NETWORK MANAGEMENT

Friendly Reminder on Chiropractic/Acupuncture Network Change & Billing Requirements

As mentioned in our October 2020 Provider Newsletter, PreferredOne has partnered with Fulcrum Health effective January 1, 2021 for our chiropractic & acupuncture provider network. If you are not contracted with Fulcrum Health & are interested in joining the network please email contracting@fulcrumhealthinc.org to start that process.

Also, if you are currently a Fulcrum participating provider please follow the instructions below should you require additional assistance from Fulcrum Health:

Self-Service:

The Fulcrum Provider Portal is your source for Fulcrum Health resources!

Once you log into the portal, you will find the following tabs:

Home Page: Find your current tier assignment, if applicable, along with your contracted health plans. Use the + symbol to expand each health plan to find the current Plan Summary Reference Sheet and Fee Schedule.
Clinical Policies: Find a list of Fulcrum’s clinical guidelines, policies, and procedures that can be downloaded for your reference.
Administrative Resources: The QConnect Access button is located within this tab; clicking on this button will bring you to the UM system, named QConnect, which is used for submitting prior authorization requests and outcome assessments. You will need credentials specific to that system to log in. You will also find the Non-Covered Services policy and Fulcrum Disclosure Forms, the Provider Dispute Form, and more.
Billing: Use this tab to find information on the claims submission process, as well as the Access Claims Portal Here button. (The Access Claims Portal Here button brings you to an external site, and you will need credentials specific to that site to log in and view claims.)
Learning Hub: Find information on prior authorization, access training videos, request specific training, Centers of Excellence information, educational modules for CE credits, and more.
Demographic Updates: Use this tab to update your clinic information, including, but not limited to, address change, email address, website address, clinic hours changes, or clinic location additions/closures.

By Phone:

Call Fulcrum Health at 877-886-4941 for assistance with Claims and Provider Services such as: Utilization Management, Credentialing, Contracting, and Compliance.

It is important to listen to the prompts as they may change.

Claims: Select option 1, and then listen to the prompts for your specific claim type.

Provider Services: Select option 2, and then listen to the prompts for your specific need.

Utilization Management department (Ext 207) supports you with prior authorization, QConnect, expedited requests, clinical review, etc.
Credentialing department (Ext 203) supports you with updating certifications and/or licensure, questions about the credentialing and/or credentialing process, and name changes
Contracting department (Ext 205) supports you with clinic/contract changes, site additions or deletions, terminations
Compliance Hotline supports your right to report Fraud, Waste, and Abuse confidentially

If you know the extension of the party you are calling, you may dial it at the onset of the call.

PHARMACY

Pre-Payment, Post Service Claim Edit Program

PreferredOne, in partnership with MagellanRx Management, is implementing a pre-payment, post service claim edit program starting July 1, 2021. The claim edit program applies edits to medical benefit claims that focus on eligible diagnosis, maximum dosage/units, duration and frequency. This ensures providers are utilizing physician office-billed drugs in accordance with FDA labels, and compendia-approved uses consistent with each drug policy. Please refer to the Pharmacy Clinical Resources webpage for details.

Each clinical policy provides specific guidelines used to determine pre-payment edits that can result in a partial or denied payment based on the submitted claim. The guidelines include, but are not limited to, covered and non-covered drugs, preferred/non-preferred drugs, step therapy requirements and exceptions, covered diagnosis code, maximum billable units, dose, frequency, and duration.

Prior authorization is not a requirement for all drugs in scope for pre-payment claims edits. However, the guidelines within their respective policies will still be applied to claims, specifically as it relates to: covered/non-covered drugs, preferred/non-preferred drugs, diagnosis, dose, frequency, duration, and maximum billable units. A list of drugs that do not require prior authorization, but are subject to pre-payment claims edits, can be found on our Pharmacy Clinical Resources webpage.

Drugs that require prior authorization will be included in our prior authorization list and will have a notation indicating the requirement. Their corresponding policies can be found in our Pharmacy Clinical Resources webpage.

Pharmacy Website

PreferredOne has recently revamped its Pharmacy Clinical Resources webpage. You can see the changes by going here. Now, each drug on our prior authorization list has a policy link next to it that you can view. In addition, there are a number of new policies that have been added for drugs on our prior authorization list. Please see our webpage to view the relevant policies.
The following are prior authorization list changes:

Pepaxto (melphalan flufenamide) added effective 6/3/2021:
Abecma (idecabtagene vicleucel) added effective 4/20/2021:
Riabni (rituximab-arrx) added to Site of Care List effective 6/4/2021:
The following medication was removed: Ixifi (infliximab-qbtx)

Important Drug Code Change

Darzalex Faspro (Daratumumab and hyaluronidase-fihj)

For services prior to December 31, 2020 – use code C9399 (unclassified drugs or biologicals), OR, J9999 (not otherwise classified, antineoplastic drugs)

For services on or after January 1, 2021 – use code J9144 (Injection, daratyumumab, 10mg and hyaluronidase-fihj)

J9144 can be used on both facility and professional billings. Use of a non-specific code when a specific code exists will be returned to the provider. A corrected claim will be required.

Drugs and Biologics must be reported with its method of administration

Access to Pharmacy Information

Pharmacy management procedures are available for provider’s to access online on the Pharmacy Clinical Resources webpage. Specific pharmacy benefit procedures and formularies are also available through the member’s Pharmacy Benefit Manager (PBM) provider portal. You can also reach out to PreferredOne customer service by calling the number on the back of the applicable member’s insurance card, or by contacting your designated provider representative for assistance in accessing criteria, formularies, policies, and other pharmacy management tools.