ConnectiCare | Office Visit - September 2021
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Preauthorization List Reductions and Updates for 2022
Good news! We are continuing to find ways to simplify our providers’ administrative burdens. Starting Jan. 1, 2022, we are removing 99 codes from the EmblemHealth Preauthorization List, and ConnectiCare’s Preauthorization Requirements for Commercial and Medicare plans. Scroll down to Clinical Corner for more details.
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City of NY Retirees Moving to New Medicare Advantage Plan in 2022
As we told you in previous newsletters, the City of New York recently awarded its group retiree business to Retiree Health Alliance, a collaboration between EmblemHealth and Empire BlueCross BlueShield (BCBS).
To help you navigate this new plan, we have a series of Upcoming Webinars to review key operational processes such as determining eligibility and benefits, preauthorization requirements, and claims submissions. Webinars start in November so sign up now!
We will be sharing more information in upcoming newsletters, and you can review previous announcements from August and September in our newsletter archive.
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Save Time by Using Our New Provider Portal
Our new provider portal offers busy provider offices and hospital staff time-saving benefits. We encourage you to turn away from the old ways of doing business and save your practice both time and administrative expense by moving your transactions to our new portal.
Learn more about these time-saving benefits, and how to set up your account, manage transactions, and get your job done faster.
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Remind Your Patients to Get Their Flu Vaccine
According to the Centers for Disease Control and Prevention (CDC), flu activity usually peaks between December and February. That means now is a key time to remind your patients that although they may have received a flu vaccine last year, the flu virus changes each year and a new vaccine is needed. If the vaccine is the only reason for the office visit, there is no copayment. If your office does not carry the vaccine, direct patients to their local pharmacy. We will be supporting your efforts by contacting our members soon about the importance of getting a flu vaccine. Together, we can make sure everyone is protected.
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November is March of Dimes Prematurity Awareness Month
November is Prematurity Awareness Month. Preterm birth rates are continuing to rise in the U.S. Here are some tips to close gaps and increase visit compliance.
HEDIS Measure: Timeliness of Prenatal Care: The percentage of deliveries in which women had a prenatal care visit in the first trimester, on or before the enrollment start date, or within 42 days of enrollment in the organization.
Tip to close gaps: Add on to the initial prenatal screening visit (typically performed by a nurse) with a 15-minute provider introduction visit, order prenatal labs, and provide first prescription for prenatal vitamins.
Tip to increase visit compliance: Researchers found that group prenatal care patients had a 37% lower risk of having a preterm birth and a 38% lower risk of having a low birth weight baby than women receiving traditional one-on-one care. Better attendance at the group visits also resulted in more pronounced benefits.
Learn more about Prematurity Awareness from the March of Dimes.
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COMMERCIAL BUSINESS UPDATE
Bridge Program Membership Continues to Grow
The Bridge Program continues to expand its membership. You can see Bridge members if you participate in any of the networks listed in the infographic below. Be sure your appointment schedulers understand this and don’t mistakenly turn away our members. Learn more about the Bridge Program.
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MEDICARE UPDATES
ConnectiCare Medicare Members – Optum/ProHealth Delegation
As of Oct. 1, 2021, we delegated the medical management of some ConnectiCare Medicare Advantage members to Optum Care. The affected members are now assigned/attributed to a PCP who is part of the Optum Care Network of Connecticut IPA; this includes ProHealth Physicians. Medicare Advantage members enrolled in ConnectiCare Dual Special Needs Plans (D-SNPs) are excluded from this delegation. Here are some frequently asked questions and answers to help you understand this change:
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Which members/plans are followed by Optum Care Network of Connecticut and how do we identify them?
All ConnectiCare Medicare Advantage members (excluding D-SNP) will be managed by Optum Care Network of Connecticut. Member ID cards will have the Optum logo on the bottom. See below for sample ID card.
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Are claims submitted to ConnectiCare or Optum Care Network of Connecticut?
At this time, all claims should continue to be submitted to ConnectiCare. We will inform you when claims will need to be sent to Optum Care Network of Connecticut.
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Is ConnectiCare or Optum Care Network of Connecticut responsible for grievances and appeals?
All grievances and appeals will be handled by ConnectiCare and can be sent to Medicare_AppealsandGrievances@connecticare.com.
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Where should providers submit preauthorization requests?
Preauthorization requests can be submitted to Optum Care Network of Connecticut by calling 888-556-7048 or by faxing the request to 855-268-2904.
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Do Not Bill Members with Full Medicaid or QMB
If Medicare-Medicaid dual eligible individuals have their Part A and Part B cost-share fully covered by their Medicaid plan, or are Qualified Medicare Beneficiaries (QMBs), they are not responsible for their Medicare Advantage cost-share for covered services.
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Medicare Outpatient Observation Notice (MOON)
All hospitals and critical access hospitals are required by the Centers for Medicare & Medicaid Services (CMS) to provide Medicare beneficiaries, including Medicare Advantage enrollees, with the Office of Management and Budget (OMB)-approved Medicare Outpatient Observation Notice (MOON). The MOON and instructions for completing it are available on CMS’ website.
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POLICIES, BILLING AND CLAIMS
The ConnectiCare website is a rich source of information that helps your practice navigate ConnectiCare claims and billing processes. Check the website often to see new postings. Similar information can be found on EmblemHealth’s website.
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Outpatient Imaging Self-Referral Reimbursement Policy
On Oct. 1, 2021, the outpatient imaging self-referral reimbursement policy was updated to allow Cardiologists (including cardiovascular specialists, interventional cardiologists, and cardiac electrophysiologists) and Pediatric Cardiologists to render MRA Chest Cardiac Magnetic Resonance Imaging (for 71555, 75557, 75559, 75561, 75563) if the facility is accredited from the American College of Radiology (ACR) with Cardiac Module, Intersocietal Accreditation Commission (IAC) with Cardiovascular MRI, or RadSite with Cardiac Module.
Starting Aug. 1, 2022, the provider will be required to have Certification Board of Cardiovascular Magnetic Resonance (CBCMR) certification in order to be paid. We recommend that physicians use the time between now and next August to obtain the required certifications. Starting Aug. 1, 2022, claims submitted by an uncertified provider will be denied.
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CLINICAL CORNER
Preauthorization List Reductions and Updates for 2022
Good news! Starting Jan. 1, 2022, we are removing 99 codes from the EmblemHealth Preauthorization List, and ConnectiCare’s Preauthorization Requirements for Commercial and Medicare plans. This is part of an ongoing evaluation of our preauthorization lists and an effort to simplify the administrative burden for our providers.
Starting Feb. 1, 2022, five new CPT codes will require preauthorization. These new codes supplement the ones that already require preauthorization for Neurostimulators (63664), Potentially Unproven Services (Q2043), and Cosmetic & Reconstructive Surgery (54416, 54401, 54405). See the full list of CPT Codes and their descriptions on our websites:
EmblemHealth
ConnectiCare
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Clinical Practice Guidelines
We encourage you to consult our Clinical Practice Guidelines (CPGs) for assistance in the treatment of acute, chronic (e.g., HIV), and behavioral health issues. We’ve adopted these guidelines from professionally recognized sources and through consultation between board-certified specialists and our Medical Policy Committee. The guidelines are reviewed and updated regularly. CPGs are not intended as a substitute for your professional assessment, but rather to assist you in the management of certain types of preventive and clinical care.
EmblemHealth Guidelines
ConnectiCare Guidelines
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Medical Policy Updates
All EmblemHealth and ConnectiCare Medical Policies are available for download from our provider websites. The following are the recently revised policies for EmblemHealth and ConnectiCare:
Revised
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Analysis of KRAS Status (EmblemHealth only)
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Carrier Screening for Parents or Prospective Parents (EmblemHealth only)
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Rhinoplasty (EmblemHealth & ConnectiCare)
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Visual Electrophysiology Testing (EmblemHealth & ConnectiCare)
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Experimental, Investigational, and Unproven (ConnectiCare only)
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Retired
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Lung Volume Reduction Surgery (EmblemHealth only)
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Visual Evoked Potential Testing for Pediatric Populations in the Primary Care Setting — Commercial/Medicaid (EmblemHealth & ConnectiCare)
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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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