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:

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:

*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:

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.