ConnectiCare | Office Visit - February 2020
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Update on explanations of payments for 2020 Medicare dates of service
Our 2020 explanation of payments (EOP) for Medicare claims with 2020 dates of services will no longer itemize the 2 percent provider payment reduction fee, known as “Medicare sequestration.” The reduction will be automatically made from the provider payment after copayments and/or coinsurance are applied. The claim line on the EOP will include a note with the letter “S” to indicate the payment was subject to Medicare sequestration.
For example:
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A provider may receive an EOP that has a claim item with the letter “S” in the notes and shows $100 allowable charge that was reduced by a $20 copayment.
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The EOP will show that the provider is owed $80 for the services.
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The claim, however, was subject to Medicare sequestration. So ConnectiCare’s payment will only reflect $78.40. A 2 percent reduction was applied to the $80 provider payment listed on the EOP.
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Providers will need to manually determine the sequestration fee by simply subtracting 2 percent from provider payment flagged with the “S” note. So if a provider sees an $80 payment flagged with the note for Medicare sequestration, the calculated payment will be $78.40.
This applies to our EOPs generated for Medicare Advantage claims with dates of service on and after Jan. 1 ,2020. EOPs for our Medicare Advantage claims with 2019 dates of services still itemize the Medicare sequestration fee.
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Vision benefits for Medicare Advantage plans have changed
Starting Jan. 1, 2020, our Medicare Advantage plans only cover one routine vision exam per year, and it must be performed by an EyeMed® participating provider. ConnectiCare providers who also participate in EyeMed’s network can continue performing routine vision exams for our Medicare Advantage members but must submit claims to EyeMed.
Please note, our Medicare Advantage plans do not have any out-of-network benefits for vision. Claims for routine vision exam submitted by nonparticipating EyeMed providers will be denied.
If you are not a participating EyeMed provider, ConnectiCare will continue to cover Medicare-covered services, such as diagnostic vision exams and eyeglasses or contacts after cataract surgery. Claims for these services can still be submitted to ConnectiCare.
Some of our plans — Passage Plan 1 (HMO), Choice Plan 3 (HMO) and Flex Plan 3 (HMO-POS) — include an allowance toward routine eyewear when a member uses an EyeMed participating provider.
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Accredo’s Convenient Care Program for commercial members
Effective Apr. 1, 2020, maintenance doses of certain infused medications will only be covered when given in your patient’s home (Place of Service 12), an ambulatory infusion suite (AIS, Place of Service 12) or a doctor’s office (in a non-hospital setting, Place of Service 11). The specialty drugs on the list below will no longer be covered in an outpatient hospital setting (Doctor’s Office-Off Campus, Place of Service 19 & On-Campus Outpatient Hospital Place of Service 22), unless ConnectiCare approves an exception* for your patient.
Members using an outpatient hospital setting for their treatments without prior authorization will be responsible for the full cost of their drugs and treatment. This only affects members age 21 and older with ConnectiCare commercial plans.
ConnectiCare is partnering with Accredo Specialty Pharmacy to provide home infusion treatments in members’ homes through Accredo’s Convenient Care Program. To help transition members from an outpatient hospital setting to home, or a doctor’s office, an Accredo pharmacist will reach out to prescribers for new prescription(s).
Once the prescription is in place, an Accredo representative will call the member to schedule the delivery of the medicine(s) and treatments. Members may request a one-time-only refill of their specialty medicine(s) at their current provider after Apr. 1, 2020, if needed.
ConnectiCare has partnered with Coram and Option Care home infusion vendors, who have ambulatory infusion suites throughout the country to serve your patients who are ConnectiCare members. For more information on ambulatory infusion suites, please call your local Coram or Option Care.
| Drugs not covered in outpatient setting
starting Apr. 1, 2020
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| BIVIGAM |
HIZENTRA |
| CARIMUNE NF |
HYQVIA |
| CUVITRU |
INFLECTRA |
| FLEBOGAMMA 5&10% |
OCTAGAM |
| GAMMAGARD LIQUID |
PANZYGA |
| GAMMAGARD S-D |
PRIVIGEN |
| GAMMAKED |
REMICADE |
| GAMMAPLEX |
REMICADE |
| GAMUNEX-C |
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Change in preauthorization process
The drugs listed above currently require preauthorization requests be submitted to our partner, Magellan Rx Management (Magellan Rx). Starting March 1, 2020, ConnectiCare will review preauthorization requests for these drugs. You can continue submitting preauthorization requests for these drugs to Magellan Rx until Feb. 29, 2020.
Through this preauthorization program, we will direct commercial members to an alternative site of service, when appropriate. ConnectiCare recognizes that home infusion (Place of Service 12), an Ambulatory Infusion Suite (AIS, Place of Service 12) or a doctor’s office (in a non-hospital setting, Place of Service 11) may not be suitable for all members. Providers must submit clinical rationale and documentation for review for exceptions as part of their preauthorization requests.
*For administration in a Doctor’s Office-Off Campus (Place of Service 19) or an On-Campus Outpatient Hospital (Place of Service 22), one of the following criteria must be met:
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Pediatric patients (under 21 years of age)
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Documented history of a severe reaction, which is defined as anaphylactic reaction, to this medication or any constituent of it
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Known cardiac condition (e.g. symptomatic cardiac arrhythmia) or pulmonary condition (e.g. significant respiratory disease, serious obstructive airway disease, %FVC ≤ 40%) that may increase the risk of an adverse reaction
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Documented intolerance to this medication requiring constant telemetry monitoring of vitals
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Unstable renal function that decreases the ability to respond to fluids
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Difficult or unstable vascular access
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Unsafe home environment
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Acute mental status changes or cognitive conditions that impact the safety of infusion therapy
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No access to emergency services
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Here’s what you need to know about existing preauthorization approvals for the drugs above:
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Your patients’ current authorizations will be valid through the date noted in the approval letter. Any renewals after March 1, 2020 must be submitted and approved by ConnectiCare’s Pharmacy Department.
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You can request authorizations and exceptions by:
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Fax: 1-800-249-1367
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Phone: 1-800-828-3407 (our hours are 8 a.m. to 6 p.m., Monday to Friday)
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If you have questions, please call us at 1-800-828-3407. We would be happy to provide you with a list of approved home infusion vendors and ambulatory infusion suites. You can also call Accredo at 844-581-4862. Their hours of operation are 8 a.m. to 5 p.m., Monday through Friday.
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Medicare contract level risk adjustment data validation (RADV) audit to begin this month
Cognisight, LLC, may contact you through June to retrieve and review medical records of patients with ConnectiCare Medicare Advantage who were seen at your office in 2014.
The Centers for Medicare & Medicaid Services (CMS) has asked ConnectiCare to undergo a contract level risk adjustment data validation (RADV) audit on a small sample of members enrolled in Medicare Advantage plan. To verify the accuracy of diagnosis date submitted, this audit requires us to submit supporting medical records on a limited population of members covered by the audit. The dates of service requested will be between Jan. 1, 2014 and Dec. 31, 2014.
Cognisight will retrieve, review and submit medical records for the members in the audit population. Cognisight will contact your offices to coordinate the chart retrieval method and set the date when the records are needed.
Please respond to Cognisight’s requests for records promptly. This is a federally-mandated audit. Notice of the need for these reviews and your required compliance are included in your contract with ConnectiCare.
As our partner and “business associate,” as defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Cognisight is fully HIPAA-compliant and 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 our provider services department at 1-877-224-8230.
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ConnectiCare is a brand name used for products and services provided by ConnectiCare Insurance Company Inc., and its affiliates, members of the EmblemHealth family of companies.
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