Network Management

Important Updates and Reminders for Participating Providers

• Please note below an important update from Aetna regarding Modifier 74 & how they will reimburse for this modifier. This update can also be found in Aetna’s December 2016 newsletter on our provider site.
  Procedure
  Surgical Procedures
  Effective Date
  March 1, 2017
  What's Changed?
  We will allow 50% of the contracted rate for services billed with modifier 74.
• For providers looking to update their address information, practitioner listing, practice name, etc please send that information to PreferredOne directly. We will update our systems & in turn will provide that updated information to Aetna & our other PPO partners. Updated information can be faxed to 763-847-4010 attention Network Management or directly to your provider relations representative.
• The PreferredOne provider website does not maintain enrollment/eligibility dates for PPO members. For PPO member enrollment/eligibility information, please verify that data via the member’s current ID card or by phoning the member’s insurance company or TPA. Providers should not determine whether a PPO member is eligible for services strictly through a search of the PreferredOne provider website as doing so could result in an inaccurate determination to not provide services to an eligible member.
• As a reminder, prior authorizations must be submitted through the PreferredOne provider website. Prior authorizations submitted through a third party prior authorization program or service are unable to be received by PreferredOne for processing.

MEDICAL MANAGEMENT

Affirmative Statement about Incentives

PreferredOne does not specifically reward practitioners or other individuals for issuing denials of coverage or service care. Financial incentives for utilization management decision-makers do not encourage decisions that result in under-utilization. Utilization management decision making is based only on appropriateness of care and service and existence of coverage.

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Member’s Rights and Responsibilities

PreferredOne presents this Member Rights & Responsibilities with the expectation that observance of these rights will contribute to high quality patient care and appropriate utilization for the patient, the providers, and PreferredOne. PreferredOne further presents these rights in the expectation that they will be supported by our providers on behalf of our members and an integral part of the health care process. It is believed that PreferredOne has a responsibility to our members. It is in recognition of these beliefs that the following rights are affirmed and presented to PreferredOne members.

PIC Member's Rights and Responsibiltiies

PCHP Member Rights and Responsibilties

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Adverse Determination – To Speak to a Physician Reviewer

PreferredOne Integrated Healthcare Services Department attempts to process all reviews in the most efficient manner. We look to our participating practitioners to supply us with the information required to complete a review in a timely fashion. We then hold ourselves to the timeframes and processes dictated by the circumstances of the case and our regulatory bodies.

Practitioners may, at any time, request to speak with a peer reviewer at PreferredOne regarding the outcome of a review by calling 763-847-4488, option 2 and the Intake Department will facilitate this request. You or your staff may also make this request of the nurse reviewer with whom you have been communicating about the case and she/he will facilitate this call. If, at any time, we do not meet your expectations and you would like to issue a formal complaint regarding the review process, criteria or any other component of the review, you may do so by calling or writing to our Customer Service Department.

Phone number: (763) 847-4488, Option 3 or (800) 379-7727, Option 3.
Address: PreferredOne, Grievance Department, 6105 Golden Hills Dr., Golden Valley, MN 55416

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Blood Pressure Readings for Controlling High Blood Pressure

In 2017 PreferredOne will once again be focusing on an initiative to control high blood pressure among our members diagnosed with hypertension. Controlling blood pressure is a HEDIS measurement specified by NCQA and is also reported by Minnesota Community Measurement. We value this project and deem it as important to our members because hypertension is the most treatable form of cardiovascular disease and medication compliance is a significant factor that contributes to the overall success of treatment. PreferredOne will be providing medication adherence education to members diagnosed with hypertension. As part of this initiative in 2017 we are asking for provider’s assistance by conducting a secondary reading of your patient’s blood pressure if it is high following the initial reading and ensuring that the patient’s medical records reflects both of the measurements taken.

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2017 HEDIS Medical Record Review

As a reminder, PreferredOne’s HEDIS Medical Record Review Vendor will be contacting clinics in the coming weeks to coordinate medical record review for PreferredOne members seen at your clinics. As a contracted provider you are obligated to allow PreferredOne and its vendor to conduct this review. HEDIS measures are nationally used by all accredited health plans and PreferredOne also has an obligation to the Minnesota Department of Health to collect HEDIS data on an annual basis. Medical record review is an important component of the HEDIS compliance audit. It ensures that medical record reviews performed by our vendor meet audit standards for sound processes and that abstracted medical data are accurate. We would appreciate your cooperation with collecting medical record review information at your clinic site(s). We appreciate your clinic’s assistance in making this a smooth process.

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Medical Record Documentation Policy

Please view our Medical Record Documentation Policy.

Serving a Culturally and Linguistically Diverse Membership

Cultural and linguistic competence is the ability of health care providers and health care organizations to understand and respond effectively to the cultural and linguistic needs brought by their patients/consumers to the health care encounter. Cultural and linguistically appropriate services lead to improved outcomes, efficiency, and satisfaction.

Culture Care Connection is an online learning and resource center, developed by Stratis Health, aimed at supporting health care providers, staff, and administrators in their ongoing efforts to provide culturally-competent care in Minnesota.

For more information regarding Stratis Health’s resource center, please visit, Culturecareconnection.org.

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Medical Policy Updates

The Integrated Health and Pharmacy and Therapeutics Quality Management Subcommittees approve new criteria sets for use in their respective areas of Integrated Healthcare Services. Quality Management Subcommittee approval is not required when there has been a decision to retire a PreferredOne criteria document or when medical polices are created or revised; approval by the Chief Medical Officer is required. The Quality Management Subcommittees are informed of these decisions.

For the most current versions of the Medical Policy documents, please access the Medical Policy section on the PreferredOne website (PreferredOne.com). (Click on Benefits and Tools then choose Medical Policy, Precertification and Prior Authorization.) Medical Policy documents are available on the PreferredOne website to members and to providers without prior registration.

Since the last newsletter, the following are the new, revised, or retired Medical Policy documents. Some of the more extensive Medical Policy updates are detailed for a few of the items below. If you wish to have paper copies of these documents, or you have questions, please contact the Medical Policy Department telephonically at (763) 847-3386 or via email to Heather.Hartwig-Caulley@PreferredOne.com

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies List

• No revisions

Integrated Health

• Medical Criteria
  • MC/B003 Orthodontic Services – Revised to remove the requirement of 24 months of continuous coverage prior to being eligible for orthodontic treatment.
  • MC/G002 Breast Reduction Surgery – Revised to now allow breast reduction for women less than 18 years of age when breast growth is deemed to be complete, as evidenced by stable breast size over the last year.
  • MC/G004 Breast Reconstruction – The EXCLUSIONS statement has been revised and now states, “Following completion of breast reconstruction, further augmentation and/or revision due to normal aging or other non-pathologic process(es) including, but not limited, to re-tattooing of the nipple/areola, does not meet the definition of a covered reconstructive health care service.”
  • MC/G007 Prophylactic Mastectomy/Oophorectomy – This criteria document has been retired. PreferredOne defaults to National Comprehensive Cancer Network (NCCN) Guidelines^® to determine the medical necessity of these procedures.
  • MC/M014 Detoxification and Addiction Stabilization: Inpatient Treatment – Due to the highly addictive nature of opiates and the variability in time of withdrawal onset, the minimum requirement of more than two weeks of daily opiate use has been deleted.
  • MC/N005 Torticollis and Plagiocephaly – Revisions were made to reflect that a diagnosis of brachycephaly also falls within the scope of the clinical indications and medical necessity determinations, and that physical therapy can be provided by an occupational or physical therapist, where applicable.
  • MC/T001 Bone Marrow/Stem Cell Transplantation – Revisions were made to reflect that transplant requests must meet PreferredOne’s criteria regardless of the availability of the transplanting institution’s protocol and whether or not the request meets the transplanting institution’s protocol, if available.
  • MC/T002 Kidney Transplantation, Simultaneous Pancreas-Kidney Transplantation, Simultaneous Cadaver-Donor Pancreas and Living-Donor Kidney Transplantation – Revisions were made to reflect that transplant requests must meet PreferredOne’s criteria regardless of the availability of the transplanting institution’s protocol and whether or not the request meets the transplanting institution’s protocol, if available. Revisions were also made to clarify the medically necessary indications for kidney transplantation.
  • MC/T003 Heart Transplantation - Revisions were made to reflect that transplant requests must meet PreferredOne’s criteria regardless of the availability of the transplanting institution’s protocol and whether or not the request meets the transplanting institution’s protocol, if available.
  • MC/T004 Liver Transplantation - Revisions were made to reflect that transplant requests must meet PreferredOne’s criteria regardless of the availability of the transplanting institution’s protocol and whether or not the request meets the transplanting institution’s protocol, if available.
  • MC/T005 Lung and Lobar Transplantation – Revisions were made to reflect that transplant requests must meet PreferredOne’s criteria regardless of the availability of the transplanting institution’s protocol and whether or not the request meets the transplanting institution’s protocol, if available.
  • MC/T007 Pancreas Transplantation, Pancreas After Kidney Transplantation, Autologous Islet Cell Transplantation – Revisions were made to reflect that transplant requests must meet PreferredOne’s criteria regardless of the availability of the transplanting institution’s protocol and whether or not the request meets the transplanting institution’s protocol, if available.
  • Medical Policy: MP/D010 Drug Testing in Substance Abuse Treatment and Chronic Pain Management Settings – This policy is no longer specific to urine drug testing alone.

  Investigative List Deletion – Vacuum Assisted Socket System (VASS)

  • Pharmacy and Therapeutics
    • Pharmacy Criteria - The criteria documents for coverage of drug requests under the Pharmacy benefit are available at PreferredOne.com, click on Benefits and Tools, choose Pharmacy, then choose Formulary. Pharmacy criteria documents developed for drug requests under the Medical benefit are found in the Medical Policy section on PreferredOne.com.
  • Pharmacy Policies
    • PP/F002 Formulary Development and Structure - Newly developed policy that describes the process for the development, structure and management of PreferredOne’s formularies
    • PP/F002 Biosimilar Products - Revisions were made to reflect the separate guidelines for drugs under the Pharmacy benefit and drugs under the Medical benefit. Also, coverage policy statements around allowing a 30-day transition of a reference product when PreferredOne has transitioned to providing coverage only for the biosimilar product and vice-versa (eg, Inflectra and Remicade) are now included in this policy document.
  • Preventive Services – Colorectal Cancer Screening
    • • The Patient Protection and Affordable Care Act of 2010 (the “ACA”) requires that “non-grandfathered” insured and self-insured group health plans and individual insurance policies provide full coverage, with no cost-sharing for the member, for certain preventive care services that members receive from participating providers. The ACA defines preventive services to include for covered adults and children, as applicable, certain annual or periodic exam, screening, counseling and immunization services, and, for women with reproductive capacity, certain contraceptive methods and related counseling.

  PreferredOne currently covers screening for colorectal cancer for men and women starting at age 50 years and continuing until age 75 years. Covered screening methods include fecal occult blood (FOBT) and fecal immunochemical (FIT) tests, sigmoidoscopy, colonoscopy or virtual colonoscopy. Effective July 1, 2017, and upon renewal thereafter, PreferredOne will provide coverage for stool-based DNA testing according to United States Preventive Services Task Force (USPSTF) colorectal cancer screening guidelines.

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  Coding

  2017 CPT^® and HCPCS Codes Highlights

  CPT^® Codes

  The information contained in this article is not inclusive of all the new, revised, and deleted CPT^® and HCPCS codes for 1st quarter 2017. Please refer to your coding manuals or encoders for the complete set of code changes.

  The American Medical Association (AMA) CPT^® Editorial Panel continues to combine procedure and diagnostic service codes that are consistently reported together 75% of the time or more. There were multiple CPT^® codes created for 2017 for this reason. This mostly affects radiological services, e.g., new codes 62320 – 62327 now have the imaging guidance included, if performed. Please carefully read the new code descriptions for all of the codes in order to avoid unnecessary claim denials.

  33340 – Percutaneous transcatheter closure of the left atrial appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and interpretation - requires a prior authorization.

  The following two new codes are for MOCA™ (ClariVein^®), which is investigative;

  • 36473 – Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein treated
  • 36474 - Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)

  76706 - Ultrasound, abdominal aorta, real time with image documentation, screening study for abdominal aortic aneurysm (AAA) - US Preventive Services Task Force (USPSTF) criteria applies, including reporting of a screening diagnosis. No other abdominal ultrasound code (76700, 76705, 76770, 73775) will be processed as screening for AAA. Those four codes are always diagnostic.

  The diagnostic and screening mammography codes now include computer-aided detection (CAD), when performed;

  • 77065 – Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral
  • 77066 – Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral
  • 77067 - Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed

  (Reminder: there is one specific ICD-10-CM code for a screening mammogram for malignant neoplasm of breas)

  Laboratory drug testing codes 80300 – 80304 were deleted and replaced with;

  • 80305 – Drug test(s), presumptive, any number of drug classes, any number of devices or procedures (eg, immunoassay); capable of being read by direct optical observation only (eg, dipsticks, cups, cards, cartridges) includes sample validation when performed, per date of service
  • 80306 - Drug test(s), presumptive, any number of drug classes, any number of devices or procedures (eg, immunoassay); read by instrument assisted direct optical observation (eg, dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service
  • 80307 - Drug test(s), presumptive, any number of drug classes, any number of devices or procedures, by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service
  • HCPCS G0659 - Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem), excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase), performed without method or drug-specific calibration, without matrix-matched quality control material, or without use of stable isotope or other universally recognized internal standard(s) for each drug, drug metabolite or drug class per specimen; qualitative or quantitative, all sources, includes specimen validity testing, per day, any number of drug classes

  PreferredOne will accept either the CPT^® drug testing codes or the equivalent HCPCS codes for presumptive and definitive testing.

  81327 - SEPT9 (Septin9) (eg, colorectal cancer) methylation analysis - ColoVantage^®; Epi proColon^®; The Septin 9 Test. These are investigative.

  96160 - Administration of patient-focused health risk assessment instrument (eg, health hazard appraisal) with scoring and documentation, per standardized instrument - is not for maternal depression screening and will process as provider liability.

  96161 - Administration of caregiver-focused health risk assessment instrument (eg, depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument - replaces code 99420 and is reported for the maternal depression screening.

  New subsections created for Physical Therapy (97161 - 97164, Occupational Therapy (97165 – 97168), and Athletic Training (97169 – 97172)b> sections. PreferredOne reserves the right to randomly audit provider documentation for adherence to the published guidelines. Athletic Training services are not covered services and will process as member liability.

  Major changes to the “Moderate Sedation” section with creation of 6 new codes, 99151 – 99157, which now reflect 15 minute increments of “intra-service” time. Please see the CPT^® manual for complete instructions for use.

  Telehealth/Telemedicine/Telecommunications

  CMS has created a new place of service (POS) code – 02 - The location where health services and health related services are provided or received, through a telecommunication system.

  AMA CPT^® has created a new modifier – 95 - Synchronous Telemedicine Service Rendered via a Real-Time Interactive Audio and Video Telecommunications System

  CMS has an existing modifier – GT - Via interactive audio and video telecommunication systems - modifier 95 does not replace the GT modifier.

  PreferredOne will allow the codes listed in Appendix P of the CPT^® Manual plus the “G” codes on the CMS official Medicare-covered telehealth services list, to be reported as telemedicine services as long as all appropriate documentation is done. POS 02 plus either modifier -95 or –GT are required to be reported on the claim, otherwise the claim will deny.

  Telemedicine:

  • IS
    • Delivery of health care services or consultations while the patient is at an originating site and the licensed health care provider is at a distant site.
    • May be provided by means of real-time two-way, interactive audio and visual communications, including the application of secure video conferencing or store-and-forward technology to provide or support health care delivery, which facilitate the assessment, diagnosis, consultation, treatment, education, and care management of a patient's health care.
    • Patient initiated contact to a licensed health care provider at a distant site utilizing Skype-like, secure, two-way interactive audio and visual communication via Smartphone, tablet, PC, or other electronic communication device. Patient is accountable for the security coverage.
  • IS NOT
    • A communication between licensed health care providers that consists solely of a telephone conversation, e-mail (e-visit), or facsimile transmission.
    • A communication between a licensed health care provider and a patient that consists solely of an e-mail (e-visit) or facsimile transmission.
    • Provider initiated telephone call, e-mail (e-visit), or facsimile transmission to a patient.

  (Reminder: codes 99441 – 99443 and 98966 – 98968 for telephone calls; 99444 and 98969 for E-visit services; and 99446 – 99449 for Interprofessional telephone/Internet consultations are not telemedicine services.)

  HCPCS Codes

  The majority of the HCPCS code changes were in the “Quality Measures” section, G8935 – G9862 range. This includes newly created, revised, and deleted codes.

  The following two codes are covered as long as the member has a prior authorized insulin pump. Only the pump requires prior authorization, not the supplies;

  • A4224 – Supplies for maintenance of insulin infusion catheter, per week
  • A4225 – Supplies for external insulin infusion pump, syringe type cartridge, sterile, each

  The following four codes are no covered;

  • A4467 – Belt, strap, sleeve, garment, or covering, any type
  • A4553 – Non-disposable underpads, all sizes
  • A9285 – Inversion/eversion correction device (Ottobock's Agilium Freestep OA Device Solution)
  • A9286 – Hygienic item or device, disposable or non-disposable, any type, each

  The following two codes will be processed according to CMS published guidelines and criteria;

  • G0491 – Dialysis procedure at a Medicare certified ESRD facility for acute kidney injury without ESRD
  • G0492 - Dialysis procedure with single evaluation by a physician or other qualified health care professional for acute kidney injury without ESRD

  The following four codes require prior authorization;

  • G0493 – Skilled services of a registered nurse (RN) for the observation and assessment of the patient's condition, each 15 minutes (the change in the patient's condition requires skilled nursing personnel to identify and evaluate the patient's need for possible modification of treatment in the home health or hospice setting)
  • G0494 – Skilled services of a licensed practical nurse (LPN) for the observation and assessment of the patient's condition, each 15 minutes (the change in the patient's condition requires skilled nursing personnel to identify and evaluate the patient's need for possible modification of treatment in the home health or hospice setting)
  • G0495 – Skilled services of a registered nurse (RN), in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes
  • G0496 - Skilled services of a licensed practical nurse (LPN), in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes

  G0500 - Moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intra-service time; patient age 5 years or older (additional time may be reported with 99153, as appropriate) – allowable service to report.

  G0501 - Resource-intensive services for patients for whom the use of specialized mobility-assistive technology (such as adjustable height chairs or tables, patient lift, and adjustable padded leg supports) is medically necessary and used during the provision of an office/outpatient, evaluation and management visit (list separately in addition to primary service) - will be bundled into all other services reported on the same date of service.

  Many new “J” codes have been created, several of them replacing deleted “C” codes. Please refer to the HCPCS Manual for those. Many of these drugs require prior authorization.

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