Effective for September 1, 2018 dates of service & beyond if a provider does not obtain a required prior authorization before rendering services, PreferredOne will deny claims as provider liability for lack of prior authorization. This requirement applies to our PCHP, PAS & PIC product lines. This change is consistent with other Minnesota payer guidelines.
As stewards of healthcare expenditures for our subscribers, we are charged with ensuring the highest quality, evidence based care for our members. One method for doing so is through the prior authorization process. The primary purpose is to ensure that evidence based care is provided to our members, driving quality, safety, and affordability.
When a prior authorization is required for a service, procedure or item, the provider must submit the clinical information in advance to PreferredOne. Our Utilization Management team reviews the clinical information and determines if the request meets medical necessity criteria based on current Medical Policy and accepted standards of care. Prior Authorizations must be completed before services are rendered.
Follow these steps to determine if a procedure requires prior authorization:
- Visit the secure provider website portal at www.PreferredOne.com.
- Click on the Medical Policy link found under Information, then click on the Prior Authorization List link.
Do not request prior authorization for services not on the lists. For questions or confirmation if a service does require prior authorization please contact PreferredOne at 763-847-4477 or 800-997-1750.
If you have questions on this process update, please contact your PreferredOne provider relations representative or contract manager.
In the coming months PreferredOne will be implementing a replacement to our current CES code auditing software. In its place we will be leveraging the Change Healthcare (formerly McKesson) ClaimsXten (CXT) clinically based claims auditing solution to provide expanded claim processing capabilities, including automated claim review & code auditing. CXT also offers flexible, rules-based claims management with the capability of creating customized rules, as well as the ability to read historical claims data. This will assist in adjudicating claims in a manner that is more efficient & cost effective.
- 007 RVU Status Indicators for Professional Services
- 008 New Patient Visit
- 016 Multiple Imaging Performed on the Same Date of Service
- 018 Modifier Payment Reductions
- 023 Modifier CT
- 027 Physical Medicine and Rehabilitation: Multiple Procedure Reduction Policy
- 028 Modifier FY
- NM042 Health Care Homes
- P-1 Assistant Surgeon
- P-30 Telemedicine
Coordination of care among providers is a vital aspect of good treatment planning to ensure appropriate diagnosis, treatment and referral. PreferredOne would like to take this opportunity to stress the importance of communicating with your patient’s other health care practitioners. This includes primary care physicians and medical specialists, as well as behavioral health practitioners. While we realize in this age of electronic medical records, many records are available to other practitioners in the same care system, currently across systems there is not this coordination of information about your patients.
Coordination of care is especially important for patients with high utilization of general medical services and those referred to a behavioral health specialist by another health care practitioner. PreferredOne urges all its practitioners to obtain the appropriate permission from these patients to coordinate care between behavioral health and other health care practitioners at the time treatment begins.
We encourage all health care practitioners to:
- Discuss with the patient the importance of communicating with other treating practitioners.
- Obtain a signed release from the patient and file a copy in the medical record.
- Document in the medical record if the patient refuses to sign a release.
- Document in the medical record if you request a consultation.
- If you make a referral, transmit necessary information; and if you are furnishing a referral, report appropriate information back to the referring practitioner.
- Document evidence of clinical feedback (i.e., consultation report) that includes, but is not limited to:
- Treatment plan
- Psychopharmacological medication (as applicable)
We appreciate your efforts to provide coordinated care among our membership population and ensuring your patients and their entire medical team is informed about patients’ medical treatment plans and outcomes.
The mission of the QM Program is to identify and act on opportunities that improve the quality, safety and value of care provided to PreferredOne members, both independently and/or collaboratively, with contracted practitioners and community efforts, and also improve service provided to PreferredOne members and other customers.
PreferredOne's member and physician website will be updated in the near future to offer the following program documents:
- 2018 PreferredOne QM Program Description, Executive Summary
- 2017 Year-End QM Program Evaluation, Executive Summary
To access these documents, log into the Provider site, and then click on the Quality Management Program link under the Information heading.
If you would like to request a paper copy of either of these documents please contact Heather Clark at 763-847-3562 or e-mail us at firstname.lastname@example.org.
PreferredOne has been notified by The Department of Health and Human Services (HHS) that we are required to participate in an Initial Validation Audit (IVA) for a sample of members both on and off the Health Insurance Exchange (HIX). This audit is not specific to you or your practice and is not designed to monitor your practice, your billing or coding patterns.
Cognisight, LLC is the IVA vendor selected to gather medical records on behalf of PreferredOne. Since this is a government mandated audit, it is your obligation to provide medical records or obtain records from your vendor and submit the requested medical records with no charge to PreferredOne or its IVA vendor, Cognisight. Please do NOT mail, fax, or email any invoice/pre-payment invoice requests. Thank you for your cooperation.
We would like to thank all of our provider groups for their cooperation and collaboration during our recent HEDIS medical record review process. We realize that this process is burdensome to clinics and staff and appreciate your willingness in working with our vendor to ensure our HEDIS results for 2018 are accurate. Thank you!
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.
Minnesota Community Measurement (MNCM) is a collaboration among health plans and provider groups designed to improve the quality of medical care in Minnesota. MNCM’s mission is to accelerate the improvement of health by publicly reporting health care information. MNCM has three goals:
- Reporting the results of health care quality improvement efforts in a fair and reliable way to medical groups, regulators, purchasers and consumers.
- Providing resources to providers and consumers to improve care.
- Increasing the efficiencies of health care reporting in order to use our health care dollars wisely.
PreferredOne is one of seven founding health plan members of MNCM. The state medical association, medical groups, consumers, businesses and health plans are all represented on the organization's board of directors. Data is supplied by participating health plans on an annual basis for use in developing their annual Health Care Quality Report.
MNCM released their 2017 Health Care Quality Report on their website during the first quarter of 2018. The 2017 Health Care Quality report features comparative provider group performance on preventive care screening and chronic disease care. One of the primary objectives of this report is to provide information to support provider group quality improvement. Provider groups will find this report useful to improve health care systems for better patient care. Sharing results with the public provides recognition for provider groups that are doing a good job now and motivates other groups to work harder. The report will allow provider groups to track their progress from year-to-year and to set and measure goals for future health care initiatives. The MNCM website also provides consumers with information regarding their role as active participants in their own care. Visit the MNCM website site to view the 2017 annual report at www.mncm.org.
The Integrated Health and Pharmacy and Therapeutics Quality Management Subcommittees approve new criteria sets for use in their respective areas of Integrated Healthcare Services. Quality Management Subcommittee approval is not required when there has been a decision to retire a PreferredOne criteria document or when medical polices are created or revised; approval by the Chief Medical Officer is required. The Quality Management Subcommittees are informed of these decisions.
For the most current versions of the Medical Policy documents, please access the Medical Policy section on the PreferredOne website (PreferredOne.com). (Click on Coverage & Benefits then choose Medical Policy). Medical Policy documents are available on the PreferredOne website to members and to providers without prior registration.
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
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies List
There have been no updates since the October 2017 Provider Newsletter.
- MC/F024 Radiofrequency Ablation Cervical, Lumbosacral, and Sacroiliac Pain – Revised pain reduction threshold from 70% to a 50% response, from a series of anesthetic blocks, to confirm the origin of the pain and predict response to an ablative procedure.
- MC/G002 Breast Reduction Surgery – Revised to reflect ipsilateral breast reduction pre-mastectomy to optimize outcome of surgical or radiation therapy treatment, in addition to what contralateral breast reduction post-mastectomy for breast cancer, when done for asymmetry.
- MC/G008 Hyperhidrosis Surgery – Added a list of acceptable routine hyperhidrosis surgery procedures and now includes palmar hyperhidrosis as an acceptable indication for hyperhidrosis surgery.
- MC/I007 Cryoablation/Cryosurgery for Oncology Indications – Revised to allow cryoablation for renal cell carcinoma tumors less than or equal to 7cm and added medical necessity criteria for cryoablation of bone metastases from renal cell carcinoma.
- MC/I008 Sacral Nerve Stimulation – Beta-adrenergic agonists are now also included as a pharmacotherapy option that members can trial for urge incontinence, urgency or frequency.
- MC/I009 Deep Brain and Cortical Brain Stimulation – Medical necessity criteria for cortical (responsive cortical) neurostimulation are now also included in this guideline.
- MC/L008 Continuous Glucose Monitoring Systems for Long-Term Use – Added medical necessity indications for combined use of various CGMS and insulin pumps.
- MC/L009 Intensity Modulated Radiation Therapy (IMRT) – Added new indications of esophageal cancer and mediastinal neoplasm. Also added medical necessity criteria for IMRT for lung cancer when the radiation dose to the spinal cord exceeds a certain threshold.
- MC/L010 Genetic Testing for Hereditary Cancer Syndromes – Revised the medical necessity criteria for a number of syndromes based on recent revisions made to the NCCN Guidelines.
- MC/L011 Insulin Infusion Pump – Added medical necessity indications for combined use of various CGMS and insulin pumps.
- MC/L012 Gene Expression Profiling – Revised the gene expression profiling for prostate cancer section to include newly proven-effective tests and to also now allow for favorable intermediate risk disease.
- New: MP/A007 Anesthesia for Routine Screening and Diagnostic Gastrointestinal Endoscopic Procedures
- Revised: MP/F007 Free-Standing Birth Centers and Associated Covered Services now includes routine and immediate post-partum and newborn care at the member’s home
- Addition: Pelvic denervation procedures for treatment of chronic pelvic pain and other indications
- Chemotherapy/ chemosensitivity/ tumor resistance assay testing: removed the statement allowing ChemoFX Assay in some scenarios.
- Gene expression profiling and/or molecular testing for prostate cancer revised by removing reference to Decipher and ProMark.
- Intervertebral disc prostheses for lumbar; now allowing use in the lumbar spine for single interspace, when medically necessary.
- Obstructive sleep apnea treatments: Apnea-triggered Muscle Stimulation, Epiglottidectomy/ Partial Epiglottidectomy, Expansion Sphincteroplasty, Genioplasty and Genial Tubercle Advancement, Mandibular Distraction Osteogenesis (MDO), Nasal Dilators, Remotely Controlled Mandibular Positioner, Tongue-based Reduction Surgery, Winx Therapy System/Oral Pressure Therapy
- Deletions: None
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 drug requests under the Medical benefit are found in the Medical Policy section on PreferredOne.com.
- Pharmacy Criteria for provider administered drugs: PC/B003 Botulinum Toxin – Revised due to recent FDA approval of Dysport for spasticity in adults.
- Pharmacy Policy – No revisions were made to Pharmacy policies.
Reliable clinical evidence indicates that the use of somatosensory evoked potentials and motor evoked potentials should not be routinely employed during spinal decompression or arthrodesis procedures for degenerative disc disease in the lumbar spine.
With ongoing concerns regarding opioid utilization, a number of pharmacy statutes and claims processing edits have been implemented since July of 2017. To help facilitate appropriate pain relief therapy an opioid/narcotic prior authorization form is now available within the Provider resources website. In addition to the initial request, a section for continuing therapy (Prior Authorization renewal) is now included.
Enhancements were made to the online pharmacy medication prior authorization request form. After completion of an online request, providers now have the option to print the request. Online submissions can be completed on PreferredOne.com.
In addition to the Minnesota Uniform Formulary Exception Form, new, printable, PDFs of PreferredOne pharmacy prior authorization request forms have been uploaded for your convenience as well.