Network Management

2019 ASC and Outpatient Hospital Rates

Details of pricing and payments can be found in our Pricing and Payment Policies located in the provider portal. Please contact your Provider Relations Representative or Contract Manager with further questions.

Update to Secure Provider Portal Member Search Functionality

Effective 2/1/2019 PreferredOne will require DOB along with First and Last name on Member Lookups on the Secure Site.

Bind Product Updates

As we did with our October 2017 provider newsletter, PreferredOne would like to provide updated information regarding the Bind product. For members new to the Bind product for 2019, please refer to the back of the ID card for the network that the patient is accessing. Bind patients access the PreferredOne network and United Healthcare network(s), depending on the employer. Below is a sample ID card (front & back) that you may see being used by your patients enrolled in the Bind product beginning 1/1/2019. In the sample below, note that services incurred within Minnesota will be processed accessing the PreferredOne network. PreferredOne has also updated our online EDI resources page here with information on Bind electronic claims submission, including the payer ID to use when submitting Bind claims.

Additionally, please note that there are slight variations in the new Bind ID cards & the existing ID cards for PreferredOne members who have access to the Bind product. A sample ID card for those existing members is also included below for reference.

For any questions related to Bind, please contact your PreferredOne provider relations representative

New Bind ID card sample effective 1/1/2019:

Existing PreferredOne Bind ID card sample:

Coding/Payment Policy Updates

H-7 Readmission within 5 days

Medical Management

Member’s Rights and Responsibilities

PreferredOne presents the 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.

The 2019 PCHP Member Rights and Responsibilities

Member Rights and Responsibilities

As a PCHP member, you have the following rights and responsibilities:

A right to receive information about, its services, its participating providers and your member rights and responsibilities.
A right to be treated with respect and recognition of your dignity and right to privacy.
A right to available and accessible services, including emergency services, 24 hours a day, 7 days a week.
A right to be informed of your health problems and to receive information regarding treatment alternatives and risks that are sufficient to assure informed choice.
A right to participate with providers in making decisions about your health care.
A right to a candid discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage.
A right to refuse treatment.
A right to privacy of medical, dental and financial records maintained by PCHP and its participating providers in accordance with existing law.
A right to voice complaints and/or appeals about PCHP policies and procedures or care provided by participating providers.
A right to file a complaint with PCHP and the Minnesota Department of Health and to initiate a legal proceeding when experiencing a problem with PCHP or its participating providers. For information, contact the Minnesota Department of Health at 651.201.5100 or 1.800.657.3916 and request information.
A right to make recommendations regarding PCHP’s member rights and responsibilities policies.
A responsibility to supply information (to the extent possible) that participating providers need in order to provide care.
A responsibility to supply information (to the extent possible) that PCHP requires for health plan processes such as enrollment, claims payment and benefit management, and providing access to care.
A responsibility to understand your health problems and participate in developing mutually agreed-upon treatment goals to the degree possible.
A responsibility to follow plans and instructions for care that you have agreed on with your providers.
A responsibility to advise PCHP of any discounts or financial arrangements between you and a provider or manufacturer for health care services that alter the charges you pay.

The 2019 PIC Member Rights and Responsibilities

Member Rights and Responsibilities

As a PIC member, you have the following rights and responsibilities:

A right to receive information about PIC, its services, its participating providers and your member rights and responsibilities.
A right to be treated with respect and recognition of your dignity and right to privacy.
A right to available and accessible services, including emergency services, 24 hours a day, 7 days a week.
A right to be informed of your health problems and to receive information regarding treatment alternatives and risks that are sufficient to assure informed choice.
A right to participate with providers in making decisions about your health care.
A right to a candid discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage.
A right to refuse treatment.
A right to privacy of medical, dental and financial records maintained by PIC and its participating providers in accordance with existing law.
A right to voice complaints and/or appeals about PIC policies and procedures or care provided by participating providers.
A right to file a complaint with PIC and the Minnesota Department of Commerce and to initiate a legal proceeding when experiencing a problem with PIC or its participating providers. For information, contact the Minnesota Department of Commerce at 651.539.1600 or 1.800.657.3602 and request information.
A right to make recommendations regarding PIC’s member rights and responsibilities policies.
A responsibility to supply information (to the extent possible) that participating providers need in order to provide care.
A responsibility to supply information (to the extent possible) that PIC requires for health plan processes such as enrollment, claims payment and benefit management, and providing access to care.
A responsibility to understand your health problems and participate in developing mutually agreed-upon treatment goals to the degree possible.
A responsibility to follow plans and instructions for care that you have agreed on with your providers.
A responsibility to advise PIC of any discounts or financial arrangements between you and a provider or manufacturer for health care services that alter the charges you pay.

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.

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.
(800) 379-7727, Option 3

Address:
PreferredOne, Grievance Department
6105 Golden Hills Dr.
Golden Valley, MN 55416

Medical Policy

Medical Policy documents are available on the PreferredOne website to members and to providers without prior registration. The most current version of Medical Policy documents are accessible under the Medical Policy section on the PreferredOne website (PreferredOne.com). (Click on Coverage & Benefits then choose Medical Policy).

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 online at Heather.Hartwig-Caulley@PreferredOne.com.

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies List

Various updates to HCPCS and quantity limits. Check PreferredOne.com for the most current version.

Medical Criteria

NEW

MC/L017 Genetic Testing for Reproductive Carrier Screening – This newly approved clinical criteria document captures the medical necessity indications for genetic testing for the purposes of reproductive carrier screening.
MC/L018 Non-invasive Prenatal Screening with Cell-Free DNA – This newly approved clinical criteria document captures the medical necessity indications for non-invasive prenatal screening with cell-free DNA.

Revised

MC/L010 Genetic Testing for Hereditary Cancer Syndromes – Revised to reflect updates on NCCN guidelines for hereditary breast and colon cancer syndromes.

Medical Policy

Revised: MP/P013 Pharmacogenetic/Pharmacogenomic Testing and Serological Testing for Inflammatory Conditions policy has undergone revisions to reflect the most recent FDA-approved companion diagnostics.
Retired: MP/P011 Prenatal Testing – Retired. Information captured in the newly created MC/L018 Non-invasive Prenatal Screening with Cell-Free DNA criteria.

Investigative List

Additions

Gene expression profiling for cutaneous melanoma
Non-invasive prenatal screening (NIPS) using cell-free DNA (CFDNA) for detection of microdeletion syndromes
Non-invasive prenatal screening (NIPS) using cell-free DNA (CFDNA) for fetal sex determination for fetal sex chromosome aneuploidy (SCA) screenin

Pharmacy

Pharmacy criteria documents for coverage of drug requests under the Pharmacy benefit are available at PreferredOne.com by clicking on Coverage and Benefits, choosing Pharmacy Information, then choosing Formulary. Pharmacy criteria documents developed for provider administered drugs are found in the Medical Policy section on PreferredOne.com.

Pharmacy Policy documents developed for provider administered drugs are found in the Medical Policy section on PreferredOne.com.

Quality Management

Blood Pressure Readings for Controlling High Blood Pressure

In 2019 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. As part of this initiative in 2019 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.

2019 HEDIS Medical Record Review

PreferredOne’s HEDIS Medical Record Review Vendor (CIOX Health on behalf of Optum) 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.

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, click on the following link, http://www.culturecareconnection.org/.

CODING

2019 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 2019. Please refer to your coding manuals or encoders for the complete set of code changes.

Evaluation and Management (E/M)

New subsection for Digitally Stored Data Services/Remote Physiologic Monitoring codes 99453 – 99457 require prior authorization. Please refer to the introductory narrative documented in the CPT® manual for reporting details.

Surgery

Fine needle aspiration biopsy services have expanded to 10 codes based on what, if any, method of imaging guidance was used for the service;

10004 – 10012 - Fine needle aspiration biopsy…..with or without imaging guidance….or including ultrasound or fluoroscopic or CT or MR guidance…..first lesion and each additional lesion
10022 - Fine needle aspiration biopsy - has been deleted as method of imaging guidance have been further differentiated.

Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure)….codes have been deleted and replaced with 6 new codes identified by method of biopsy, i.e., shave, punch, incisional.

KEY: When more than one method of biopsy is performed, only one (1) primary biopsy code is to be reported with the appropriate add-on biopsy code(s).

11102 – 11107 - Tangential or punch or incisional biopsy of skin…; single or each additional lesion

The following are three new add-on codes for allograft surgical service site;

20932 - 20934 – Allograft, includes templating…..osteoarticular or hemicortical or intercalary…partial or complete (List separately in addition to code for primary procedure)

New knee arthrography code which replaces deleted code 27370. CAUTION: Performed for hyaluronate type joint injection warrants additional review for medical necessity.

27369 - Injection procedure for contrast knee arthrography or contrast enhanced CT/MRI knee arthrography

This new code requires prior authorization;

33274 - Transcatheter insertion or replacement of permanent leadless pacemaker, right ventricular, including imaging guidance (eg, fluoroscopy, venous ultrasound, ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when performed

This new code does not require prior authorization;

33275 - Transcatheter removal of permanent leadless pacemaker, right ventricular

This new code is investigative as noted on the PreferredOne Investigative List accessible on the PreferredOne website;

33289 - Transcatheter implantation of wireless pulmonary artery pressure sensor for long-term hemodynamic monitoring, including deployment and calibration of the sensor, right heart catheterization, selective pulmonary catheterization, radiological supervision and interpretation, and pulmonary artery angiography, when performed

Associated new code to 33289 is also investigative (new code represents CardioMEMS^TM);

93264 - Remote monitoring of a wireless pulmonary artery pressure sensor for up to 30 days, including at least weekly downloads of pulmonary artery pressure recordings, interpretation(s), trend analysis, and report(s) by a physician or other qualified health care professional

This new code, which represents the Rezum^® procedure, requires prior authorization;

53854 - Transurethral destruction of prostate tissue; by radiofrequency generated water vapor thermotherapy

Laboratory

Genetic Testing

The following new Molecular Pathology codes and code ranges require prior authorization as these represent genetic testing;

81164 - 81167
81171 – 81190
81204
81233 – 81239
81271 – 81274
81284 – 81289
81305 – 81312
81320 – 81337
81343 – 81345
81443
81518

Medicine

New subsection for Neurostimulators, Analysis – Programming codes 95976 – 95984 do not require prior authorization and are not investigative. Please refer to the introductory narrative documented in the CPT® manual for reporting details.

New subsection for Central Nervous System Assessments/Test (eg, Neuro-Cognitive, Mental Status, Speech Testing) codes 96112 – 96113, 96121 and 96130 – 96146 = please refer to the introductory narrative and table documented in the CPT® manual for reporting details.

New subsection for Adaptive Behavior Services (eg, Assessment and Treatment) codes 97151 – 97158 are by contractual agreement only.

Category III

New codes 0537T – 0540T, representing Yescarta®, require prior authorization.

As a general rule, PreferredOne assigns investigative status to Category III codes since they represent new technology. As these are fully researched for potential coverage, there may be status change. It is highly recommended providers inquire of the status for a Category III code prior to performing the service.

HCPCS Codes

This new code requires prior authorization. Code represents Eclipse^TM Vaginal Insert system;

A4563 - Rectal control system for vaginal insertion, for long term use, includes pump and all supplies and accessories, any type

Many new “C” codes have been created for injectable or infusion drugs. Most of these require prior authorization if the “C” code has been granted pass-through status. Please refer to the HCPCS Manual for identification of these drugs.

This new code requires prior authorization and if approved will be reported as a rental only item. All repairs, maintenance, replacement parts are not separately reportable as they are included in the monthly rental charge;

E0467 - Home ventilator, multi-function respiratory device, also performs any or all of the additional functions of oxygen concentration, drug nebulization, aspiration, and cough stimulation, includes all accessories, components and supplies for all functions

The following new code range will be processed as provider liability as PreferredOne® does not participate in the Medicare-approved Center for Medicare & Medicaid Innovation (CMMI) model.

G0076 – G0087 - Care management home visit…

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.

The following new “J” codes are restricted to knee osteoarthritis diagnosis based on PreferredOne policy;

J7318 - Hyaluronan or derivative, durolane, for intra-articular injection, 1 mg - represents Durolane^®, a single injection treatment
J7329 - Hyaluronan or derivative, trivisc, for intra-articular injection, 1 mg - represents TriVisc^TM, a series of three injections one week apart

New quality measurement codes – M1000 - M1071, which will process as provider liability.

Modifiers

G0 - Telehealth services for diagnosis, evaluation, or treatment, of symptoms of an acute stroke. Please refer to MLN 10883; CR R21420TN documents for reporting details.

CREDENTIALING

MN Uniform Facility Credentialing Application

The MN Health plans (Preferred One, Medica, UCare, HealthPartners, BlueCross BlueShield, and Hennepin Health) worked together to create a MN Uniform Facility Credentialing Application that can be used by all providers. This new application intends to streamline the process by allowing providers to send the same application to all the identified plans. Previously, each health plan had a separate credentialing application form.

The MN Uniform Facility Credentialing Application is the latest work by credentialing leadership across the health insurers in Minnesota that aims to help reduce the administrative work of medical staff in the clinics and hospitals.

As with all credentialing decisions, each health insurer will continue to independently make its own decisions regarding whether the facility meets its credentialing requirements.

This form fillable application can be found on PreferredOne’s website at www.PreferredOne.com and on the MAMSS website at www.mnamss.org

Pharmacy

Renovation

We have overhauled the Pharmacy Information page under the secure provider portal. We have removed 4 outdated forms; Erectile dysfunction medication request, infertility medication request, breast cancer risk reduction, and Hepatitis C medications reauthorization. We have updated links to formularies and quantity level limits. Additionally, the Fairview Specialty Program links were updated to reflect current, expanded information. We have begun work on updating our online submission portal for online authorization requests to facilitate ease of use for providers and internal PreferredOne staff.

New Construction

Coming this spring will be a new authorization form incorporating Site of Service into medical necessity determinations for typically infused medications. Please watch this space for additional information forthcoming, along with targeted communications to high impact providers.