As a friendly reminder, services rendered to PreferredOne members that are deemed investigative will deny as provider liability unless the member has agreed in writing to be financially responsible for the services prior to services being rendered. For providers wanting to view the investigative services list, please visit https://www.preferredone.com/getting-care/medical-policy/. Once you’ve accepted the terms, you will be able to pull up both the Investigative Medical Services and Investigative Pharmacy Services lists in PDF format. These lists are also accessible by logging in to the secure PreferredOne provider portal. If a member determines that they would like to receive an investigative service and have agreed to be held financially responsible providers should ensure that a proper financial liability waiver has been completed by the member. A CMS Advanced Beneficiary Notice (ABN) of non-coverage can be used or a document similar to the attached sample. Key elements that must be included in order for the waiver to be recognized by PreferredOne as valid are a description/name of the service, an approximate dollar amount the member has agreed to be liable for, and a signature and date that is on or prior to the date the service is being rendered. Providers should submit the investigative service CPT/HCPCS codes with a GA modifier appended and attached the ABN or valid waiver form upon claim submission following Minnesota AUC guidelines. Instructions on how to submit an attachment with a claim can be found here by clicking on the document titled Attachment Cover Sheet (DOC) and Attachment Cover Sheet Instructions (PDF) located at the right-hand side of the screen.
As a reminder, PreferredOne administers the Bind insurance product for the Minnesota market. Below we’ve compiled some helpful hints & tools to navigate the Bind claims submission process, along with some general information around the PreferredOne & Bind partnership.
Bind On-Demand Health Insurance is a new product offering for self-insured employers. Bind Benefits, Inc., accesses PreferredOne provider contracts in Minnesota, as an affiliate of PreferredOne. Bind/PreferredOne administer the first-ever on-demand health insurance product model. The on-demand model delivers:
- Answers to key consumer questions upfront - Is the treatment or service covered? How much it will cost?
- A solution to the ever-increasing health insurance cost to employers without impacting quality or cost shifting to employees.
The Bind plan includes in-network preventive care; primary and specialty care; urgent, emergency and hospital care; chronic care for long-term and recurring illnesses; and pharmacy. Members pay a copay for services received under Bind plan. There is no deductible or co- insurance. Copay amounts are available to the member in advance for any in network visit through the My Bind app, website, or Bind Help team. Providers will be able to view copay amounts using the same methods they use to verify benefits and copay amounts today – through the PreferredOne provider portal or by calling the provider services number on a member’s ID card.
How do I submit claims for Bind members?
Please add the Bind Benefits, Inc., payer ID number into your systems; this is a critical step to avoid delays in claims handling and processing.
Bind Benefits Inc. is the payer. Payer ID: 25463
- Bind Benefits, Inc., may be entered as the “insurance” carrier (dependent on provider processing system).
- All claims should be routed to Bind Benefits, Inc., following the instructions on the Member ID card.
- Claims address: Bind · PO Box 211758 · Eagan, MN 55121
This payer ID may be attached to multiple networks. Examples of these include:
- PreferredOne networks
- UnitedHealthcare networks
- SmartHealth network
Refer to the Member ID card for the specific network accessed by the member.
What does the Member ID card look like for Bind?
Each member ID card may look different depending on the employer, the member location, and also depending on the location that the provider services are rendered.
Sample member ID cards for illustration only; actual information varies depending on payer, plan and other requirements.
- Claims column – provides the payer ID and claim mailing address.
- Networks column – provides the network and provider resources. For some members, the network accessed will depend on the location of the provider.
Who do I contact for prior authorizations and notifications?
Advance notification and prior authorization requirements for Bind member services received in Minnesota are the same as all other PreferredOne products. Those advance notification and prior authorization requirements can be found by logging in to the secure provider portal at PreferredOne.com
Who do I contact if I have questions?
PPO Account Management
PPO payor Cypress Benefit Administrators was acquired by Lucent Health. In addition to acquiring Cypress Benefit Administrators, Lucent Health also acquired North America Administrators and Capitol Administrators. They are moving all of their operating companies under the Lucent Health brand beginning January 1, 2020. You will see a new logo on ID cards. Please update your patient records to reflect this change as they present the new ID cards.
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
- 12/31/19 Infusions/Injections – removed Mvasi and Zirabev – PA is no longer required for these medications; Lab Tests – Gene Expression Assays, Heart Transplant Rejection testing, Kidney Transplant Rejection testing, Pharmacogenetic/Pharmacogenomic Testing entries - CPTs/HCPCS added; Other Procedures/Treatments - Leadless Pacemaker Insertion and Left Atrial Appendage cardiac device deleted (these are on the Investigative List); Myocardial imaging, PET, with specific CPTs added; Radiofrequency ablation – addition of CPTs 64624 and 64625 (representative of procedures that were already on the list [RFA genicular and sacroiliac nerves] but did not have specific CPT codes).
- 11/11/19 Hospice and Home Palliative Care: removed (no longer requires PA); Infusion/Injection: revised HCPCS code for Lumoxiti; Other Procedures: Remote monitoring of physiologic parameters - added 99457 HCPCS code.
- 10/22/19 Cosmetic: added Gynecomastia surgery; Infusions/Injections: added Kanjinti, Polivy, Ruxience, Truxima, Zirabev, Zolgensma; various CPTs HCPCS codes updated through-out.
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies List
- BiPAP - Added Purchase as an option
- Compression Garments – Revised HCPCS
- Continuous Glucose Monitors – Under Comments, added examples of devices and referenced the criteria document
- CPAP – Under Comments, added medical necessity information for new and replacement. Added information re: claims for both CPAP and oral devices
- Insulin Pump - Under Comments, added notation for what requires PA and what does not; added examples of devices
- Oral appliances - Under Comments, added notation reflecting that requests for new or replacement devices must be accompanied by recent (within the past 12 months) clinical documentation from the sleep appliance specialist (provider such as physician or dentist).
- Orthopedic Shoe additions, shoe heels and wedges – are covered per benefit
Various updates to HCPCS and quantity limits. Check PreferredOne.com for the most current version.
- MC/L020 Proton Beam Therapy – Created to have a clearly stated coverage position, reflecting use of the American Society for Radiation Oncology (ASTRO) guidelines in determining medical necessity for the use of proton beam therapy.
- MC/T008 Solid Organ Transplantation – Created to align with, and therefore refer to, clinical guidelines developed by our designated transplant network for all solid organ transplant requests
- MC/G002 Breast Reduction and Gynecomastia Surgery - Revised to clarify the requirement for failure of conservative management and associated timeframe
- MC/G004 Breast Reconstruction –
- Revised to more clearly reflect the area detailing the medical necessity requirements for reconstruction 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.
- Revised to more clearly reflect the area detailing the medical necessity requirements for reconstruction being requested due to psychological issues has been revised and now requires:
- Removed the exclusion re: no longer allowing further augmentation and/or revision due to normal aging or other non-pathologic process(es), including but not limited to re-tattooing of the nipple/areola.
- MP/P017 Preventive Services for Lung Cancer Screening - Reflects the United States Preventive Services Task Force (USPSTF) position for lung cancer screening by low dose CT
- MP/P018 Preventive Coverage of Cervical Cancer Screening – Reflects the USPSTF position, Health Resources & Services Administration (HRSA) Women’s Preventive Services Guidelines, the Periodicity Schedule of the Bright Futures Recommendations for Pediatric Preventive Health Care and MN statute 62A.30 required coverage for cervical cancer screening in normal risk women.
- MP/P019 Preventive Coverage for Breast Cancer Screening – Reflects the USPSTF position, (HRSA Women’s Preventive Services Guidelines, the Periodicity Schedule of the Bright Futures Recommendations for Pediatric Preventive Health Care and MN statute 62A.30 required coverage for breast cancer screening in normal and high-risk individuals
- MP/A004 Acupuncture – Revised to separate non-chronic conditions from chronic conditions
- MP/H007 Hospice Care – Revised to no longer require prior authorization
- MP/P013 Pharmacogenetic/Pharmacogenomic and Serologic Markers for Inflammatory Conditions – Revised to reflect the new FDA-approved companion diagnostics and genetic tests required to determine drug eligibility
- MP/P017 Preventive Coverage for Colorectal Cancer Screening – Revised to reflect the diagnosis codes which support the coverage of pathology services at the no cost-sharing level of benefit when services are performed in conjunction with a preventive colonoscopy
Milliman Care Guidelines
Starting March 2nd, PreferredOne will add Milliman Care Guidelines (MCG) to our Utilization Management process. The guidelines are evidence based and will help support decision making for the PreferredOne Medical team around certain procedures, admissions, and level of care decisions.
The authorization process at PreferredOne will continue based on the current prior authorization list and process. There are no changes to the way in which prior authorization is sought by our provider community. Practitioners will continue to follow the same process in submitting requests to PreferredOne for medical review by contacting the IHS Intake team.
“Milliman Care Guidelines Health, part of the Hearst Health Network, helps healthcare organizations implement informed care strategies that proactively and efficiently move patients towards health. MCG’s clinical editors analyze and classify peer-reviewed papers and research studies each year to develop the care guidelines in strict accordance with the principles of evidence bas-based medicine."
"Care guidelines from MCG provide fast access to evidence-based best practices and care-planning tools across the continuum of care, supporting clinical decision-making and documentation as well as enabling efficient transitions between care settings. Data analysis provides insight into critical benchmarks such as length of stay, re-admissions, and skilled nursing facility/inpatient rehabilitation admission rates. Milliman Care Guidelines is URAC certified as Health Utilization Management.“
- Leadless Cardiac Pacemaker
Please visit www.preferredone.com for the most current version.
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.
- PC/S008 Spinal Muscular Atrophy Medications Prior Authorization – Created to capture the medically necessary indications for use of Spinraza and Zolgensma
The following were revised to include Ruxience and Truxima, and change “Rituxan” to “rituximab” throughout the criteria document.
- PC/B004 Biologics for Rheumatoid Arthritis
- PC/R004 Rituximab Prior Authorization
The following guidelines were revised to reflect preferred products
- B004 Biologics for Rheumatoid Arthritis
- B005 Biologics for Plaque Psoriasis
- B006 Biologics for Crohn’s Disease
- B010 Biologics for Juvenile Idiopathic Arthritis and Juvenile Rheumatoid Arthritis
- B011 Biologics for Psoriatic Arthritis
- B012 Biologics for Ankylosing Spondylitis
- B013 Biologics for Ulcerative Colitis
PC/I002 Immune Globulin Therapy – Revised to now include medically necessary indications for the use of these agents for PANS and PANDAS
No new or revised policies since the last Provider Newsletter update
Cancer Screening Update:
As required by Minnesota Statute 62A.30, all fully-insured plans providing coverage to a Minnesota resident must provide coverage for routine screening procedures for cancer and the office or facility visit, including mammograms, surveillance tests for ovarian cancer for women who are at risk for ovarian cancer, pap smears, and colorectal screening tests for men and women, when ordered or provided by a physician in accordance with the standard practice of medicine.
New: Starting January 1, 2020, Minnesota fully insured plans must also cover digital breast tomosynthesis at the preventive level for persons deemed “at risk” of breast cancer. This additional benefit is added as of the plan’s first effective or renewal date on or after January 1, 2020.
Cervical cancer screening:
The US Preventive Services Task Force, American College of Obstetricians and Gynecologists and the American Academy of Family Physicians all agree that screening of normal risk women with Pap smears should not be done until age 21 and not more often than every 3 years. Starting before age 21 or testing more frequently leads to excess cost and does not result in improved diagnosis as it takes significant time for the HPV virus to transform cells after exposure. HPV DNA testing should not begin until age 30 and if negative can extend frequency of testing to every 5 years.
Testing more often can be harmful because of the possibility of false positive testing leading to more testing or painful procedures like colposcopy.
Adverse Determination – To Speak to a Physician Reviewer
PreferredOne Integrated Healthcare Services Department attempts to process all reviews in the most efficient manner. We look to our participating practitioners to supply us with the information required to complete a review in a timely fashion. We then hold ourselves to the timeframes and processes dictated by the circumstances of the case and our regulatory bodies.
Practitioners may request to speak with a peer reviewer at PreferredOne to discuss the case at hand and to provide clarity for the decision made. To initiate a peer to peer discussion, the Peer to Peer Request form can be accessed at www.preferredone.com. Once completed, the form may be e-mailed back to firstname.lastname@example.org Practitioners may also call 763-847-4488 option 2 and the precertification staff will facilitate completion of the form for submission. If, at any time, we do not meet your expectations and you would like to issue a formal complaint regarding the review process, criteria or any other component of the review, you may do so by calling or writing to our Customer Service Department.
(763) 847-4488, Option 2
(800) 379-7727, Option 2
PreferredOne, Grievance Department
6105 Golden Hills Dr.
Golden Valley, MN 55416
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.
Member’s Rights and Responsibilities
PreferredOne presents the Member Rights & Responsibilities with the expectation that observance of these rights will contribute to high quality patient care and appropriate utilization for the patient, the providers, and PreferredOne. PreferredOne further presents these rights in the expectation that they will be supported by our providers on behalf of our members and an integral part of the health care process. It is believed that PreferredOne has a responsibility to our members. It is in recognition of these beliefs that the following rights are affirmed and presented to PreferredOne members.PIC Member Rights and Responsibilities
PCHP Member Rights and Responsibilities
In 2020 PreferredOne will once again be focusing on an initiative to control high blood pressure among our members diagnosed with hypertension. Controlling blood pressure is a HEDIS measurement specified by NCQA and is also reported by Minnesota Community Measurement. We value this project and deem it as important to our members because hypertension is the most treatable form of cardiovascular disease and medication compliance is a significant factor that contributes to the overall success of treatment. As part of this initiative in 2020 we are asking for provider’s assistance by conducting a secondary reading of your patient’s blood pressure if it is high following the initial reading and ensuring that the patient’s medical records reflects both of the measurements taken.
PreferredOne’s HEDIS Medical Record Review Vendor (CIOX Health on behalf of Optum) will be contacting clinics in the coming weeks to coordinate medical record review for PreferredOne members seen at your clinics. As a contracted provider you are obligated to allow PreferredOne and its vendor to conduct this review. HEDIS measures are nationally used by all accredited health plans and PreferredOne also has an obligation to the Minnesota Department of Health to collect HEDIS data on an annual basis. Medical record review is an important component of the HEDIS compliance audit. It ensures that medical record reviews performed by our vendor meet audit standards for sound processes and that abstracted medical data are accurate. We would appreciate your cooperation with collecting medical record review information at your clinic site(s). We appreciate your clinic’s assistance in making this a smooth process.
Cultural and linguistic competence is the ability of health care providers and health care organizations to understand and respond effectively to the cultural and linguistic needs brought by their patients/consumers to the health care encounter. Cultural and linguistically appropriate services lead to improved outcomes, efficiency, and satisfaction.
Culture Care Connection is an online learning and resource center, developed by Stratis Health, aimed at supporting health care providers, staff, and administrators in their ongoing efforts to provide culturally-competent care in Minnesota.
For more information regarding Stratis Health’s resource center, click on the following link, http://www.culturecareconnection.org/.
Please note that PreferredOne’s policy on Medical Record Documentation Guidelines has been updated to include the proper utilization of Templated, Cloned, SmartPhrase or Copy Forward notes. Using Templated, Cloned, SmartPhrase or Copy Forward notes regarding clinical circumstances should always be updated on date of service to reflect the evidence that treatment plans are consistent with diagnoses. The final level of service for billing purposes must be based upon the medical necessity of the service actually rendered. Please see attached policy (M001 Medical Record Documentation)
(update to September, 2019 Coding article) (Policy MP/P019)
PreferredOne follows the United States Preventive Service Task Force (USPSTF) recommendation of screening mammography, with or without clinical breast examination (CBE), every 1-2 years for women aged 40 and older.
For some groups, PreferredOne also follows criteria in MN statute 62A.30 Coverage for Diagnostic Procedures for Cancer, which allows additional preventive services for insured individual, small and large groups. This coverage does not apply to PAS self-insured groups, with the exception for plans sponsored by governmental entities and political subdivisions.
Frequency: For normal risk individuals, mammography is covered annual for men and women beginning at age 40 when submitted with a normal risk diagnosis code. For high-risk individuals, mammography is covered for men and women at any interval/ age when submitted with a high-risk diagnosis code.
Any subsequent service will not be processed as a preventive benefit and member may incur cost sharing in the form of deductible, copay or coinsurance charges based on their benefit coverage. The same applies to any other diagnosis submitted with one of the below procedure codes.
- 77063 Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure)
- 77067 Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed
ICD-10-CM Diagnosis Codes (Official ICD-10-CM Guidelines apply)
- Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Z12.39 Encounter for other screening for malignant neoplasm of breast
- Z80.3 Family history of malignant neoplasm of breast
- R92.2 Inconclusive mammogram (dense breasts NOS)
- Z15.01 Genetic susceptibility to malignant neoplasm of breast
- Z80.3 Family history of malignant neoplasm of breast
- Z85.3 Personal history of malignant neoplasm of breast. Conditions classifiable to C50.- (C50-C50.929)
- Z86.000 Personal history of in-situ neoplasm of breast. Conditions classifiable to D05.- (D05-D05.92)
PreferredOne has invested in a more robust clinical editing software, ClaimsXten, implemented on 11/1/2018. This software assists in adjudicating claims in a manner that is more efficient and cost effective. It also puts the accountability on you, as the provider, to code to the highest level of specificity, as required by CMS and CPT®.
One of the major issues we have determined by utilizing this software is the overuse of modifiers 59 and X(E/P/S/U). Since the implementation of ClaimsXten, PreferredOne® has been enforcing the industry standard policy to append the appropriate modifiers to your claims for it to process accurately the first time.
Within the description of modifier 59 is “… when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.” It’s imperative that all applicable modifiers representing a repeated procedure/service be reviewed for usage prior to determining if the 59 or one of the X(E/P/S/U) modifiers should be reported.
Moving forward, claims appended with the 59 or X(E/P/S/U) modifier will be denied for repeated procedures/services on the same date of service, since there are established industry standard modifiers available for reporting.