Network Management

2020 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, 2020. 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 2019 CMS Medicare physician RVU file without geographic practice index (GPCI) applied and without the work adjuster applied, as published in the Federal Register released March 2019 ad posted in April. New codes for 2020 will be based on the 2020 CMS Medicare physician RVU file without geographic practice index applied and without the work adjuster applied as published in the Federal Register November 2019. 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.

Various fees for services without an assigned CMS RVU have been updated accordingly. New codes that are not RVU-based will also be added. Examples of these services include labs, supplies/durable medical equipment, injectable drugs, immunizations and oral surgery services. The lab methodology as a % of CMS will remain the same for all products. PreferredOne will maintain the current default values for codes that do not have an established rate.

The 2020 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 Fee and Dental schedules will also be updated January 1, 2020. New codes were added to this fee schedule and reminder that any code not on the fee schedule will not be reimbursed.

New ASA codes for Anesthesia services will be updated with the 2020 release of Relative Value Guide by the American Society of Anesthesiologists. This update will take place by January 1, 2020.

Requests for a market basket fee schedule may be made in writing to PreferredOne Provider Relations. Reminder that new codes for 2020 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 2020 Calendar year DRG schedule will be based on the CMS MS-DRG Grouper Version 37 as published in the final rule Federal Register October 2019.

For those on Ambulatory Payment Classifications (APC), we are using Optum hospital-based grouper that will be one-year lag. For example, for 2020 rates, PreferredOne may use the 2019 APC grouper and edits and weights as of October 2019.

The Facility (UB04) CPT fee schedule will consist of all physician CPT/HCPC code ranges and will be based on the 2019 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 2020 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, 2020.

PreferredOne Code Auditing Process

PreferredOne uses both an automated code auditing tool as well as third party code auditing vendors to help expedite and improve the accuracy of claims processing.

The types of edits identified through the use of these tools and vendors include but are not limited to:

Unbundling
Mutually Exclusive Procedures
Incidental
Services Deemed Investigative

These audits are performed & applied based on CPT guidelines, a review of the Center for Medicare and Medicaid Services (CMS), National Correct Coding Initiative (NCCI) policies and guidelines, specialty society guidelines, & industry standard practices. As stated in our provider agreement, PreferredOne may change, combine or recode the procedure codes or other billing codes in accordance with industry standards, American Medical Association CPT coding guidelines, and/or Company or Payor’s reimbursement policies and methodologies, and will notify providers of any such changes through a standard remittance advice.

Coding/Payment Policy Updates

Reimbursement for Free Standing Ambulatory Surgery Centers and Hospital Outpatient Ambulatory Centers on APC Methodology

Medical Management

New Prior Authorization Forms Now Live

PreferredOne has updated our existing prior authorization (PA) request forms and those forms are now live on our site for providers to use. The purpose of updating & creating new PA request forms is to improve efficiencies & allow for more timely & accurate case review. All PA request forms are now available as a form-fillable PDF which allows users to complete the form online and submit via email. Please note that at the top of every PA request form there is a PreferredOne email address where you can submit the form/data electronically. In addition, the PA request forms have been revised to include additional provider data fields which is needed to set-up cases. The new PA forms can be found by visiting www.preferredone.com/providers/provider-forms.aspx & selecting the appropriate form under the Medical Management section of the site.

Concurrent Inpatient Certification

PreferredOne has updated the Inpatient Certification Letter to include: “*If further hospitalization is required beyond the certified dates, please provide additional clinical information for continued review through the date of discharge.” Providers must submit clinical documentation for medical necessity review when rendering services beyond the certified end-date. Submit clinical documentation for continued certification by email to UM@PreferredOne.com.

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.

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).

Clarification of Existing Coverage Policy for Preventive Services:

In general, PreferredOne follows USPSTF guidelines for preventive care and disease screening. In keeping with these guidelines, as well as the current guidelines of the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Family Physicians (AAFP), we will continue to cover screening Pap smears every 3 years for women aged 21-65 and screening for high risk HPV every 5 years for women aged 30-65.

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.

Prior Authorization List

Prior Authorization Effective 9/1/2019

Alpha-1 proteinase inhibitor, NOS (Prolastin, Zemaira) J0256
Belrapzo (bendamustine) C9042, J9036
Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) J9355

07/29/19 Cosmetic: Septoplasty - updated diagnosis codes; Home Health, Hospice, and Home Palliative Care Services: removed, “Open case after the initial evaluation has been completed and the HHC agency will be going out again” notation; Infusions/Injections – added more examples of immune globulins; Other Procedures/Treatments – added Hyoid Myotomy for sleep apnea with associated diagnosis and CPT codes; various CPT does updated through-out.

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

REVISED

MC/A006 Ventricular Assist Devices (VAD) and Total Artificial Heart (TAH) – Revised to include FDA-approved indications for temporary Total Artificial Heart and to capture unique FDA-approved and medically necessary indications for the use of pediatric VADs.
MC/F022 Intervertebral Disc Prostheses – Revised to include FDA-approved and medically necessary indications for use in the lumbar spine and to capture additional devices and contraindications based on the FDA Summary of Safety and Effectiveness Data (SSED).
MC/F024 Radiofrequency Ablation (Neurotomy, Denervation, Rhizotomy) Cervical, Thoracic, Lumbosacral, and Sacroiliac Pain – Revised to allow RFA in the thoracic spine as appropriate and to incorporate specific site-of-care criterion indications/exceptions to delivery of RFA intervention at anywhere other than an office or ambulatory surgery center setting.
MC/G002 Breast Reduction Surgery and Gynecomastia Surgery – Revised to now include medically necessary indications for gynecomastia surgery and to capture new medically necessary indications for breast reduction or male gynecomastia surgery when there is a psychological condition associated.
MC/G004 Breast Reconstruction – Revised the criterion for removal of breast implants to now allow for Grade III Baker’s class contractures in addition to class IV.
MC/G011 Hyperbaric Oxygen Therapy (HBOT) – Revised to lower the decibel threshold from 41 to 30 for use of HBOT in the setting of Idiopathic Sudden Sensorineural Hearing Loss.
MC/L008 Continuous Glucose Monitoring Systems – Removed the requirement that the member is managed by a provider-coordinated team expert in both in the management of and support of patients with complex diabetic conditions; revised by add the FDA definition of malfunctioning.
MC/L011 Insulin Infusion Pump – Revised to add the FDA definition of malfunctioning.
MC/L012 Gene Expression Profiling – Revised to reflect the newly updated position from NCCN regarding the use of Decipher post-prostate biopsy.
MC/L015 Comparative Genomic Hybridization – Revised to no longer require congenital abnormalities in addition to DD/ID or ASD.
MC/M025 Transcranial Magnetic Stimulation – Revised to include criteria to ensure the request for treatment is for a true major depressive episode, to more clearly define treatment resistance, and to incorporate clarifying attributes to the contraindications for use of TMS.

Medical Policy

REVISED

MP/C002 Cosmetic Treatments - Revised to more clearly reflect the area detailing the medical necessity requirements for cosmetic treatment being requested due to psychological issues has been revised and now requires:
- Documentation from a mental health professional that there is a DSM mental disorder diagnosis causing significant distress and impairment as evidenced by validated scales and measures.
- Specific criterion regarding objective measurements for distress and impairment have been included.
- Additional definitions have been added for clarity. The Exclusions area has been revised by grouping like treatments/indications together
MP/G002 Gender Reassignment - The exclusions related to treatments for potentially “cosmetic” indications have been removed. All requests for these type of treatments are subject to the Cosmetic criteria indications
MP/S008 Scar Revision – Revised to capture the new medically necessary indications for scar revision when it is being requested due to a psychological condition.

Investigative List

Please visit www.preferredone.com for the most current version.

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.

Pharmacy Criteria

NEW

PC/S007 Spravato Prior Authorization – Created to capture medically necessary indications for the use of this new FDA-approved drug.

REVISED

PC/A011 Altered Bone Homeostasis Treatment Medications – Revised to reflect new FDA-approved drug for the treatment of osteoporosis.

Quality Management

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.

Programs from PreferredOne at No Cost to Your Patients

Case Management

What is Case Management?

Case management is a collaborative process between the Case Manager (RNs and Licensed Social Workers), the PreferredOne member and their family, and the care team. The goal of case management is to help high risk members navigate the complex medical system and reduce their risk of unplanned hospital and emergency room visits and poor outcomes by closing/preventing gaps in care. 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 providers to improve the member’s quality of life
Identify resources that may be helpful for the member and provider
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

PreferredOne offers condition focused support to help members who have the chronic and episodic conditions listed below. Your patients will still have the same level of benefits, access to ancillary services and access to your referral network. They will also continue to see their practitioner(s) and receive the same services currently provided.

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)
Healthy Mom and Baby

The Goals of Case Management are:

Promote self-management of conditions
Address barriers and social determinants of health
Improve adherence to treatment plans
Improve adherence to medication regimes
Reduce or delay disease progression and complications
Reduce risk of avoidable hospitalizations and emergency room visits
Help members save money by understanding and optimizing benefits
Improve quality of life
Maintain high levels of member and provider satisfaction

Case Management Referral

Eligibility and Access

All members of the health plan experiencing complex health needs are eligible for case management. There is no cost for this service and it is confidential. Participation is voluntary.

Health care providers can refer PreferredOne members or members can self-refer by contacting PreferredOne and requesting to speak with a Case Manager. The telephone number to make a referral is 763-847-3456 or email at IHSenrollment@preferredone.com. Include member name, member ID and date of birth.

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 PreferredOne nurse or social worker, 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
Program participants receive ongoing support and motivation to make the necessary lifestyle changes practitioners have recommended to them
Case management can assist members who are 17 and need to transition from a pediatric provider to an adult primary care provider

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
Access to Healthwise®, an online health library at www.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

Questions?

Contact PreferredOne toll free at 1-800-940-5049 Ext. 3456. Monday-Friday 7:00am to 7:00pm CST.

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.

Pediatric Case Management/Care Coordination

Minnesota law now requires hospitals to provide care coordination for children with high-cost medical or chronic conditions who need post hospital extended care services or outpatient services or is at risk of recurrent hospitalization or emergency room services by notifying the PCP and Health Plan of the anticipated discharge date, a description of the child’s needs, and a copy of the discharge plan including any necessary medical information release forms. This information can be emailed to IHSenrollment@preferredone.com.

Mental Health Case Management/Care Coordination

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 substantial 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.

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 www.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. (Download QOC form)

CODING

Initial Vaccine Administration Code Reporting

Initial Administration Code Sets

There are three code sets that can be used to report initial vaccine administration codes:

90460 – Used for face-to-face counseling to the patient and/or family for patients younger than 19 years old
990471, 90473 – Used when there is no face-to-face counseling for patients of any age
9G0008 – G0010 – Used on a limited number of vaccines (usually Medicare beneficiaries)

If one or more vaccines are performed during an encounter, an initial administration code must be reported.

When more than one vaccine is given during the same visit, coders must decide which initial administration code to use:

Report only one initial administration code per claim. Additional initial administration code(s) will result in claim denial.
Report counseling administration codes (90460 – 90461) before non-counseling administration codes (90471 - 90474).
Report administration codes for injectable vaccines (90460 - 90461, 90470 - 90472) before oral or intranasal vaccines (90473 - 90474).

Units

Apply units to the subsequent administration code (90461, 90472, 90474) for every additional vaccine (two or more) of the same type (injectable or oral).

Vaccine Administration Codes

90460 - Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered

90461 - Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine or toxoid component administered (List separately in addition to code for primary procedure)

90471 - Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)

90472 - Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)

90473 - Immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid)

90474 - Immunization administration by intranasal or oral route; each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)

G0008 - Administration of influenza virus vaccine

G0009 - Administration of pneumococcal vaccine

G0010 - Administration of hepatitis B vaccine

SYNAGIS^® (PALIVIZUMAB)

90378 - Respiratory syncytial virus, monoclonal antibody, recombinant, for intramuscular use, 50 mg, each

96372 - Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular

S9562 - Home injectable therapy, palivizumab, including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

Home Infusion Therapy Service Reporting

90378 + S9562 (96372 is included in S9562)

Clinic or Facility Service Reporting

90378 + 96372 (subcutaneous or intramuscular injection)

Unit Reporting for H0035

H0035 - Mental health partial hospitalization, treatment, less than 24 hours

The units reportable for code H0035 is one (1) as the code unit of measure is “…less than 24 hours”. It is not described as “….each hour up to 24 hours”, therefore it is not a multiple unit type of service. Claims submitted with units >1 will be denied.