Network Management

2019 Fee Schedule Update

Professional Services

PreferredOne’s Physician, Mental Health and Allied Health Fee Schedules are complete and will become effective for dates of service beginning January 1, 2019. These changes are expected to be an increase in overall reimbursement. As with prior updates, the effect on physician reimbursement will vary by specialty and the mix of services provided.

Physician fee schedules will be based on the 2018 CMS Medicare physician RVU file without geographic practice index (GPCI) applied and without the work adjuster applied, as published in the Federal Register February 20218. New codes for 2019 will be based on the 2019 CMS Medicare physician RVU file without geographic practice index applied and without the work adjuster applied as published in the Federal Register November 2018. Other new non-RVU based codes will be added according to PreferredOne methodology. The fee schedules for other provider types (such as allied, PhD, Masters and BA) will also be updated.

The 2019 Physician fee schedules will continue to apply site of service differential for RVU –based services performed in a facility setting (Place of Service 19, 21-25 are considered facility).

The Convenience Care and Dental fee schedules will also be updated January 1, 2019. New codes were added to these fee schedules. Also, please remember that any code not on the Convenience Care fee schedule will not be reimbursed.

New ASA codes for Anesthesia services will be updated with the 2019 release of Relative Value Guide by the American Society of Anesthesiologists. This update will take place by January 1, 2019.

Requests for a market basket fee schedule may be made in writing to PreferredOne Provider Relations. Reminder that new codes for 2019 will be added to all fee schedules using the above listed methodology. PreferredOne reserves the right to analyze and adjust individual rates throughout the year to reflect current market conditions. Any changes will be communicated via the “PreferredOne Provider Bulletin”.

Hospital Services/UB07/Outpatient Fee Schedules

The 2019 Calendar year DRG schedule will be based on the CMS MS-DRG Grouper Version 36 as published in the final rule Federal Register to be effective October 2018.

For those on Ambulatory Payment Classifications (APC), we are using Optum hospital-based grouper that will be one year lag. For example, for 2019 rates, PreferredOne may use the 2018 APC grouper and edits and weights as of October 2018.

The Facility (UB04) CPT fee schedule will consist of all physician CPT/HCPC code ranges and will be based on the 2017 CMS Medicare physician RVU file, without the geographic practice index applied and without the work adjust applied. The global rules for the facility CPT fee schedule are as follows:

The surgical codes (10000 – 69999 and selected HCPCS codes including, but not limited to G codes and Category III codes) are set to reimburse at the practice and malpractice RVU’s
Office visit codes (i.e. 908xx, 99xxx code range) are set to reimburse at the practice expense RVU’s
Therapy codes are set at the Allied Health Practitioner rates
For those codes that the Federal Register has published a technical component (TC) rate. This rate will be set as the base rate.

All other remaining codes are set to reimburse at the professional services established methodology.

Reminder that new codes for 2019 will be added to all fee schedules using the above listed methodology. PreferredOne reserves the right to analyze and adjust individual rates throughout the year to reflect current market conditions. Any changes will be communicated via the “PreferredOne Provider Bulletin”.

Off-Cycle Fee Schedule Updates

Other provider types such as DME, Home Health, Skilled Nursing Facility updates will take place April 1, 2019.

PPO/Aetna Additional ID Card Notification

PreferredOne has been supplied a sample ID card for one of the new Aetna/Allina joint venture product lines (see below), as this product line will access the PreferredOne PPO network. Please keep in mind that if you see an ID card like the one below where the PreferredOne logo is present the member does have access to the PreferredOne contracted PPO network of providers. Just as you do today for the existing Aetna products that access the PreferredOne PPO network, claims for this new product line should be submitted directly to Aetna for processing as per the back of the ID card. Allina Health Aetna members whose ID cards do not contain the PreferredOne logo do not have access to the PreferredOne PPO network/rates.

PreferredOne/Aetna PPO Network Reminder

Similar to last year, PreferredOne would like to remind our contracted providers that you will once again need to be mindful of Aetna PPO claims that are for first quarter 2019 dates of service. PreferredOne will not be able to hold claims for you (you will be submitting claims directly to Aetna) while your 2019 rates are being negotiated or loaded into Aetna’s system. Providers will be responsible for holding Aetna claims temporarily (for contracts with 1/1/2019 effective dates) until Aetna completes their process of loading the new rates. If claims are submitted to Aetna prior to your 1/1/2019 contract being loaded into their system, claims will be paid at the previous year’s rates. There will be no reprocessing of claims. Please be sure to check with Aetna that your new rates are loaded for 1/1/2019 before you release claims for those dates of service on or after 1/1/2019.

Corrected/Replacement Claim Reminder

When submitting a corrected/replacement claim, PreferredOne would like to provide a friendly reminder to include ALL services on the corrected claim form. Please do not submit only the corrected code line without the remainder of any other claim lines that were submitted on the original claim form. Doing so will cause any services that were omitted on the corrected/replacement claim to be considered voided. Our claims adjudication system will only process those service lines present on the corrected/replacement claim & will initiate a recoupment of payment for any of the missing services from the original claim submission.

Coding/Payment Policy Updates

Medical Management

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 (IHS). 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 Coverage & Benefits then choose Medical Policy). 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 online at Heather.Hartwig-Caulley@PreferredOne.com.

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies List

BiPAP for diagnosis of sleep apnea, HCPCS E0470: Removed notes related to first time versus replacement. This is rent to purchase.
BiPAP/ASV E0471: Changed entry from rent to purchase, to rental only.
Enema System - New entry added - with HCPCS, M/N and quantity limits.
Orthotic supplies - New entry added with non-covered items.
Ultraviolet light therapy devices: Rent to purchase added to entry.

Medical Criteria

NEW

MC/F022 Intervertebral Disc Prosthesis, Cervical and Lumbar

Revised

MC/A006 Ventricular Assist Device (VAD) – Revised to reflect FDA-approved labeling for CentriMag Right Ventricular Assist System and to include medical necessity criteria for a new right VAD, the Impella RP System, and for device replacement / upgrade requests.
MC/F021 Bone Growth Stimulators (Osteogenic): Electrical and Ultrasonic – Revised to allow ultrasonic bone growth stimulators for tibial diaphyseal fracture, which is a proven effective indication that is also part of the FDA-approved labeling for the device.
MC/G002 Breast Reduction Surgery – Revised to require a recent mammogram; to detect any suspicious breast abnormalities and to have a presurgical road map that may aid during any potential post-operative evaluation of new versus preexisting masses or lesions.

Investigative List

Addition: Single-pulse transcranial magnetic stimulation (sTMS) for treatment and prevention of migraine
Deletions: Nasal/sinus endoscopy, surgical; with dilation of maxillary or sphenoid sinus ostium (eg, balloon dilation), transnasal or via canine fossa for chronic sinusitis – Deleted from the Investigative List because reliable evidence supports the use of balloon ostial dilation as a therapeutic option for chronic rhinosinusitis, in maxillary and sphenoid sinuses.

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 Criteria for provider administered drugs

PC/I002 Immune Globulin Therapy (IgG, IVIg, SCIg) – Revised to reflect the evidence supporting the use of IVIG in the treatment of myasthenia gravis that is refractory to first line therapy.
Ixifi (infliximab-qbtx), the newly approved biosimilar to Remicade, has been added to the following criteria

PC/B004 Biologics for Rheumatoid Arthritis
PC/B005 Biologics for Plaque Psoriasis
PC/B006 Biologics for Crohn’s Disease
PC/B011 Biologics for Psoriatic Arthritis
PC/B012 Biologics for Ankylosing Spondylitis
PC/B013 Biologics for Ulcerative Colitis

On June 28, 2018 the Food and Drug Administration approved the first AB-rated generic, hydroxyprogesterone caproate injection, to the medication Makena. Hydroxyprogesterone caproate injection, USP is available in a 250 mg/mL, 1mL preservative free single dose vial. Effective January 1, 2019, the generic hydroxyprogesterone caproate injection, will be the preferred medication on PreferredOne formularies. This drug should be billed with HCPCS J1729; also provide the national drug code (NDC) on the claim submission. Note this includes both Medical and Pharmacy benefits. Please contact your Provider Relations Representative with any questions.

Other

Coverage Determination Guidelines

The use of health care services must be based on medical standards and accepted practice parameters of the community and provided at a frequency that is accepted by the medical community as medically appropriate. Based on this, unnecessary tests and treatments are not-covered, such as but not limited to:

Routine use of preoperative diagnostic testing and imaging in low-risk members for low-risk surgeries.
Low-value medical procedures including diagnostic imaging and disease screening that

Are not supported by evidence
May be duplicative of other procedures
May provide harm
Are truly unnecessary

For specific examples of low-value health services, please refer to the Minnesota Department of Health (MDH) May, 2017 Issue Brief, titled, “Analysis of Low-Value Health Services in the Minnesota All Payer Claims Database”, available at http://www.health.state.mn.us/healthreform/allpayer/lvsissuebrief.pdf

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.

Quality Management

Clinical Practice Guidelines

PreferredOne supports the Institute for Clinical Systems Improvement’s (ICSI) mission and promotes clinical practice guidelines to increase the knowledge of both our members and contracted providers about best practices for safe, effective and appropriate care. Although PreferredOne endorses all of ICSI’s guidelines, it has chosen to adopt several of them and monitor their performance within our network (Clinical Practice Guidelines QM.C003). The guidelines that PreferredOne’s Quality Management Committee has adopted include ICSI’s clinical guidelines for Asthma, Diabetes, Depression, ADHD, Prenatal - Routine Care, Preventive Services for Children and Adolescents, and Preventive Services for Adults. The performance of these guidelines by our network practitioner's is monitored utilizing HEDIS and Minnesota Community Measurement data. The most recent version of the ICSI guidelines that we have adopted can be found on ICSI's website at www.icsi.org.

Preventive Health Services for Children and Adolescents

The ICSI Preventive Health Services for Children and Adolescents guideline provides the basis for measurement and monitoring of several relevant clinical indicators. The measures that are assessed for adherence to the clinical guideline include the spectrum of childhood immunizations (using HEDIS technical specifications) and Chlamydia screening for adolescents (using HEDIS technical specifications). Utilizing 2017 claims data PreferredOne evaluated adherence to this set of guidelines through our HEDIS data collection process. The results for the entire PreferredOne network were as follows:

Preventive Health Measures for Children & Adolescents	2017
Four DTaP/DT	86.25%
Three IPV	92.44%
One MMR	91.75%
Three Hib	93.47%
Three Hepatitis B	91.07%
One VAR, or documented chicken pox disease	90.38%
Four pneumococcal	88.32%
Two Hepatitis A	87.97%
Rotavirus Two doses of the two-dose vaccine; or one dose of the two-dose and two doses of the three-dose vaccine; or three doses of the three-dose vaccine	83.85%
Two influenza	62.89%
Chlamydia screening	45.23%

PreferredOne strongly encourages our provider network clinic systems to send their immunization information to the Minnesota Immunization Information Connection (MIIC). MICC data is utilized to support our HEDIS data collection process and may reduce the burden of chart review at your clinic. To learn more about MICC and how you can participate please visit: http://www.health.state.mn.us/miic.

Continuity & Coordination of Care

Continuity and coordination of care is important to PreferredOne. If your clinic is terminating your contract with PreferredOne please notify your PreferredOne provider representative immediately. According to the Minnesota Department of Health statute 62Q.56 subdivision 1: the health plan must inform the affected enrollees about termination at least 30 days before the termination is effective, if the health plan company has received at least 120 days’ prior notice. If you need further information please contact your network representative at PreferredOne regarding this statute.

Case Management Referral

What is Case Management?

Case management is a collaborative process between the Case Manager (an RN or Social Worker), the PreferredOne member and their family, and the care team. The goal of case management is to help members navigate the complex medical system and reduce their risk of poor outcomes. The Case Manager will assist in preventing gaps in care with the goal of achieving optimal health care outcomes in an efficient and cost-effective manner. This service is intended to support the work of the care team.

Core Services

Assess individual member needs and develop a care plan with the member and provider to improve the member’s quality of life
Identify resources that may be helpful for the member
Provide both verbal and written education regarding a disease condition
Promote compliance with provider’s treatment plan
Serve as a liaison between the health plan, member and providers

Eligibility and Access

All members of the health plan experiencing complex health needs are eligible for case management. A Case Manager may call out to a member based on information that has been received at PreferredOne or members may call and request a Case Manager. There is no cost for this service and it is confidential. Participation is voluntary.

Health care provider referrals and member self referrals are accepted by contacting PreferredOne and requesting to speak with a Case Manager. The telephone number for the case management department is 763-847-4477, option 4.

Programs from PreferredOne at No Cost to Your Patients

PreferredOne has Chronic Illness Management (CIM) and Treatment Decision Support (TDS) programs available to help patients who live with chronic conditions. Your patients will still have the same level of benefits, access to any ancillary services and access to your referral network. They will also continue to see their practitioner(s) and receive the same services that they currently provide them.

The Chronic Illness Management (CIM) and Treatment Decision Support (TDS) Programs focus on the following conditions;

CIM:

Diabetes
Coronary Heart Disease
Congestive Heart Failure
Chronic Obstructive Pulmonary Disease
Asthma (adult and juvenile)
Multiple Sclerosis
Rheumatoid Arthritis
Ulcerative Colitis
Crohn’s Disease
Rare conditions (Sickle Cell, Cystic Fibrosis, Lupus, Parkinsons, Myasthenia Gravis, Hemophilia, Scleroderma, Dermatomyositis, Myositis, Polymyositis, CIDP, ALS, and Gaucher Disease)

TDS:

Low Back Pain
Health Mom and Baby

The goals of these programs are to:

Promote self-management of chronic conditions.
Improve adherence to treatment plans.
Improve adherence to medication regimes.
Reduce or delay disease progression and complications.
Reduce hospitalizations and emergency room visits.
Improve quality of life.

Benefits to You and Your Practice:

PreferredOne programs are designed to increase adherence to the practitioner’s recommended treatment plans. With the help of a nurse health coach, patients are educated telephonically about their chronic conditions and taught how to track important signs and symptoms specific to their condition. There are several benefits when your patients participate in these PreferredOne programs;

Program participants learn how to better follow and adhere to treatment plan
Program participants learn how to prepare for and maximize their office visits
If clinically concerning warning signs are discovered through the program, practitioners are notified via telephone or a faxed Health Alert
Program participants receive ongoing support and motivation to make the necessary lifestyle changes practitioners have recommended to them

Benefits to Patients:

Access to a PreferredOne Registered Nurse or Social Worker
Information about managing their health condition
Education and tools to track their health condition
Equipment, as needed, for participation in the program
Access to Healthwise®, an online health library at PreferredOne.com

Program Participants learn to:

Track important signs and symptoms to detect changes in their health status early enough to avoid complications and possible hospitalizations
Make better food choices
Start an exercise program
Regularly take their medications
Avoid situations that might make their condition worse

To make a Referral to the PreferredOne CIM or TDS programs: Contact PreferredOne toll free at 1-800-940-5049 Ext. 3456. Monday-Friday 7:00am to 7:00pm CST.

Is there a doctor in your practice who is not accepting new patients?

PreferredOne is requesting all physicians to submit information regarding acceptance of new patients. If you are a clinic site who has a physician that is not accepting new patients you can go to PreferredOne.com, select For Providers, login, select Your Clinic Providers and edit the Accepting New Patients information for your provider. Our provider directories will be updated with this information.

If you are unable to access the provider secured website please send an alert to PreferredOne by electronic mail to quality@preferredone.com. We would ask that you please include your clinic(s) site name and address, the practitioner(s) name and NPI number who are no longer accepting new patients and the contact information for the individual sending us the notification in case we have questions.

Quality Complaint Reporting for Primary Care Clinics

MN Rules 4685.1110 and 4685.1900 require health plans to collect and analyze quality of care (QOC) complaints, including those that originate at the clinic level.

A QOC complaint is any matter relating to the care rendered to the member by the physician or physician’s staff in a clinic setting. Examples of QOC include, but are not limited, to the following:

Clinical practitioner/provider – knowledge or skill, behavior, attitude, diagnosis and treatment, violation of member’s rights, etc.
Non-clinical staff/facility – competence, communication, behavior, environment (cleanliness, lacking areas for confidential communications, unsafe), violation of member’s rights, etc.

QOC complaints directed to the clinic are to be investigated and resolved by the clinic, whenever possible. PreferredOne's requires clinics to submit quarterly reports to our Quality Management Department as specified in the provider administrative manual. We have attached the form for your reference. If you'd like to have the file electronically please e-mail quality@preferredone.com. If you have any questions or concerns please contact Arpita Dumra at 800-940-5049, ext. 3564 or e-mail arpita.dumra@preferredone.com. (See QOC form)

Follow-up Appointments Following Mental Health Hospitalization

Hospitalizations for mental illness are monitored by PreferredOne with the intent on assisting members in their transition home or to another facility. The goal of PreferredOne’s Mental Health Admission Transition Management (ATM) Program is to reduce risk of adverse behavioral health and medical outcomes including readmissions and ER visits after discharge from an inpatient setting by the increasing the number of members who follow up with a mental health provider within seven days of discharge.

In coordination with hospital discharge planners, our Care Management staff can assist members and their care team navigate scheduling an appointment with a behavioral health specialist prior to hospital discharge within the optimal seven-day time frame. The seven-day time frame is strongly encouraged as there is strong evidence supporting reduced readmissions. We would ask that care teams consider this goal as they work on discharge plans with PreferredOne members and work to schedule the initial follow-up appointment prior to the member being released from the hospital. If our care management team can be of assistance to find an available mental health practitioner appointment in the member’s network please connect with us and we would be happy to help. Please call our Enrollment Specialists at 763-847-3456 and they will assist you. We appreciate you working with our members to achieve this goal and assist them in their healthcare needs.

Pharmacy

Pharmacy Information

On June 28, 2018 the Food and Drug Administration approved the first AP rated generic, Hydroxyprogesterone Caproate Injection, to the medication Makena. Hydroxyprogesterone Caproate Injection, USP will be available in a 250 mg/mL, 1mL preservative free Single Dose Vial. Effective January 1, 2019, the generic Hydroxyprogesterone Caproate Injection, will be the preferred medication on PreferredOne formularies, please use the code j1729 with the NDC for claim submission. Note this includes both Medical and Pharmacy benefits. Please contact your provider relations representative with any questions.

CODING

ICD-10-CM Coding Reminders

Z79.01 - Z79.899Long-term (current) drug therapy

PreferredOne receives claims with diagnosis Z79.899 (Other long term (current) drug therapy) on claims for drug testing (CPT^® codes 80305 – 80307, 80320 – 80377, HCPCS codes G0480 – G0484 and G0659). This is incorrect and will result in the claim being denied for incorrect diagnosis.Resource for this determination is the ICD-10-CM Official Guidelines for Coding and Reporting, Chapter 21: Factors influencing health status and contact with health services (Z00 – Z99).

Subcategory Z79 has this direction (page 94 of the FY 2019 Guide); Codes from this category indicate a patient’s continuous use of a prescribed drug (including such things as aspirin therapy) for the long-term treatment of a condition or for prophylactic use. It is not for use for patients who have addictions to drugs. This subcategory is not for use of medications for detoxification or maintenance programs to prevent withdrawal symptoms in patients with drug dependence (e.g., methadone maintenance for opiate dependence). Assign the appropriate code for the drug dependence instead.

October 1, 2018 – September 30, 2019 ICD-10 Diagnosis and Procedure Codes

All of the ICD-10-CM and ICD-10-PCS code updates have been made to our system.

General Coding

General Coding

There are specific requirements to use when it is necessary to submit a corrected claim in order to avoid inappropriate duplicate claim denials.

Physician services reported on an 837P (CMS-1500) requires field 22 (Resubmission Code) to be completed, both sections, with the appropriate indicator identifying this as a replacement/corrected claim. Failure to provide the appropriate information will result in the claim processing as a duplicate.

Hospital services reported on an 837I (UB-04) requires the Type of Bill (TOB) to have the appropriate indicator identifying this is a replacement/corrected claim. Failure to provide the appropriate information will result in the claim processing as a duplicate.

8-Minute Rule for Time Designated CPT® and HCPCS Codes

PreferredOne follows the American Medical Association (AMA^®) 8-minute Rule for all timed codes, especially the physical therapy, occupational therapy and speech language pathology services.

This is also the direction in the MN Administrative Uniformity Committee’s (MN AUC) Minnesota Uniform Companion Guides (837) found on the MN AUC’s website - http://www.health.state.mn.us/auc/guides/index.htm, Appendix A , under A.3.4.2 Units (basis for measurement), bullets 3 and 4;

In the case of time as part of the code definition, follow HCPCS/CPT guidelines to determine the appropriate unit(s) of time to report. Per the guidelines, more than half the time of a time-based code must be spent performing the service in order to report the code. If the time spent results in more than one and one half times the defined value of the code, and no additional time increment code exists, round up to the next whole number.
For therapy codes, follow HCPCS/CPT guidelines for determining rounding time. [See rounding rule instructions in Chapter 5 of Appendix A, Table A.5.1 for physical, occupational, and speech language pathology services (PT/OT/SLP).