NETWORK Management

2023 Fee Schedule Update

Professional Services

Physician fee schedules will be based on the 2021 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 2021 and posted in April. New codes for 2023 will be based on the 2022 CMS Medicare physician RVU file without geographic practice index applied and without the work adjuster applied as published in the Federal Register November 2022. 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

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 2023 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).

New ASA codes for Anesthesia services will be updated with the 2023 release of Relative Value Guide by the American Society of Anesthesiologists. This update will take place by January 1, 2023.

Requests for a market basket fee schedule may be made in writing to PreferredOne Provider Relations. Reminder that new codes for 2023 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 2023 Calendar year DRG schedule will be based on the CMS MS-DRG Grouper Version 40 as published in the final rule Federal Register October 2022.

For those on Ambulatory Payment Classifications (APC), we are using Optum hospital-based grouper that will be one year lag. For example, for 2023 rates, PreferredOne may use the 2022 APC grouper and edits and weights as of October 2022.

The Facility (UB04) CPT fee schedule will consist of all physician CPT/HCPC code ranges and will be based on the 2021 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 2023 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, 2023.

Reminder to Verify Member Eligibility

As a friendly reminder, following normal process PreferredOne would like to encourage providers to request updated member ID cards and verify member eligibility, especially at the start of the new year. With PreferredOne becoming a part of UnitedHealthcare we have a number of members moving from their PreferredOne plans to other plans, including UnitedHealth plans at the start of 2023. PreferredOne will also continue to have members on PreferredOne plans into 2023 so it will be most important to request those updated ID cards and confirm member eligibility to ensure proper benefit verification and claims processing. PreferredOne will only be able to process PreferredOne plan claims. Please be sure to follow claim submission instructions as indicated on the updated member ID cards should the members plan have changed to another carrier.

Medical Management

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).

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.Thompson@PreferredOne.com.

Prior Authorization List

Cosmetic and/or Reconstructive Procedures: added potentially; Laboratory Testing: Molecular Testing, Gene Expression – added CPT code 0013M; Neurology: Hypoglossal Nerve Stimulation – deleted CPT 64568; Oncology: Cryoablation – added soft tissue sarcoma/desmoid tumors; Other Procedures/Treatments: deleted Risk Reducing Mastectomy (this no longer requires prior authorization)
Laboratory: under Pharmacogenetic/Pharmacogenomic Testing added CPT codes 81225,81226.
Neurology: Radiofrequency ablation – CPT code 64569 replaced with 64629.
Gender Reassignment: CPT code 19803 replaced with 19303.

Medical Clinical Policies

New: None

Revisions (substantive clinical revisions)

Cryoablation/Cryosurgery for Oncology Indications (MC/I007) – revised to include medical necessity requirements for renal cell carcinoma and desmoid tumors, as supported by NCCN
Genetic Testing, Hereditary Cancer Syndromes (MC/L010) - revised to align with shift in clinical practice approach from primarily single gene testing to panel testing, and as supported by evidence
Genetic Testing, Preimplantation Genetic Diagnosis (MC/L026) – revised to expand indications for use and testing focus
Genetic Testing, Whole Exome and Whole Genome Sequencing (MC/L021) – revised to reflect inclusion of Whole Genome Sequencing (WGS)
Intervertebral Disc Prosthesis, Cervical and Lumbar (MC/F022) – deleted contraindications
Laboratory Testing for Detection of Heart Transplant Rejection (MC/L014) - revised to include medical necessity indications for AlloSure®
Molecular Testing, Tumor/Neoplasm Biomarkers (MC/L012)
- revised to reflect expansion of coverage beyond gene expression assays
- revised tests and indications based on market availability and supporting evidence
- added medical necessity indications for pre- and post-prostate biopsy biomarker testing, per NCCN guidelines
- revised to quantify the number of tests allowed in a targeted genomic next generation sequencing (NGS) panel
Occupational Therapy and Physical Therapy (MC/N003) – revised to include specific indications for continuation of PT for congenital muscular torticollis
Radiation Therapy, Intensity Modulated (IMRT) (MC/L009) – revised based on guidelines supported by Radiation Therapy Oncology Group [RTOG] and/or Quantitative Analysis of Normal Tissue Effects in the Clinic [QUANTEC] guidelines
Radiation Therapy, Selective Internal Microspheres (MC/L025) – revised to include criterion for use in intrahepatic cholangiocarcinoma

Retired

Anesthesia Services for Routine Screening and Diagnostic Gastrointestinal Endoscopic Procedures (MC/G013)
Risk Reducing Mastectomy or Salpingo-Oophorectomy (MC/G007)

Medical Investigative List

Addition: Amyloid brain PET for diagnosis of Alzheimer’s disease

Revision: Molecular testing for detection of prostate cancer

Please visit PreferredOne.com for the most current version.

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

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

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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

1. Assess individual member needs and develop a care plan with the member and providers to improve the member’s quality of life
2. Identify resources that may be helpful for the member and provider
3. Provide both verbal and written education regarding a disease condition
4. Promote compliance with provider’s treatment plan
5. 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

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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 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?

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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 ne 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 or if you have any questions please email quality@preferredone.com.

Clinic Complaint Reporting Form.pdf

Reminding Patients of Yearly Preventive Screenings
As the end of 2022 rapidly approaches, we want to encourage all our practitioners to remind and encourage their patients to make an appointment for their annual preventive screenings. In the wake of the COVID-19 pandemic, annual preventive screenings, especially for older adults and those with chronic or pre-existing conditions, decreased. Now with robust vaccination programs and effective safety protocols in place patients can feel safe to visit their primary care practitioner and have their annual preventive screenings performed.

CODING

Coding and Billing for Surgical Pathology for Prostate biopsies

Beginning November 15, 2022, (received date) PreferredOne will be following CMS billing guidelines for surgical pathologies for prostate biopsies.

Claims received prior to November 15, 2022
The surgical pathology for prostate biopsies - was reported as CPT code 88305
Code 88305 – surgical pathology – gross and microscopic examination.
This code “88305” is no longer allowed for surgical pathology for prostate biopsies.

Claims received on and after November 15, 2022,
HCPCS code G0416 should be sent for surgical pathology for prostate biopsies.
G0416 – Surgical pathology gross and microscopic examinations, for prostate biopsies, any method.
HCPCS code G0416 should be reported with one unit for a single patient.
Claims received on and after with CPT code 88305 surgical pathology for prostate biopsies will be denied.

Source: National Correct Coding CMS
AMA/CPT Assistant 2022, Second Quarter