Network Management

PreferredOne Chiropractic and Acupuncture Vendor Change

PreferredOne is excited to announce that we are partnering with Fulcrum Health effective 1/1/2021 as our chiropractic and acupuncture network. Chiropractic and acupuncture providers contracted with Fulcrum should submit their PreferredOne member claims for dates of service on or after 1/1/2021 through Fulcrum Health. If you are not currently contracted with Fulcrum and are interested in becoming a participating provider please follow the steps below based on your provider specialty or email Fulcrum at contracting@fulcrumhealthinc.org. Please remember that contracting with Fulcrum will be for 1/1/2021 forward effective dates. For contracts with effective dates in 2020 please continue to work with Magellan.

Process for chiropractors:

Visit ChiroCare.com website
Click on ‘Join ChiroCare’
Complete the information form and click ‘submit’
Watch for an email with additional information and instructions via the email address you provided.

(Note: The information is sent only by email, so be sure to check not only your email but also your spam/junk mailbox.)

Process for acupuncturists:

Visit AcuNet.org website
Click on ‘Join AcuNet’
Complete the information form and click ‘submit’
Watch for an email with additional information and instructions via the email address you provided.

(Note: The information is sent only by email, so be sure to check not only your email but also your spam/junk mailbox.)

If you have any questions regarding contracting with Fulcrum or the process, please contact Fulcrum Contracting at contracting@fulcrumhealthinc.org and they will be happy to assist you!

As a reminder, chiropractic and acupuncture claims for dates of service prior to this change should continue to be submitted through Magellan Health. Beginning with dates of service 1/1/2021 the Magellan chiropractic and acupuncture network will no longer be utilized by PreferredOne and claims for dates of service 1/1/2021 and after will not be accepted through Magellan. 2020 dates of service will continue to be accepted through Magellan with normal timely filing guidelines being applied.

2021 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, 2021. 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 2020 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 2020 and posted in April. New codes for 2021 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 2020. 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. Please note a change on the timing for when the new codes are added. They will hit the default rate until the fee schedules can be updated in March. In addition, although PreferredOne is following CMS updated E/M coding guidelines for 2021, the RVUs are still based on 2020.

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 2021 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, 2021. 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 2021 release of Relative Value Guide by the American Society of Anesthesiologists. This update will take place by January 1, 2021.

Requests for a market basket fee schedule may be made in writing to PreferredOne Provider Relations. Reminder that new codes for 2021 will be added to all fee schedules using the above listed methodology. The new codes will hit default rate until the fee schedules can be updated in March. 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 2021 Calendar year DRG schedule will be based on the CMS MS-DRG Grouper Version 38 as published in the final rule Federal Register October 2020.

For those on Ambulatory Payment Classifications (APC), we are using Optum hospital-based grouper that will be one year lag. For example, for 2021 rates, PreferredOne may use the 2020 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 2020 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 2021 will be added to all fee schedules using the above listed methodology. The new codes will hit default rate until the fee schedules can be updated in March. 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, 2021.

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

Care Management

What is Care Management?

Care management is a collaborative process between the Care Manager (RNs and Licensed Social Workers), the PreferredOne member, their caregivers, 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 Care 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

Care 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 Care 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 Care 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. (See form)

Medical Management

Documentation Requirements for Prior Authorization

PreferredOne PA request forms are available as form-fillable PDFs which allow users to complete the form online and submit via email. The information requested on the form, such as the Ordering Provider’s Name and NPI #, Servicing Provider and NPI # , Diagnosis Code and Specific Requested Service/Procedure/Device/Test Procedure Code are all required to set up and review a case for Prior Authorization. Entering comments such as “see clinical” or leaving blank can create confusion which may result in delays in the review process or denial.

In addition to the form, Clinical documentation supporting the medical necessity of the requested service, procedure, device, or test is required. This may include a provider order, medications, lab results, therapy notes, consult notes and plan of care (as applicable to the request).

Medical Policies/Medical Criteria are available on our PreferredOne Website. 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.

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

Prior Authorization List

08/06/20 Infusions/Injections: Fensolvi added HCPCS code and notation that it requires PA when billed with specific diagnosis codes; Neurology – addition of Cranial nerve stimulation, include vagus/vagal and CPT code
06/30/20 Infusions/injections: asterisks have been added to Actimmune, Adakveo, Arcalyst, Avsola, Fensolvi, Givlaari, Phesgo, Reblozyl, Tepezza, Ultomiris, Uplizna, and Vyepti to note they are subject to Site of Care review; HCPCS replaced on Adakveo and Givlaari; HCPCS added to anti-hemophilia/blood clotting/coagulation factors entry, Avsola, Enhertu, immune globulin, Myozyme, Nulojix, Padcev, Reblozyl, Ruxience, Tepezza, Vyepti and Zolgensma entries; added Actimmune, Arcalyst, Fensolvi, Phesgo, Uplizna, and Zepzelca; deleted Gemzar (gemcitabine) and Taxotere (docetaxel) – PA is no longer required; Lab Tests: PLA code 0018U added to Gene Expression Profiling entry; Neurology: Peripheral nerve stimulation - CPT codes for cranial/vagus nerve and entries of pudendal, sacral stimulation have been removed: CPTs added to phrenic nerve stimulator – Remede entry; New Technology – Under Comments, removed “Includes most health care services billed with Category III “T” codes, eg, 0278T” – all T codes that require PA are noted on the List under the applicable category; Orthopedic surgery, Total disc arthroplasty – initial and revisions and the CPT code for revision added. Lab Tests: PLA code 0018U added to Gene Expression Profiling entry; Neurology: Peripheral nerve stimulation - CPT codes for cranial/vagus nerve and entries of pudendal, sacral stimulation have been removed: CPTs added to phrenic nerve stimulator – Remede entry; Orthopedic surgery, Total disc arthroplasty – initial and revisions and the CPT code for revision added.

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies List

Breast pump supplies – HCPCS K1005 has been added under HCPCS and Comments
Continuous Glucose Monitor Systems – Under HCPCS and Comments,
- a note was added regarding moving CGMS pharmacy benefit, effective 10/1, for most employer groups
- HCPCS S1030 added to the receiver (monitor) PA entry
Diathermy Units – added HCPCS K1004 (this is a non-covered device)
Lifts, patient
- deleted E0627 from this entry (it is a seat lift mechanism -and is also listed under that entry); deleted the notation that these require prior authorization
- added E0636 to this entry - it was not reflected on the DMEPOS List; added E0621 to reflect the supply
Oral Appliances/mouth guard – added notation to see MC/C011 if requesting for treatment of OSA
Orthotic Devices, Lower Limb – added not that this does not include L2006 (new code): separate entry added for HCPCS L2006 coverage is subject to plan benefits as this is an orthotic that would be used for activities beyond those of daily living, which is often a plan exclusion
Seat lift/mechanism - deleted E0628, no longer a valid code
Temporomandibular Joint Appliance – deleted HCPCS S8262, no longer a valid code

Medical Criteria

Changes to the look of Medical Criteria and Medical Policy documents are in process and will be rolled out in phases

Going forward, they will all be called Clinical Policy documents
The Product Application area has been removed
General reformatting in the body of the document, including standardized Purpose and Policy statements
Under Prior Authorization, it is noted that when required, it is only for contracted providers

NEW

B004 Dental Services, Hospitalization, and Anesthesia for Dental Services Covered Under the Medical Benefit
G013 Anesthesia Services for Routine Screening and Diagnostic Gastrointestinal Endoscopic procedures
G014 Gender Reassignment
G016 Scar Revision
K003 Site of Care for Provider-Administered Medications
L022 Drug Testing in Substance Abuse Treatment and Chronic Pain Management Settings
M026 Behavioral Health, Autism Spectrum Disorders in Children

REVISED

B002 Orthognathic Surgery - Under vertical discrepancies, II.B. 2.a., the specific measurement regarding the mm of vertical overlap of anterior teeth has been removed.
C011 OSA, Non-Surgical Treatment - Under initial requests for PAP, II.A.2.g. has been added to also allow for mild OSA when the oxygen saturation less is than or equal to 88% for > 5 minutes.
F022 Intervertebral Disc Prosthesis, Cervical and Lumbar – Revised to broaden the scope and include other neurosurgical emergencies
F024 Radiofrequency Ablation (Neurotomy, Denervation, Rhizotomy) Cervical, Thoracic, Lumbosacral, Sacroiliac or Knee Pain – Revised to allow for situations where a hospital is the most appropriate setting for the member and to reflect contraindications to non-pulsed RFA
G003 Panniculectomy Excision/Removal Redundant Skin/Tissue - Revised to capture the medically necessary reasons for these procedures when they are associated with a psychological condition.
G008 Hyperhidrosis Surgery - Revised to capture the new language that would support medical necessity for surgery when hyperhidrosis is causing a psychological condition.
G015 Lipoma Removal - This newly created criteria/guideline (previous policy was retired) reflects the medically necessary reasons for this procedure, including when there is an associated with a psychological condition.
I007 Cryoablation/Cryosurgery for Oncology Indications - The tumor size for cryoablation for renal cell carcinoma (V.A.) has been revised from the previous indication of less than or equal to 7cm to less than or equal to 3cm.
I009 Neurostimulation, Deep Brain and Cortical Brain - Severe disabling tremor of idiopathic Parkinson’s disease (PD) has been added, under I.A.1., to incorporate another FDA-approved use of the Activa Tremor Control System in PD that is distinct from the use of the Activa Parkinson’s Control Therapy System device, which is FDA-approved for motor complications of PD.
I012 Neurostimulation, Hypoglossal Nerve Stimulation - Revised to capture the new FDA approved age for this device as 18 (previously 22) and to reflect the indications for replacement/revision of the stimulator generator/battery, lead or electrode, or patient programmer (controller).
L008 DMEPOS, Continuous Glucose Monitoring Systems for Long-Term Use – Revised to allow for Type 2 DM on intensive insulin therapy to allow more access to CGM. Revised to reduce number of finger sticks per day from 4 to 3 to allow more access to CGM and to align with PBM quantity limits for glucose test strips. Under Exclusions, the addition of “Implantable interstitial glucose monitoring system (such as, but not limited to, Senseonics Eversense) is considered investigative (see Investigative List).”
L009 Radiation Therapy, IMRT - Resectable rectal cancer was removed from Exclusions as investigative. Requests for this treatment should now be assessed under II. of the guideline, ie, there are no specific indications for use and a treatment plan for IMRT should show significant clinical benefit over a 3-D conformal RT approach.
L011 DMEPOS, Insulin Infusion Pump – Revised to allow more access to CGM and to align with PBM quantity limits for glucose test strips.
L012 Molecular Testing, Gene Expression Profiling - Revised to remove the requirement that the member is a candidate for chemotherapy and the addition of specific pathology stating for node involvement. Revised to incorporate additional indication for the use of Decipher.
L015 Genetic Testing, Comparative Genomic Hybridization (CGH, aCGH) – Revised to incorporate an additional use of CGH, supported by ACOG.

Medical Policies

Changes to the look of Medical Criteria and Medical Policy documents are in process and will be rolled out in phases.

Going forward, they will all be called Clinical Policy documents
The Product Application area has been removed
General reformatting in the body of the document, including standardized Purpose and Policy statements
Under Prior Authorization, it is noted that when required, it is only for contracted providers

NEW

L004 Levels of Evidence and Evaluation of Health Care Services - Captures the types of scientific evidence that are reviewed, and the level of evidence rating that is required, to determine when a health care service is proven effective for our members. Note, only services with a high level of evidence showing safety, effectiveness and positive effects on health outcomes will be considered for coverage.
P015 Preventive Coverage for Prenatal Services - Reflects the ACA and MN State Statute required preventive/no-cost sharing coverage for prenatal services
P020 Preventive Coverage for Routine Immunizations – Reflects information that was previously found In MP/I003, just in a new format

REVISED

C002 Cosmetic Procedures/Treatments - Revised to capture the new language/indications for cosmetic procedures when they are associated with a psychological condition.
C009 Coverage Determination Guidelines - Additional statement has been added on to the Continuation bullet... “For continuation of health care services, effectiveness or measurable improvement/progress must be documented and objectively quantified. Absence of placement and/or availability at a lower level of care does not constitute medical necessity for continuation of care at the current level of care.”
M001 Molecular Testing, Tumor/Neoplasm Biomarkers - Revisions under IV
- Removed the reference to 5-50 genes, as some NGS panels contain more than 50 genes
- To reflect that as it relates to Next Generation Sequencing panels, we also consider what is approved/reflected by/in the U.S. Food and Drug Administration (FDA) List of Cleared or Approved Companion Diagnostic Devices
- Addition of more indications, specific lab tests and HCPCS
R001 Reconstructive Surgery - Revised to capture the new language/indications for these procedures when they are associated with a psychological condition.
T004 Therapeutic Pass - I. statement has been added to the document, “Documentation supports that a temporary leave from the current level of care are part of the therapeutic treatment plan with specific, measurable, attainable and relevant goals.”, to ensure this is assessed when a therapeutic pass is requested. The setting of acute inpatient has been removed from II., as it is not felt that this level of care is outside of the scope of a therapeutic pass.

Investigative List

Added

All investigative services reflected by Category III codes (codes reflecting emerging technology)
Diabetes Biomarker Risk Score Test
6 central carbon metabolites and LC-MS/MS (NPDX ASD Energy Metabolism – 0139U) under the Investigative Assessments entry
Intervertebral Disc Prosthesis, Hybrid Procedure
Obstructive Sleep Apnea (OSA) oral appliance for prevention of temporomandibular joint dysfunction – also known as a day treatment device
Pharmacogenetic/pharmacogenomic Multi-gene Panels
Proprietary Laboratory Analyses (PLA) Codes

Deleted

External electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage
Intensity Modulated Radiation Therapy (IMRT) for resectable rectal cancer

Revised

Subtalar joint arthroereisis and implant for flexible flat foot syndrome has been revised by removing the reference to “in children”

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

IC-03222 Rituxan Hycela (rituximab and hyaluronidase) subcutaneous

REVISED

PC/B004 Biologics for Rheumatoid Arthritis
- Revised to require failure of both preferred rituximab biosimilars, Ruxience and Truxima before the non-preferred, Rituxan, will be allowed
- II.C./III.D. Quantity limits and maximum units for the rituximab products have been added into this document
PC/B016 Biologics for Multiple Sclerosis
- Revised by the addition of the rituximab products (off-label use) and also to require failure of both preferred rituximab biosimilars, Ruxience and Truxima before the non-preferred, Rituxan, will be allowed
- I.A.3., I.B.4. have been revised to now require failure (at least a 2-month trial) of one self-administered drug (previously required failure of 2).
- I.A.4. indications have been added for highly active or aggressive disease; allowing use of Ocrevus, Ruxience, Truxima or Tysabri without requiring failure of self-administered drugs
PC/R004 Rituximab Prior Authorization
- Revised to require failure of both preferred rituximab biosimilars, Ruxience and Truxima before the non-preferred, Rituxan, will be allowed
- III. Continuation - timeframe for approval was reduced from allowing up to 24 months to allowing up to 12 months
- IV. Quantity limits and maximum units have been added into this document
PC/S005 Synagis Prior Authorization - The age of eligibility for treatment with Synagis has been revised under I.B. and C. The Synagis Prior Authorization form has been revised to reflect the guideline changes.
PC/S007 Spravato Prior Authorization – Revised to allow use of this medication without failure of psychopharmacologic and psychotherapy treatment, when the current major depressive episode is similar to a previous episode.

Pharmacy Policy

Revised

R001 Review of new FDA-Approved Drugs and Clinical Indications - Removed the entry stating that a review will be initiated within 90 days of FDA approval. Replaced the language stating that requests for new medications will require prior authorization prior to review, to a drug will not be covered.

Pharmacy Investigative List

No changes

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.

Hyaluronic Acid PA Requirement Communication

Effective 11/15/2020, PreferredOne will implement new Prior Authorization criteria for Intra-articular Hyaluronan Therapy (Viscosupplementation). All hyaluronic acid products, except for the preferred products, will require prospective prior review. The full criteria is available for review here (https://www.preferredone.com/getting-care/medical-policy/). Euflexxa (J7323), Synvisc (J7325), and Synvisc-One (J7325) are the preferred products and will be allowed before all other hyaluronic acid derivatives, including (but not limited to) Durolane, Gel-One, GelSyn-3, GenVisc 850, Hyalgan, Hymovis, Monovisc, Orthovisc, sodium hyaluronate, Supartz/Supartz FX, Synojoynt, Trivisc, VISCO-3, and Triluron. For exceptions, the patient must have a documented contraindication, intolerance, or failure to Euflexxa AND Synvisc (or Synvisc-One). Patients will be allowed to complete their current weekly administrations (duration is product dependent) of the non-preferred products, but will require prior approval according to the new criteria (along with documented failure or intolerance to the preferred products) upon continuation. All intra-articular hyaluronan therapy (including preferred products) for temporomandibular joint (TMJ), osteoarthritis of the other joints, including but not limited to hip, shoulder, ankle or hand/thumb is investigative and therefore NOT COVERED and will be subject to retrospective review. Please reach out to your PreferredOne Network Management Representative if you have any questions or concerns.

PreferredOne Partners with Pear Therapeutics, Inc.

Boston and Golden Valley, Minn., September 21, 2020 – Pear Therapeutics, Inc. and PreferredOne announced today that reSET^® and reSET-O^®, the first two prescription digital therapeutics (PDTs) to receive authorization to treat disease from the U.S. Food and Drug Administration (FDA), have been added to PreferredOne’s medical benefits as covered products for its members.

"We are excited to partner and develop an innovative agreement with Pear Therapeutics to provide access to reSET^® and reSET-O^® for our members, furthering our commitment to providing evidence-based therapeutics,” said Samir Mistry, Vice President of Pharmacy at PreferredOne. “We are proud to announce during National Recovery Month that we now pay for two innovative PDTs to treat addiction. The addiction crisis was the top health crisis in America before the pandemic, and it has since grown worse. PreferredOne is doing its part to help fight the addiction crisis by adding reSET and reSET-O to our covered medical benefits."

CODING

Effective 1/1/2021, PreferredOne will be adopting CMS guidelines regarding evaluation and management codes (E/M) 99201-99215.

REVISION

CPT code 99201 will be deleted
History and examination components will no longer be used in the selection of the level of evaluation and management code 99202-99215.
Code selection will be based on level of medical decision making or the time performing the service on the day of the encounter
Time associated with codes 99202-99215 has been revised from the typical face-to-face time to total time spent on the day of the encounter.
Medical decision making will consist of three elements
- Number and complexity of problems addressed
- Amount and/or complexity of data to be reviewed
- Risk of complication and/or morbidity or mortality of patient management
A new code has been created for prolonged service(99XXX)

The new code is only to be reported with the highest-level evaluation and management codes (99205/99215)
Only when time is the basis for the code selection
Only when the designated maximum time in the code description has been exceeded
Documentation must include what comprised the total time being reported

For Submission of claims for G2066:

Documentation including the device name will be required in order to ensure accurate coverage determination for code G2066.

Code G2066:

Interrogation device evaluation(s), (remote) up to 30 days; implantable cardiovascular physiologic monitor system, implantable loop recorder system, or subcutaneous cardiac rhythm monitor system, remote data acquisition(s), receipt of transmissions and technician review, technical support and distribution of results.