NETWORK MANAGEMENT

Friendly Reminder on Chiropractic/Acupuncture Network Change & Billing Requirements

As mentioned in our October 2020 Provider Newsletter, PreferredOne has partnered with Fulcrum Health effective January 1, 2021 for our chiropractic & acupuncture provider network. If you are not contracted with Fulcrum Health & are interested in joining the network please email contracting@fulcrumhealthinc.org to start that process.

Additionally, PreferredOne wanted to take this opportunity to provide a friendly reminder on some of the billing requirements for chiropractic & acupuncture services being sent to Fulcrum Health. Please see those reminders below. These billing requirements allow claims to be triaged appropriately to the proper plan/payer & will provide a more efficient & accurate claims processing experience.

Billing requirements include, but are not limited to the following:

  • Plan Name or Program Name: Specific Product must be named. This is one of the products listed on the next page (e.g Aetna, Allied Benefit Systems, etc.) o Paper submission: enter this information in Box 11c . Electronic submission: this information is included in Loop 2000B Segment SBR04

  • Taxonomy: Chiropractor taxonomy must be indicated on the claim form. Chiropractor taxonomy code is 111N00000X.

  • Taxonomy: Acupuncture Taxonomy must be indicated on the claim form. Acupuncturist taxonomy code is 171100000X
    • Paper Submission: Box 24i = ZZ, Box 24j (shaded) = taxonomy code

    • Electronic Submission: Loop 2310B, Segment PRV03

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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).

Since the last newsletter, as previously noted, the transition of Medical Policy criteria and policy documents to Clinical Policies has been completed. The Medical Policy page has been revised and now lists all clinical policy documents together, arranged alphabetically. The Search box and links to other Medical Policy documents have been placed together in a separate box.

Additionally, a new page has been created for the Pharmacy Clinical Policies and documents, including a separate Medical Drugs Prior Authorization List.

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

Reminder for Orthopedic Surgery Providers

PreferredOne encourages the use of outpatient surgical sites when medically appropriate for elective procedures such as joint replacement.

Additionally, PreferredOne will be auditing some total joint replacement claims in 2021 to ensure they are medically appropriate and in alignment with our criteria. Our criteria can be found on the Medical Policy webpage.

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Prior Authorization List

The Medical Prior Authorization List has been reformatted.

Effective 1/1/2021, the List reflects all health care services that require prior authorization, including durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). Many items have been moved from the prior authorization process to post-service auditing and management of utilization trends.

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Durable Medical Equipment, Prosthetics, Orthotics, and Supplies List

  • Removed PA notations
  • Rolled all individual entries that referenced higher level categories up into the high-level category entry.
  • E0179 deleted from list of non-covered items under egg crate mattress entry (no longer a valid code)
  • E0483 High-frequency chest wall oscillation air-pulse generator or system (vest) – revised by the addition of covered diagnoses/conditions.
  • E0770 Functional electrical stimulator - added more examples of devices that are considered exercise equipment and therefore excluded from coverage.
  • E0764 Functional Neuromuscular Stimulation - added reference to Parastep I to this entry.
  • Non-thermal pulsed high frequency radiowaves… added HCPCS G0295 to the list of non-covered items.
  • Percussive, ventilation systems intrapulmonary; Under Comments, changed to not routinely covered.

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Medical Clinical Policies

NEW

  • Cardiac Devices & Procedures for Occlusion of Left Atrial Appendage
  • Clinical Policy Application, Development, Oversight and Distribution
  • DMEPOS, Wheelchairs and Mobility Equipment
  • DMEPOS, Upper Limb Prostheses
  • DMEPOS, Lower Limb Prostheses
  • DMEPOS, Pneumatic Compression Devices and Heat & Cold Therapy Units
  • DMEPOS, Standing Systems and Gait Trainers
  • Fetal Surgery In Utero
  • Nuclear Medicine, Cardiac Positron Emission Tomography/CT
  • Radiation Therapy, Stereotactic Body Radiation Therapy, Stereotactic Radiosurgery
  • Radiation Therapy, Neutron Beam
  • Radiation Therapy, Selective Internal Microspheres
  • Rhinoplasty and Excision of Nasal Dermoid Cyst
  • Varicose Vein Treatments

REVISED (substantive clinical revisions)

  • Ambulance Services
  • Behavioral Health, Mental Health Disorders: Residential Crisis Stabilization Services (CSS)
  • Behavioral Health, Substance-Related Disorders: Inpatient Primary Treatment
  • Cosmetic Procedures/Treatments
  • Coverage Determination Guidelines
  • Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)
  • DMEPOS, Continuous Glucose Monitoring Systems
  • Free-Standing Birth Centers
  • Genetic Testing
  • Genetic Testing, Comparative Genomic Hybridization
  • Genetic Testing, Whole Exome Sequencing
  • Home Health Services, Intermittent
  • Laboratory Testing for Detection of Heart Transplant Rejection
  • Molecular Testing, Gene Expression Profiling
  • Molecular Testing, Tumor/Neoplasm Biomarkers
  • Obstructive Sleep Apnea, Surgical
  • Pharmacogenetic/Pharmacogenomic Testing and Serologic Testing for Inflammatory Conditions
  • Radiation Therapy, IMRT
  • Radiofrequency Ablation, Cervical, Thoracic, Lumbosacral, Sacroiliac or Knee Pain

RETIRED

  • Criteria Management Development, Application and Oversight
  • Elective Termination of Early Pregnancy (Abortion)
  • Medical Policy Management and Application
  • UVB Phototherapy for Skin Disorders
  • Vision Care, Pediatric

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Chiropractic Clinical Policies

Replaced previous documents with link to Clinical Policies, ChiroCare by Fulcrum Health

Medical Investigative List

ADDITIONS

  • Absolute quantification of myocardial blood flow (AQMBF), PET, rest and pharmacologic stress
  • Continuous Glucose Monitoring Systems for Long-Term Use in non-insulin dependent Diabetes Mellitus
  • Fetal in-utero surgery for any of the following indications
    • Fetal aortic valvuloplasty
    • Fetal tracheal occlusion for congenital diaphragmatic hernia (FETO)
    • Fetoscopic laser ablation for type 2 vasa previa
    • Shunting for the treatment of fetal cerebral ventriculomegaly
    • Treatment of amniotic band syndrome
    • Treatment of aqueductal stenosis (ie, hydrocephalus)
    • Treatment of cleft lip and/or cleft palate
    • Treatment of congenital heart disease (eg, mitral valve dysplasia)
    • Treatment of fetal hydronephrosis
    • Treatment of gastroschisis
  • Gene therapy in utero
  • Genetic testing, simultaneous RNA NGS for detection of variants of unknown significance in hereditary cancer, Such as, but not limited to, +RNA InsightTM for ColoNext©, BreastNext©, OvaNext©, ProstateNext©, CancerNext©, GYNPlus©, ATM, PALB2, BRCA1/2; CustomNext + RNA for APC, MLH1, MSH2, MSH6, PMS2, Lynch (also added to MC/L010 under Investigative)
  • Pneumatic compression device with calibrated gradient pressure used to treat lymphedema not extending onto the chest, trunk and/or abdomen.
  • Neutron beam therapy for all other indications including, such as but not limited to:
    • Colon cancer
    • Dermatofibrosarcoma protuberans
    • Ghost cell odontogenic carcinoma
    • Glioma
    • Kidney cancer
    • Laryngeal cancer
    • Lung cancer
    • Pancreatic cancer
    • Prostate cancer
    • Rectal cancer
    • Soft tissue sarcoma
  • Stem cell transplantation in utero
  • Varicose Veins Treatments
    • Endovenous ablation (laser or radiofrequency) for treatment of reflux of the common femoral vein
    • Measurements of plasma growth factors (eg, angiopoietin-1 [ANG1], angiopoietin-2 [ANG2], epidermal growth factor [EGF], platelet-derived growth factor [PDGF], and vascular endothelial growth factor [VEGF]) for predicting adequacy of treatment and recurrence risk before and after treatment with endovenous laser ablation.
    • Polymorphism genotyping of matrix metalloproteinases genes (eg, MMP1, MMP2, MMP3, and MMP7) as markers of predisposition to varicose veins
    • Synthetic matrix metalloproteinases inhibitors
    • Transdermal laser treatment for the treatment of large varicose veins
    • VeinOPlus vascular device for treatment of muscle atrophy due to varicose veins
  • All investigative services reflected by Category III and Proprietary Laboratory Analyses (PLA) Codes

REVISED

  • Amniotic membrane allograft for all indications except corneal grafting and multi-layer biologic dehydrated human amniotic membrane (EpiFix©) for the treatment of diabetic foot ulcers (DFU) was replaced with Acellular and cellular dermal replacement products from human placental membrane and umbilical tissue for wound care, with the exception of AmnioBand® Allograft Placental Matrix, Epifix©, Grafix©, or GrafixPL Prime for treatment of diabetic foot and chronic venous ulcers.
  • Functional electrical stimulator: removed examples of devices as the HCPCS code is most definitive.
  • HCPCS K1002 removed from Microcurrent stimulation devices. This is not the correct code for this device.
  • Neuromuscular electrical stimulation: revised current entry by separating out/creating new entry specific to scoliosis (E0744)
  • Transcatheter mitral valve annulus… entry revised: Separated 0545T out and created own entry as this code represents transcatheter tricuspid valve annulus…
  • Transurethral ablation of malignant prostate tissue by high-energy water vapor thermotherapy entry revised to “Transurethral ablation of prostate tissue.”

DELETED

  • Category III codes/services that are no longer valid for 2021.

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

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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.

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, at any time, request to speak with a peer reviewer at PreferredOne regarding the outcome of a review by calling 763-847-4488, option 2 and the Intake Department will facilitate this request. You or your staff may also make this request of the nurse reviewer with whom you have been communicating about the case and she/he will facilitate this call. 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.

Phone number:(763) 847-4488, Option 3.
(800) 379-7727, Option 3
Address: PreferredOne, Grievance Department
6105 Golden Hills Dr. Golden Valley, MN 55416

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Quality Management

Blood Pressure Readings for Controlling High Blood Pressure

In 2021 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 reflect both measurements taken.

2021 HEDIS Medical Record Review

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.

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Serving a Culturally and Linguistically Diverse Membership

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/.

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Medical Record Documentation Guidelines

Please note that PreferredOne’s policy on Medical Record Documentation Guidelines has been updated to include the proper utilization of Cloned or SmartPhrase templates. Using Cloned or SmartPhrase 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 rendered. Please see the below policies.

PAS Members Rights & Responsibilities

PCHP Member Rights & Responsibilities

PIC Member Rights & Responsibilities

Medical Record Documentation

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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.

Prior Authorization Changes

Added the following drugs to the prior authorization list (effective 3/15/2021):

Zevalin (Ibritumomab tiuxetan) A9543, Beovu (brolucizumab-dbll) J0179, Monjuvi (C9070), Asceniv (C9072), Darzalex Faspro J9144, Trodelvy (J9317)

Removed the following drugs from the prior authorization list:

Rebinyn C9468 (duplicate listing with inactive HCPC), Vivaglobin (discontinued)

Added HCPC codes to the following:

Blenrep (C9069), Tecartus (C9073), Uplizna (J1823), Sevenfact (J7212), Scenesse (J7352), Zepzelca (J9223), Phesgo (J9316)

Added the following drugs to Site of Care list:

All Immunoglobulin (IVIG) products

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CODING

Friendly Reminder for Billing Code G2066

PreferredOne would like to remind our provider partners who bill for code G2066 that this code is included on our Investigational List with the exception of instances where the code is billed with diagnosis codes Z45.010, Z45.018 or Z45.02. Along with one of those DX codes, facility providers billing this service on a UB claim form should bill code G2066 with one of the following applicable revenue codes: 0480, 0969, 098X, 0981, 0982, 0983, 0985 or 0988. Please include the device name and model number on the claim form.

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COVID-19 Provider Billing Guidance Update - Vaccine & Vaccine Administration Codes - March 1, 2021

  • Prior Guidance: To submit bills with the appropriate vaccine administration codes without reporting the vaccine administration code. This was per state and federal guidance.

  • New Guidance: Submit all claims with both the appropriate vaccine administration codes and the appropriate corresponding vaccine administration code with the SL (State supplied vaccine) modifier appended.

  • Purpose: Fore reporting and tracking purposes of dsitribution, administration, and coverage of all vaccines at the state level.

PreferredOne is NOT requiring that prior claims be re-submitted. Moving forward, PreferredOne will follow the new guidance issued above.

For ease of correct, compliant coding & billing submission, the following resource has been issued by the AMA: Find your COVID-19 Vaccine CPT® Codes | American Medical Association (ama-assn.org) (see table below)

Vaccine Code Vaccine Administration Code(s) Manufacturer Vaccine Name(s) NDC 10/NDC11
91300 0001A (1st Dose) Pfizer, Inc Pfizer-BioNTech COVID-19 Vaccine 59267-1000-1 59267-1000-01
91300 0002A (2nd Dose) Pfizer, Inc Pfizer-BioNTech COVID-19 Vaccine 59267-1000-1 59267-1000-01
91301 0011A (1st Dose) Moderna, Inc Moderna COVID-19 Vaccine 80777-273-10 80777-0273-10
91301 0012A (2nd Dose) Moderna, Inc Moderna COVID-19 Vaccine 80777-273-10 80777-0273-10
91302 0021A (1st Dose) AstraZeneca AstraZeneca COVID-19 Vaccine 0310-1222-10 00310-1222-10
91302 0022A (2nd Dose) AstraZeneca AstraZeneca COVID-19 Vaccine 0310-1222-10 00310-1222-10
91303 0031A (Single Dose) Janssen Janssen COVID-19 Vaccine 59676-580-05 59676-0580-05

Disclaimer: Information provided by the AMA contained within this resource is for medical coding guidance purposes only. It does not (i) supersede or replace the AMA's Current Procedural Terminology manual ("CPT® Manual") or other coding authority, (ii) constitute clinical advice, (iii) address or dictate payer coverage or reimbursement policy, and (iv) substitute for the professional judgement of the practitioner performing a prodecure, who remains responsible for correct coding.

Copyright 2021 American Medical Association (AMA). All rights reserved. CPT is copyrighted and trademarked by the AMA.