Our preauthorization policies will include site-of-service reviews for dates of services on or after Aug. 1, 2019. The changes are:
Preauthorization requests for certain non-emergent surgical services and/or procedures will be reviewed to determine if the proposed site of service is medically appropriate for the service or procedure. This will apply to all commercial plans, including group and individual plans.
Certain medical-injectable drugs (J-codes) will need prior approval for all commercial and Medicare Advantage plans.
Medical services preauthorization updates Under the new policy, providers will need to submit preauthorization requests to us if:
Office-based procedures are provided in an outpatient hospital or ambulatory surgery center, or
Certain outpatient surgical procedures are provided in an outpatient hospital, including hospital-owned, off-campus facilities.
Affected services include, but are not limited to: dermatology, gastrointestinal, gynecological, orthopedic, ophthalmologic and urologic procedures. The medical services preauthorization program seeks to ensure the members receive care in the most appropriate setting.
Providers who have ordered or scheduled affected services for dates on or after Aug. 1, 2019 should make sure they obtain authorizations before services are performed on patients with ConnectiCare commercial plans. If providers do not get the site-of-service approvals for affected medical services, claims may be denied and members cannot be billed for the services.
You can fax preauthorization requests for medical services to 1-800-923-2882 or call 1-800-562-6833.
Reimbursement policy: Observation stay
Under this new policy, to go into effect Aug. 1, 2019, we will no longer reimburse observation stays that are less than eight (8) hours or more than 48 hours. This policy follows guidance from the Centers for Medicare & Medicaid Services. It will apply to our commercial and Medicare Advantage plans.
Payment policy: After-hours and weekend care
We have updated this policy to note we will only reimburse after-hours care under CPT codes 99050 and 99058 to participating primary care providers (PCPs) when the care is provided in a non-facility based, in-office setting, POS 11 (place of service) designation. This policy goes into effect Sept. 1, 2019 and will only apply to commercial plans.
The Centers for Medicare & Medicaid Services (CMS) restructured the Beneficiary Family Centered Care-Quality Improvement Organizations (BFCC-QIO) and changed the organization supervising the quality of care received by ConnectiCare members. After June 8, the new organization responsible for Quality Improvement Organization (QIO) Region 1, which includes ConnectiCare, is KEPRO, an organization independent of ConnectiCare.
KEPRO’s contact information is listed below:
Telephone: 888-319-8452 or 216-447-9604 (TTY: 855-843-4776), available from 9 a.m. to 5 p.m. Monday through Friday, and 11 a.m. to 3 p.m. on weekends and holidays. A Medicare beneficiary can also leave a message at KEPRO’s toll-free number, 888-319-8452, 24 hours a day, seven days a week. Translation services are available for beneficiaries or caregivers who do not speak English.
Mailing address: 5700 Lombardo Center Dr. Suite 100, Seven Hills, OH 44131
Last year, we expanded our existing partnership with Magellan Healthcare to include preauthorization management of cardiac imaging program and implantable devices and outpatient interventional spine pain management. As part of this effort, Magellan implemented a clinical validation of records (CVR) process. This means Magellan will review a patient’s medical records to make sure clinical criteria are met and support the requested service. Please follow the CVR process. Magellan’s audit of clinical records helps us make sure our members receive the most appropriate and effective care.
Submitting clinical record for Outpatient Imaging, Cardiac Procedures and Musculoskeletal Management Program (MSK)
As part of Magellan’s preauthorization review, providers are asked to submit certain aspects of the record for review. There are two ways you can submit clinical records to Magellan:
Upload the records through the upload clinical document feature on Magellan’s website, www.RadMD.com. This is the fastest option and expedites the provider’s request because the information is automatically added to the case and sent to Magellan clinicians for review.
Please use a fax cover sheet. Magellan will fax providers back if more clinical information is needed for the preauthorization review.
Reminders about the Magellan preauthorization review:
Providers may seek peer-to-peer consultations with Magellan Healthcare’s board-certified physicians by calling Magellan Healthcare at 1-877-607-2363.
Providers can find clinical guidelines on www.RadMD.com under “Online Tools/Clinical Guidelines.” The website also offers other online tools and resources for providers, such as checklists and other information.
If you have any questions, please call Magellan Healthcare’s Provider Services Department at 800-327-0641 or Dedicated Magellan Healthcare Provider Relations Manager Charmaine S. Everett at 1-800-450-7281, ext. 32615.