PreferredOne’s Physician, Mental Health and Allied Health Fee Schedules are complete and will become effective for dates of service beginning January 1, 2018. These changes are expected to be an increase in overall reimbursement. As with prior updates, the effect on physician reimbursement will vary by specialty and the mix of services provided.
Physician fee schedules will be based on the 2017 CMS Medicare physician RVU file without geographic practice index (GPCI) applied and without the work adjuster applied, as published in the Federal Register May 2017. New codes for 2018 will be based on the 2018 CMS Medicare physician RVU file without geographic practice index applied and without the work adjuster applied as published in the Federal Register November 2017. 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.
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 2018 Physician fee schedules will continue to apply site of service differential for RVU –based services performed in a facility setting (Place of Service 10, 21-25 are considered facility).
The Convenience Care Fee and Dental schedules will also be updated January 1, 2018. New codes were added to this fee schedule and reminder that any code not on the fee schedule will not be reimbursed.
New ASA codes for Anesthesia services will be updated with the 2018 release of Relative Value Guide by the American Society of Anesthesiologists. This update will take place by January 1, 2018.
Requests for a market basket fee schedule may be made in writing to PreferredOne Provider Relations. Reminder that new codes for 2018 will be added to all fee schedules using the above listed methodology. 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 2018 Calendar year DRG schedule will be based on the CMS MS-DRG Grouper Version 35 as published in the final rule Federal Register to be effective October 2017.
For those on Ambulatory Payment Classifications (APC), we are using Optum hospital-based grouper that will be one year lag. For example, for 2018 rates, PreferredOne may use the 2017 APC grouper and edits and weights as of October 2017.
The Facility (UB04) CPT fee schedule will consist of all physician CPT/HCPC code ranges and will be based on the 2017 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 2018 will be added to all fee schedules using the above listed methodology. 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, 2018.
New Pricing and Payment Policy
Revised Coding Reimbursement Policy
PreferredOne has received growing interest from employer groups and the Minnesota Health Action Group surrounding treatment for Postpartum Mood and Anxiety Disorders (PMADs). In response to initiatives such as the 2020 Mom Project, PreferredOne wants to make all our collaborative partners aware of resources available for referral. In addition to our online provider directory which lists provider resources, our nurse line works with a non-profit organization called Pregnancy and Postpartum Support MN for referral of maternal mental health issues. PPSM provides training, resources, advocacy and awareness, as well as a free helpline and online Facebook support group for families struggling with PMADs. The PPSM works closely with the Maternal Mental Health Advisory Board through the Department of Health and has provided training for our own Healthy Mom and Baby program.
PreferredOne has compiled a referral list through the PPSM of PreferredOne contracted providers that have a high level of competency in treating PMADs---this requires them to have numerous CEUs specific to PMADs, at least 2 years clinical experience specific to PMADs, and a commitment to see a mother within 3 days of contact seeking services. A list of these providers can be obtained through our customer service department by calling 763-847-4477.
Similar to last year, PreferredOne would like to remind our contracted providers that you will once again need to be mindful of Aetna PPO claims that are for first quarter 2018 dates of service. PreferredOne will not be able to hold claims for you (you will be submitting claims directly to Aetna) while your 2018 rates are being negotiated or loaded into Aetna’s system. Providers will be responsible for holding Aetna claims temporarily (for contracts with 1/1/2018 effective dates) until Aetna completes their process of loading the new rates. If claims are submitted to Aetna prior to your 1/1/2018 contract being loaded into their system, claims will be paid at the previous year’s rates. There will be no reprocessing of claims. Please be sure to check with Aetna that your new rates are loaded for 1/1/2018 before you release claims for those dates of service on or after 1/1/2018.
PreferredOne supports the Institute for Clinical Systems Improvement’s (ICSI) mission and promotes clinical practice guidelines to increase the knowledge of both our members and contracted providers about best practices for safe, effective and appropriate care. Although PreferredOne endorses all of ICSI’s guidelines, it has chosen to adopt several of them and monitor their performance within our network (Clinical Practice Guidelines). The guidelines that PreferredOne’s Quality Management Committee has adopted include ICSI’s clinical guidelines for Asthma, Diabetes, Depression, ADHD, Prenatal - Routine Care, Preventive Services for Children and Adolescents, and Preventive Services for Adults. The performance of these guidelines by our network practitioner's is monitored utilizing HEDIS and Minnesota Community Measurement data. The most recent version of the ICSI guidelines that we have adopted can be found on ICSI's website at www.icsi.org.Preventive Health Services for Children and Adolescents
The ICSI Preventive Health Services for Children and Adolescents guideline provides the basis for measurement and monitoring of several relevant clinical indicators. The measures that are assessed for adherence to the clinical guideline include the spectrum of childhood immunizations (using HEDIS technical specifications) and Chlamydia screening for adolescents (using HEDIS technical specifications). Utilizing 2016 claims data PreferredOne evaluated adherence to this set of guidelines through our HEDIS data collection process. The results for the entire PreferredOne network were as follows:
|Preventive Health Measures for Children & Adolescents||2016|
|Three Hepatitis B||90.45%|
|One VAR, or documented chicken pox disease||89.61%|
|Two Hepatitis A||88.48%|
Two doses of the two-dose vaccine; or one dose of the two-dose and two doses of the three-dose vaccine; or three doses of the three-dose vaccine
PreferredOne strongly encourages our provider network clinic systems to send their immunization information to the Minnesota Immunization Information Connection (MIIC). MICC data is utilized to support our HEDIS data collection process and may reduce the burden of chart review at your clinic. To learn more about MICC and how you can participate please visit: http://www.health.state.mn.us/miic.
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.
Medical Policy Updates
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 Coverage and 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
- CPAP accessories/supplies/humidifiers – Added “water or waterless humidifiers are covered” under the Comments section
- Osteogenesis stimulator (bone growth stimulator) – These items no longer require prior authorization.
- Penile Implant – Added CPT 54410 under the Comments section
- MC/A006 Ventricular Assist Devices (VAD) – Revised to reflect an option for off-label use of a VAD that is well-supported by reliable evidence, when it is more appropriate for the member’s anatomy.
- MC/I002 Hypoglossal Nerve Stimulation – Revised to reflect the updated FDA approval lowering the threshold for the Apnea Hypopnea Index (AHI) score from 20 to 15
- MC/T005 Lung and Lobar Transplantation – Revised the contraindication related to smoking from, “Tobacco use in the last 12 (twelve) months (absolute)” to “Current smoker or history of smoking when the transplant center determines that the member’s smoking status will compromise the transplant outcome (absolute).”
- No revisions were made to medical policies.
Investigative List – Additions:
- Balloon dilation (extraurethral, retropubic) / adjustable compression devices for treatment of urinary incontinence (such as, but not limited to, ProACT [for men] and ACT [for women] Therapy Systems)
- Balloon dilation / tuboplasty of Eustachian tube (such as, but not limited to, the Aera System)
- High Intensity Focused Ultrasound (HIFU) for all indications, except prostate cancer
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 under the Medical Benefit – PC/A011 Altered Bone Homeostasis Treatment Medications: Extensive revisions have been made to this Pharmacy criteria document. To view the currently posted criteria, please visit the Pharmacy criteria documents in the Medical Policy section on PreferredOne.com.
- Pharmacy Policy – No revisions were made to Pharmacy policies.
PreferredOne recently developed a Lung Cancer Screening by Low-Dose Computed Tomography Authorization Form for use in conjunction with medical criteria MC/L016 Lung Cancer Screening by Low-Dose Computed Tomography. It is now available on PreferredOne.com under the Provider Forms section.
Prior Authorization forms that have corresponding criteria or policies are now attached to and linked in their appropriate criteria or policy document. In addition, prior authorization forms have been reformatted to also allow for electronic completion.
It is important that the forms are completed as clearly and specifically as possible and that they are completed by a person with thorough clinical knowledge of the member’s current clinical presentation and clinical evaluation history. Incomplete or illegible forms may result in the return of the form for further completion or clarification and a delay in processing the request. Forms and other relevant documents must be faxed to (763) 847-4014.
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.
What is Case Management?
Case management is a collaborative process between the Case Manager (an RN or Social Worker), the PreferredOne member and their family, and the care team. The goal of case management is to help members navigate the complex medical system and reduce their risk of poor outcomes. The Case Manager will assist in preventing gaps in care with the goal of achieving optimal health care outcomes in an efficient and cost-effective manner. This service is intended to support the work of the care team.
- Assess individual member needs and develop a care plan with the member and provider to improve the member’s quality of life
- identify resources that may be helpful for the member
- Provide both verbal and written education regarding a disease condition
- Promote compliance with provider’s treatment plan
- Serve as a liaison between the health plan, member and providers
Eligibility and Access
All members of the health plan experiencing complex health needs are eligible for case management. A Case Manager may call out to a member based on information that has been received at PreferredOne or members may call and request a Case Manager. There is no cost for this service and it is confidential. Participation is voluntary. Health care provider referrals and member self referrals are accepted by contacting PreferredOne and requesting to speak with a Case Manager. The telephone number for the case management department is 763-847-4477, option 4.
PreferredOne has implemented Chronic Illness Management and Treatment Decision Support programs available to your patients who live with chronic conditions. Your patients will still have the same level of benefits, access to any ancillary services and access to your referral network. They will also continue to see their practitioner(s) and receive the same services that they currently provide them.
The Chronic Illness Management (CIM) and Treatment Decision Support (TDS) Programs focus on the following conditions;
- 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)
- Low Back Pain
- Health Mom and Baby
The goals of these programs are to:
- Promote self-management of chronic conditions.
- Improve adherence to treatment plans.
- Improve adherence to medication regimes.
- Reduce or delay disease progression and complications.
- Reduce hospitalizations and emergency room visits.
- Improve quality of life.
Benefits to You and Your Practice
These PreferredOne programs are designed to collaborate with a practitioner’s recommended treatment plans. With the help of a nurse health coach, 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
- If clinically concerning warning signs are discovered through the program, practitioners are notified via telephone or a faxed Health Alert
- Program participants receive ongoing support and motivation to make the necessary lifestyle changes practitioners have recommended to them
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
- Equipment, as needed, for participation in the program
- Access to Healthwise®, an online health library at www.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
To make a Referral to the PreferredOne CIM or TDS programs: Contact PreferredOne toll free at 1-800-940-5049 Ext. 3456. Monday-Friday 7:00am to 7:00pm CST.
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 new 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 email@example.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.
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 included the form for your reference. If you'd like to have the file electronically please e-mail firstname.lastname@example.org. If you have any questions or concerns please contact Arpita Dumra at 800-940-5049, ext. 3564 or e-mail email@example.com. (Clinic Complaint Reporting Form)
These codes are always secondary codes to be reported on a claim form – never a primary diagnosis. Appropriate code selection(s) from the O00.00 – O9A.53 category are to be reported as the primary diagnosis based on the visit documentation. They are to be on the maternal record only.
CPT® code 90756 (Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, antibiotic free, 0.5 mL dosage, for intramuscular use) is effective January 1, 2018 based on CPT release information. Please report code Q2039 (Influenza virus vaccine, not otherwise specified) if providing this vaccine prior to January 1, 2018.Urgent Care Place of Service (POS)
The Urgent Care POS is 20 (Location, distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention.) is to be submitted on the professional claim form in item 24B.
When areas within an ED (Emergency Department) or other area in a facility setting are designated as Urgent Care, POS 20 is to be submitted on the professional claim. POS 22 (A portion of a hospital’s main campus which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.), is incorrect and will result in a denied claim.GN, GO, GP Modifiers for PT/OT/SLP Claims
PreferredOne has always required the appropriate modifier be appended to all Physical Therapy (PT), Occupational Therapy (OT), and Speech Language Pathology (SLP) reported services. This allows the appropriate member benefit to be applied during processing. Claims from these providers received without one of the required (below) modifiers will be returned.New Patient Evaluation and Management (E/M)
The AMA and CMS accepted definition of a new patient is;
A patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice/other qualified health care professional (same physician/other qualified health care professional specialty) within the previous three years. An interpretation of a diagnostic test, reading an x-ray, EKG, lab, etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.Unlisted Procedure Codes with Modifiers 22, 52, 53
Some services or procedures performed by providers might not have specific Current Procedural Code (CPT®). When submitting claims for these services or procedures that are not otherwise specified, unlisted codes are designated. Unlisted codes provide the means of reporting and tracking services and procedures until a more specific code is established. Do not report a CPT® code for a specific procedure if it does not accurately describe the service performed. It is inappropriate to report the best fit HCPCS/CPT® code unless it accurately describes the service performed, and all components of the HCPCS/CPT® code were performed.
When submitting an unlisted procedure, a concise description of the procedure must be included on the claim form.
When submitting supporting documentation, clearly designate the portion of the report that identifies the test or procedure associated with the unlisted procedure code.
Modifiers 22, 52, and 53 (descriptions below) are inappropriate to submit with an unlisted code as the code should already take into account whether there was reduced, discontinued, or extensive time due to complications, etc. Claims reported with these modifiers will be denied and returned for correction.
22 - Increased Procedural Services
52 - Reduced Services
53 - Discontinued Procedure
A self-insured product with two parts. Part one is called the Core Coverage which is all care except for procedures which are carved out for special management called Add-In Coverage (see Add-In list below).How it works:
All Core Coverage works just like all other PreferredOne products. All Add-In coverage needs to be purchased by the member prior to services being rendered and can vary depending upon how the member chooses to customize their coverage. All coverage is structured with copays.What this means for you:
Just three things!
- Set up Bind as a new Payer in your system - All billing remains fee for service and the Bind product must be setup with a new Payer ID to ensure claims will route appropriately. The new Bind payer ID is 25463.
- Set up the Bind Payer ID and address for submitting claims as the following:
PO Box 211758
Eagan, MN 55121
Payer ID 25463
- Send in Pre-Determinations: Surgical coverage can vary among members, depending on how they have customized their coverage. If you have scheduled a procedure that falls within one of Bind’s Add-In Coverages, we ask that you send a Predetermination to the Bind product website to verify if the member has coverage for that procedure. This functionality through the Bind website will be available for use very soon.
To learn more, please contact your provider relations representative and watch for the Bind Product button on the PreferredOne website in the Provider area.Add in Benefit Procedure List
- Ankle Surgery - Ligament Reconstruction
- Back Surgery – Cervical Spine Fusion
- Back Surgery – Lumbar Spine Fusion
- Back Surgery – Discectomy, Laminectomy and Decompression
- Bariatric Surgery
- Breast Reduction Surgery
- Carotid Endarterectomy
- Carpal Tunnel Procedure
- Coronary Catheterization – Diagnostic
- Coronary Angioplasty with or without Stents
- Coronary Artery Bypass Surgery
- Ear Tubes
- Endometrial Ablation
- Foot Bone Fusion
- Functional Nasal Procedure/Sinus Surgery/Septoplasty
- Ganglion Cyst Surgery
- Hammer Toe Surgery
- Hernia Repairs – Ventral
- Hip Arthroscopy
- Hip Replacement/Hip Resurfacing
- Hysterectomy (for non-cancerous reasons)
- Knee Surgery – Arthroscopy
- Knee Surgery – Replacement
- Morton's Neuroma – Excision
- Nissen Fundoplication (Reflux Surgery)
- Plantar Fasciitis Surgery
- Shoulder Surgery
- Upper GI Endoscopy
- Urinary Incontinence – Sling Procedure
PreferredOne is pleased to announce the addition of a new remittance code that has now been implemented into our system to provide greater clarity around specific claim denial instances. The new denial code is XEA and will read on the remittance as “Prior authorization is required for this service.” The intent of this new code is to decrease the review and processing time for claims where a prior authorization is required but one is not obtained. The system will be able to identify that a prior authorization was required and was not obtained and will auto adjudicate the claim to deny as provider liability. This will greatly decrease the processing time of these claims and will allow for a remittance to post for provider review more quickly. Please keep in mind that providers may still request a post service review and potential authorization through our Utilization Management department. However, we highly recommend that providers keep an eye on the Prior Authorization list available through the secured provider website. Prior authorizations completed before services are rendered help both providers and members in determining what services will be covered and can significantly decrease risk of provider liability for those services.