & Headlines:

Working to improve critical follow-up care for children with ADHD
Detailed reimbursement policy on Maximum Daily Frequency (MDF)
Reminder to use in-network labs

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