ConnectiCare | Office Visit - August 2019
ConnectiCare
June 2019 Office Visit

August 2019 - In this issue

Educating your patients on statins
Administrative policy for PCPs accepting Passage plans
A reminder about our new site-of-service utilization policy
Payment integrity admission policy for inpatient claim submissions
Claims edit goes into effect Oct. 29, 2019
Formulary update effective Oct. 1, 2019
Refer patients to our care management team
Recent provider headlines

Educating your patients on statins

You know how important statins can be in maintaining the health of certain patients. But patients may not understand the purpose of these medicines. Share this blog post in your patient communications to help them learn more about statins and how they may help to lower the risk of heart disease and stroke.

Read our blog post on statins

Administrative policy for PCPs accepting Passage plans

We regularly review our policies to ensure we are addressing our members’ interests. Recently, we published the Administrative policy: Criteria for primary care providers to accept Passage plans (commercial and Medicare Advantage) on our website. The policy details the requirements for primary care providers who accept Passage plan members. This policy will go into effect Sept. 1, 2019 for both commercial and Medicare Advantage plans.

A reminder about our new site-of-service utilization policy

Our new Medical Policy: Site of Service Utilization for commercial plans went into effect Aug. 1. Please remember, if you are providing a service in a preferred site, preauthorization is not required.

For example, if you are providing a colonoscopy at an ambulatory surgical center, you do not need to get prior approval. You only need preauthorization if the colonoscopy is scheduled in a hospital setting.

Services listed in the office-based code list can be performed in a doctor’s office without prior approval. Preauthorization is required for these procedures to be performed at an ambulatory surgical center or outpatient hospital, including hospital-owned, off-campus facilities.

Services listed in the outpatient hospital code list do not require preauthorization when they are being done in an ambulatory surgical center. Preauthorization is required when the services are being performed in an outpatient hospital, including hospital-owned, off-campus facilities.

Please note, this site-of-service utilization policy does not apply to members who are age 18 or younger.

Here’s a table to help you understand when you need to submit a site-of-service preauthorization request:

Services Doctor’s office Ambulatory surgical center Outpatient hospital, including hospital-owned, off-campus facilities
Services/procedures on office-based code list No preauthorization needed. Yes, preauthorization required. Yes, preauthorization required.
Services/procedures on outpatient hospital code list N/A No preauthorization needed. Yes, preauthorization required.

If you are submitting a preauthorization request, please use this form. Want more information about the policy? Please refer to this provider headline for details.

Payment integrity admission policy for inpatient claim submissions

At providers’ request, we have consolidated all requirements for inpatient claim submissions into one document, Payment integrity administrative policy: Inpatient claim submission requirements. This policy has been in effect for our commercial plans since December 2015. We expanded the policy to include our Medicare Advantage plans effective Aug. 1.

Claims edit goes into effect Oct. 29, 2019

The following claims edit will go into effect Oct. 29, 2019:

Policy: Electroencephalogram (EEG) – Epileptic Spike Analysis

Policy description: CPT codes for “monitoring for identification and lateralization of cerebral seizure focus” (95951, 95953 or 95956) already include epileptic spike analysis. Therefore, reporting 95957 (Epileptic spike analysis) with 95951, 95953 or 95956 when performed for spike analysis represents overlapping services. CPT 95957 will be denied when billed on same date of service as 95951, 95953 or 95956.

Reference: American Academy of Neurology: (FAQs – Digital EEG Analysis (95957))

Plans affected: ConnectiCare commercial plans

Formulary update effective Oct. 1, 2019

Spiriva is now the preferred drug to treat bronchospasm caused by chronic obstructive pulmonary disease (COPD) for ConnectiCare commercial members.

Starting Oct. 1, 2019, Tudorza Pressair will be moved to a non-preferred tier on the commercial plan formularies. This means commercial members who continue to take this drug after Oct. 1 may pay higher copayments or coinsurance. We have sent letters to patients who are affected by this.

If you want to keep your commercial patient on Tudorza Pressair after Oct. 1, submit a preauthorization request before prescribing the medication. Fax the preauthorization request to us at 1-800-249-1367.

Please note, the preauthorization requirement does not apply to patients with employer-sponsored plans through municipal governments.

Refer patients to our care management team

Our care management team is here to work with and beside you to improve your patients’ health. Our nurses, health coaches, social workers and pharmacists serve patients who may benefit from ongoing support, palliative care, health coaching and referrals to community resources. We welcome your referrals to our care management team. Call 1-800-829-0696 from 8 a.m. to 4 p.m. Monday-Friday, when you notice or suspect any of these circumstances:

Struggling to manage chronic conditions (like diabetes or heart failure) or complex health conditions
Not taking medications as prescribed
Depression or other mental health conditions
Substance abuse
Overuse of the emergency room
Lack of caregiver
Financial issues
Transportation needs for medical appointments

We can help with:

Diabetes
Metabolic syndrome
Hypertension
Heart disease
Heart failure
Asthma and COPD
Complex/serious illness
Smoking cessation
Getting care in the appropriate setting

Learn more about our care management program.

Recent provider headlines

Check out the latest Provider News & Headlines:

In-home palliative care services available to your patients
New medical policies for ocular photoscreening and otoacoustic emissions testing
Medical record reviews for your ConnectiCare commercial patients to start in August
Has any of your information changed? Let us know.

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