NETWORK MANAGEMENT

Cosmetic Services Reminder

As a friendly reminder, services rendered to PreferredOne members that are deemed cosmetic 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 Cosmetic Procedures/Treatments policy, please visit https://www.preferredone.com/getting-care/medical-policy/. Once you’ve accepted the terms, you will be able to search for the Cosmetic Procedures/Treatments policy in PDF format. This policy is also accessible by logging in to the secure PreferredOne provider portal. If a member determines that they would like to receive a cosmetic 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 cosmetic 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.

Cosmetic Procedures/Treatments Waiver Form

New: Process to Escalate Aetna Claims Issues

Effective July 1, 2023, PreferredOne Provider Relations will no longer be able to accept or assist with appeal escalations for Aetna related claims issues. Instead providers will want to work directly with Aetna on claims issues following our PPO Provider Follow-up instructions as indicated in the PreferredOne Office Procedures Manual. To assist providers in working directly with Aetna, we have listed below some helpful links & contact numbers to navigate & connect on any of your Aetna-related claims appeals, questions or concerns.

  • Providers should submit claims inquiries via their secure Aetna or Allina Health|Aetna provider portal login through Availity. To sign up for an Availity login please visit https://www.availity.com/.
  • Providers should phone Aetna’s provider services call center with claims inquiries at 1-888-632-3862 or via the phone number indicated on the back of the member’s ID card.
  • Aetna Medicare claims do not access the PreferredOne network/provider contracts. For questions regarding Aetna Medicare claims providers should call 1-800-624-0756 or request a call from Aetna by visiting https://www.aetnamedicare.com/en/contact-us.html.
  • Additional contact details for Aetna can be found here: https://www.aetna.com/health-care-professionals/contact-aetna.html
  • Aetna escalations submitted to PreferredOne Provider Relations will not be able to be responded to & will be returned to the sender.

APC Gouper Update

On May 21st 2023, PreferredOne loaded the April 2023 Medicare APC grouper into production so that the new diagnosis codes would group and price. The weight and rate files did not change, so there should be no impact on reimbursement.

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

  • Dental, Coverage for Anesthesia: addition of HCPCS G0330
  • Durable Medical Equipment – Continuous glucose monitoring system
    • added HCPCS E2103, S1034: deleted HCPCS K0554
  • Durable Medical Equipment – Insulin infusion pump
    • added HCPCS E2102
  • Fetal surgery in utero: replaced HCPCS S2049 with S2409
  • Laboratory Testing
    • addition of CPTs 81418,81441,81449,81451,81456,0355U: deleted CPTs 81306,0236U,0333U,0338U
    • addition of CPTs 0091U, 0179U, 0306U, 0326U, 0333U, 0338U, 0356U, 0364U, 0376U, 0378U, 0379U
  • Neurology – Sacral nerve stimulation: deleted CPTs 64590, 64595
  • New/Emerging Technology – added reference to the new policy New/Emerging Technology/Health Care Services, Omnibus Code List (MP/N003)
  • Oncology – Cryoablation/cryosurgery moved under Other Procedures/ Treatments
  • Other Procedures/Treatments – Biofeedback: CPT 909012 replaced with CPT 90912
  • Radiology/Radiation Therapy - Selective Internal Radiation Therapy with microspheres (SIRT): deleted CPT 37243
  • Transplantation – Solid organ: deleted CPT code 48160

Medical Clinical Policies

  • New: New/Emerging Technology/Health Care Services, Omnibus Code List (MP/N003)

  • Revisions (substantive clinical revisions)

    • Cryoablation/Cryosurgery for Oncology Indications (MC/I007) – revised medical necessity requirements for use in renal conditions
    • DMEPOS, CGM Systems for Long-term Use (MC/L008) – revised to reflect updates in AACE and ADA guidelines
    • Genetic Testing, Hereditary Cancer Syndromes (MC/L010) – revised to include updates to applicable NCCN guidelines
    • Special Coverage for the COVID-19 Pandemic (MP/C015) – revised to reflect coverage upon expiration of the Public Health Emergency
  • Retired: None

Medical/Surgical and Behavioral Health Services Investigative List

  • Additions
    • Molecular testing, blood-based testing (including algorithmic analyses) of autoantibody or protein/proteomic biomarkers for differentiation of benign pulmonary nodule from malignant nodule, in lung cancer screening - Addition of 0360U as an excluded code (used for Nodify CDT)
    • Neurostimulation/electrical stimulation, trigeminal nerve – for attention-deficit/ hyperactivity disorder (ADHD) in pediatrics; non-invasive/external - Addition of K1016 as an excluded code when submitted for this diagnosis
    • Neurostimulation/electrical stimulation, vagus nerve – for prevention and treatment of headache; non-invasive/external - Addition of K1020 as an excluded code when submitted for this diagnosis
    • Pharmacogenetic/pharmacogenomic testing
      • Under Cytochrome P450… addition of CYP2C9 and CPT 81227, as investigative
      • Under MTHFR genotyping for determining therapeutic response to antifolate chemotherapy and for guiding antidepressant therapy, added CPT 81291
      • Under SLCO1B1 genotyping to determine drug metabolizer status for all drugs, added CPT 81328
  • Deletions
    • Sacroiliac joint fusion (arthrodesis) open for low back pain due to sacroiliac joint syndrome, mechanical low back pain, degenerative sacroiliac joint, and radicular pain syndromes (CPT 27280)
  • Revisions
    • Decipher Bladder TURBT - Renamed entry as Molecular pathology test for genetic analysis of bladder tumor
    • Genetic testing (DNA, mRNA [analytics]) by any method (eg, NGS [next-generation sequencing], Sanger sequencing, MLPA [multiplex ligation-dependent probe amplification], array CGH [comparative genomic hybridization]) for detection of variants of unknown significance in hereditary cancer - Deleted any notation of the proprietary name of the primary test, as these are not part of the investigative position (ColoNext®, BreastNext® , OvaNext® , ProstateNext®, CancerNext® , GYNPlus®)
    • Interferential current therapy and devices - Under Comments, added NexWave as another example of an investigative device
    • Laser therapy, low level - Under Comments, added Breathe as another example of this investigative device (also/previously known as Breathe Laser)
    • Molecular testing, circulating tumor cells/markers (ctDNA) or cell-free DNA (cfDNA) testing - Under Comments, added NavDx (cell-free DNA) 0356U as another example of investigative testing
    • Molecular testing, gene expression profiling and/or molecular testing for prostate cancer - Added IsoPSA 0359U
    • NMES and TENS combination - Under Comments, added NexWave as another example of an investigative device
    • Skin and Soft Tissue Substitutes - The range of non-covered HCPCS was extended to include Q4262, Q4263, Q4264 for Dual Layer Impax Membrane, SurGraft TL, and Cocoon Membrane (Note, new HCPCS Q4236 for carePATCH is included in range of currently excluded skin and soft tissue substitutes)

DMEPOS List

  • Additions
    • Electrical stimulation used for cancer treatment: Added medical necessity coverage note
    • Infection control supplies billed with HCPCS S8301: Added as excluded (was previously in the Special Coverage for the COVID-19 Pandemic policy)
  • Deletion: None
  • Revision: None

Please visit www.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 underutilization. Utilization management decision making is based only on the appropriateness of care and service and existence of coverage.

PHARMACY

On June 1, 2023 PreferredOne will be concluding our partnership with Rx Savings Solutions. This is a program all fully-insured members currently have access to. Rx Savings Solutions is an online tool that alerts members when there is way to reduce cost on one or more of their prescription drugs. The tool contacts the member’s provider if a new prescription is required to take advantage of the cost savings. Beginning June 1, 2023, you should no longer receive any requests from Rx Savings Solutions for any of our members. Please contact your provider representative if you receive any requests after this date.

QUALITY MANAGEMENT

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:

  • 1. Discuss with the patient the importance of communicating with other treating practitioners.
  • 2. Obtain a signed release from the patient and file a copy in the medical record.
  • 3. Document in the medical record if the patient refuses to sign a release.
  • 4. Document in the medical record if you request a consultation.
  • 5. If you make a referral, transmit necessary information; and if you are furnishing a referral, report appropriate information back to the referring practitioner.
  • 6. Document evidence of clinical feedback (i.e., consultation report) that includes, but is not limited to:
    • Diagnosis
    • Treatment plan
    • Referrals
    • 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.

Minnesota Community Measurement - Release of the 2022 Health Care Quality Report

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 2022 Health Care Quality Report on their website during the first quarter of 2023. The 2022 Health Care Quality report features comparative provider group performance on depression care, preventive health 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 2022 Minnesota Health Care Quality Report at www.mncm.org.

HEDIS Measurement and Specification

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. The measures listed below are hybrid measures; this means the data can be collected both from administrative data and chart information. What you may not realize is that the difficulty of collecting this information from clinic records could be lessened if practitioners were to use appropriate codes when submitting their billing statements. These measures have appropriate codes that would assist PreferredOne in collecting this information administratively through claims data.

  • Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents:

    This measure examines the percentage of members 3-17 years of age who had an outpatient office visit with a PCP or OB/GYN and who had evidence of BMI percentile documentation, counseling for nutrition, and counseling for physical activity.

    Please ensure that for adolescents that a BMI is both calculated, and a percentile is coded and documented accordingly.

    Description CPT ICD-10-CM Diagnosis HCPCS
    BMI Percentile Z68.51-Z68.54 3008F
    Counseling for nutrition 97802-97804 Z71.3 S9470, S9452, S9449, G0270-G0271, G0447
    Counseling for physical activity Z02.5, Z71.82 S9451, G0447
  • Controlling High Blood Pressure

    This measure examines the percentage of members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled (<140/90 mm Hg) during the measurement year.

    Systolic Blood Pressure CPT ICD-10-CM Diagnosis HCPCS
    Systolic Blood Pressure 3074F(systolic < 130mmHg), 3075F(systolic 130-139mmHg), 3077F(> or = 140 mmHg) I10
    Diastolic Blood Pressure 3079F(diastolic 80-89mmHg), 3078F(diastolic <80mmHg), 3079F(diastolic 80-89 mmHg), 3080F(diastolic> or = 90 mmHg) I10

We encourage practitioners to use the above coding specifications to reduce the burden of chart review that will need to be performed at your clinic in the following year. If you have questions about these measures, you may visit NCQA’s website at www.ncqa.org or contact us at quality@preferredone.com.

HEDIS Data

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 measurement year 2022 are accurate. Thank you!

Reminding Patients of Yearly Physical Exam

We want to encourage all our practitioners to remind their patients to make an appointment for their annual physical exam. In the wake of the COVID-19 pandemic annual 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 screenings performed.

Back to Top ↑