Quality Management

Exchange of information

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

  • Phychopharmacological 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.

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Minnesota Community Measurement - Release of the 2020 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 2020 Health Care Quality Report on their website during the first quarter of 2021.  The 2020 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 2020 Minnesota Health Care Quality Report at www.mncm.org.

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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)


Diastolic Blood Pressure 3079F(diastolic 80-89mmHg),
3078F(diastolic <80mmHg),
3079F(diastolic 80-89 mmHg),
3080F(diastolic > or = 90 mmHg)

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.

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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 2021 are accurate. Thank you!

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Reminding Patients of Yearly Physical Exam

As the end of 2021 rapidly approaches, 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.

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Medical Management

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.

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PreferredOne has implemented a new way to submit Prior Authorizations

PreferredOne has rolled out iExchange which is our automated authorization tool that supports the direct submission and processing of healthcare transactions including notices of admissions, outpatient authorizations, and extensions directly to PreferredOne 24 hours a day, 7 days a week.

Benefits include:

  • Ability to submit notices of admission, outpatient authorizations, and extensions directly to PreferredOne and receive immediate feedback.

  • Receipt of a status upon request submission, with a tracking number. Requests will be auto approved or pended. Pended requests are immediately routed to a PreferredOne Nurse Reviewer who will review your request.

  • Real-time alerts from PreferredOne when a request has been reviewed and updated by the Nurse Reviewer.

  • Ability to provide clinical notes and attachments to PreferredOne.

  • Ability to print an authorization request confirmation for your patient and your files.

Getting Started:

If you do not have a current loginID/password to the provider site, please contact your Provider Relations Representative.

Mark your Calendars

We will be an offering (virtual) iExchange demonstration on Wednesday October 27,2021 2:00 - 3:00. If you would like to attend, please register by sending an email to providerreps@preferredone.com by October 13th.

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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).

Below are the new, revised, or retired Medical Clinical Policies. 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.Thompson@PreferredOne.com.

Prior Authorization List

  • 01/14/21 - Acupuncture: deleted (effective 1/1); Obstructive Sleep Apnea – Adenoidectomy/Tonsillectomy deleted duplicate CPTs, added D7944; Fetal Surgery In Utero - added CPTs 59072, 59074, 59076, 59897.
  • 02/09/21 - Cardiovascular: added CPT 33995; Cosmetic: deleted 19324, 19366 (no longer valid), added Fat grafting, autologous, harvested by liposuction or any other means and CPTs 15771/15772 for 4/1 effective date; Neurology: deleted 61870 (no longer valid).
  • 03/09/21 - Laboratory testing: deleted Non-invasive Pregnancy Testing (NIPT) using cell-free DNA (cfDNA)
  • 03/26/21 - Other Procedures: added Prophylactic Mastectomy for 6/8 effective date
  • 05/11/21 - Cardiovascular: Total Artificial Heart - addition of CPT codes 33927, 33929; Cosmetic and/or Reconstructive: Pectus excavatum or carinatum repair replaced with Chest wall deformities, surgical reconstruction; Laboratory Testing: Molecular Testing - addition of CPT codes 81546, 0026U, 0245U; Pharmacogenetic testing - deletion of CPT codes 82491 (no-longer valid), 82657 (non-specific and no longer flagged for PA); Whole Exome Sequencing - addition of CPT codes 0214U, 0215U; Neurology: RFA - addition of HCPCS C9752, C9753
  • 06/09/21 - Dental: Removed Orthodontia from this entry and created a new, separate entry - added dental HCPCS for comprehensive orthodontia services; Hyperhidrosis Surgery: under Service/Procedure column – added note, “When billed with diagnosis codes L74.510-L74.519, L74.52” ; Laboratory Testing : Molecular Testing, Gene Expression - added 81210 and 0208U and deleted 0108U, 0114U, 0120U – these are on the Investigative List; Pharmacogenetic/Pharmacogenomic Testing: added 0155U, 0239U, 0242U, 81236, 81273, 81311, 81314  - deleted 81287 and 86152  - PA no longer required; Other Procedures: Prophylactic Mastectomy entry relabeled to Risk Reducing Mastectomy.
  • 06/18/21 - Cardiovascular: Varicose vein treatments – added CPTs 36473 and 36474; Orthopedic: Total Disc Arthroplasty – changed title to Intervertebral Disc Prosthesis (to match clinical policy) and removed CPT 0098T

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies List


  • CGM and Insulin Infusion Pump – Supplies HCPCS
    • Added A4226
  • Enteral therapy and Enteral feeding supplies: under the Eligible column, changed the Y to B (per benefit)
  • Exoskeleton suit, lower body – robotic – HCPCS K1007 - New entry added to reflect HCPCS and investigative position
  • Functional electrical stimulator/ Functional neuromuscular stimulator
    • deleted WalkAide; this is now considered investigative
  • Orthotic Devices, Lower Limb; Hip: new entry added with HCPCS range and allowance of one per year
  • Orthotic Devices, Lower Limb: revised entry to expand HCPCS range
  • Pressure reducing surfaces: combined separate entries(below), added HCPCS and updated Comments
    • Under Eligible, changed to N
    • Under comments, added see Investigative List

  • Orthotic Devices, Lower Limb; Hip: new entry added with HCPCS range and allowance of one per year
  • Orthotic Devices, Lower Limb: revised entry to expand HCPCS range
  • Pressure reducing surfaces: combined separate entries(below), added HCPCS and updated Comments
    • Cushions, specialty
    • Egg crate mattress
    • Foam wedges
    • Positional devices
    • Wedges for infant GERD
  • Prosthesis, eye added as covered
  • Pulse generator system for tympanic treatment of inner ear endolymphatic fluid: removed A4368 from list of non-covered HCPCS
  • Urological supplies: added HCPCS K1006 and its description as an allowed device for use with external urine management systems
  • Ventricular Assist Devices: updated HCPCS range


  • Deleted health care services that are on the Investigative List and do not have specific HCPCS
    • Active Cooling Therapy
    • H-Wave Electrical Stimulation
    • Interferential Current Devices
    • NMES/TENS combination and devices
    • NTI-tss Device for migraine headaches
    • RS-4I Sequential Stimulator
    • Spinal unloading devices
  • Deleted health care services that are no longer on the market/have no utilization

Medical Clinical Policies


  • Chest Wall Deformities (Pectus Excavatum and Poland Syndrome), Surgical Reconstruction
  • Risk Reducing Mastectomy or Salpingo-Oophorectomy


  • Breast Reconstruction - IV. A. has been revised for clarity - to reflect that implant removal is appropriate for any member that has breast cancer or has a personal history of breast cancer. This includes when the implant was initially inserted for cosmetic reasons
  • DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics and Supplies) - The indications for insulin infusion pump replacement have been added under II. J.
  • DMEPOS, Insulin Infusion Pump - The indications for insulin infusion pump replacement have been removed from MC/L011 and added into the overarching DMEPOS clinical policy, under II. J.
  • DMEPOS, Pneumatic Compression Devices and Heat/Cold Therapy Units - The statement regarding use of the devices for 3 month rental before prior authorization has been removed from this clinical policy (previous I.).
  • Genetic Testing, Comparative Genomic Hybridization (CGH, aCGH)
    • Replaced the statements under I, II, and III that required testing to be ordered by a provider with a certain specialty related to the condition being assessed with specialty providers and the conditions they manage to the definition of health care professional trained in genetics
          • – Obstetrician ordering genetic testing for chromosomal abnormalities
          • – Child neurologist ordering genetic testing for global developmental delay or intellectual disability, developmental pediatrician
        • – Child/adolescent psychiatrist ordering genetic testing for autism
  • Genetic Testing, Hereditary Cancer Syndromes
    • III. and XIV. Revisions to reflect genes/genetic mutations with strong or very strong evidence for increased risk of an inherited cancer/cancer syndrome, only
    • IV., VIII., VII., IX., XII. Revisions to align with current NCCN positions
    • Definitions – revised “Health Care Professionals Trained in Genetics”
  • Genetic Testing, Non-Invasive Prenatal Testing (NIPT) with cell-free DNA(cfDNA)
    • Revisions to allow for any singleton pregnancy
  • Genetic Testing, Whole Exome Sequencing (WES)
    • Deletion of the “Characteristics of Covered Tests” statements, as WES has already met this threshold; the clinical utility, ie, how this will impact clinical care, is implied in in the other guideline statements
  • Molecular Testing, Tumor/Neoplasm Biomarkers - This clinical policy contains extensive revisions. Please review the clinical policy document MP/M001.
  • Molecular Testing, Gene Expression
    • II. A. Addition to reflect that repeat testing is not indicated
    • II.B. Deletion of “newly diagnosed”, ie, can be used at other intervals (eg, to assess need for extended hormonal therapy)
    • II.B.1.,2.,3. Revisions to break out indications for each test by gender
    • II.D.3. Revised to remove specific pathologic and molecular finding indications for the use of Decipher in this setting
    • II.E. Revised to capture all proven effective gene expression tests for use in cytologically indeterminate FNA thyroid neoplasms/nodules
  • Neurostimulation, all applicable clinical policies
    • Added indications for replacing and/or revising the leads/ electrodes
  • Neurostimulation, Spinal Cord/Dorsal Column and Dorsal Root Ganglion
    • Revisions under I.A. to allow for high-frequency or burst forms of stimulation for these same indications
  • Neurostimulation, Hypoglossal Nerve
    • Revision referring user back to initial placement indications
  • Pharmacogenetic/Pharmacogenomic Testing and Serological Testing for Inflammatory Conditions - This clinical policy contains extensive revisions. Please review the clinical policy document MP/P013.
  • Preventive Coverage for Colorectal Cancer Screening - This policy has been revised to include an additional diagnosis code for pathology services associated with a colonoscopy; K63.5.
  • Preventive Coverage for Lung Cancer Screening - This policy has been revised to include counseling services for shared decision making, HCPCS G0296, at the no cost-sharing/preventive level of coverage.
  • Radiation Therapy, Selective Internal Microspheres (SIRT)
    • Indications for TheraSphere (I.) have been revised as follows:
      • – Removal of the HDE language
      • – To reflect that it is allowed for unresectable, primary hepatocellular carcinoma. It is not limited to neoadjuvant to surgery or transplantation.
    • Downstaging has been defined.
  • Total Joint Arthroplasty of Knee or Hip, Elective - Revised the requirements for non-surgical management
  • Varicose Vein Treatment
    • Under I., revised to now include MOCA as a treatment option for use in great or small saphenous veins
    • Added CPTs for MOCA

Revised Health Clinical Policies impacted by transition to Milliman Care Guidelines

  • Behavioral Health, Mental Health Disorders: Inpatient Primary Treatment
  • Behavioral Health, Eating Disorders Level of Care Criteria
  • Behavioral Health, Mental Health and Substance Related Disorders: Residential Treatment
  • Behavioral Health, Substance Related Disorders: Inpatient Primary Treatment
  • Behavioral Health, Detoxification and Addiction Stabilization: Inpatient Treatment
  • Behavioral Health, Mental Health Disorders: Residential Crisis Stabilization Services (CSS
  • Skilled Nursing Facility Services


  • Genetic Testing, Non-invasive Prenatal Testing (NIPT) with cell-free DNA (cfDNA) - Prior authorization is no longer required

For Addiction Medicine/Substance Abuse Disorder Providers:

Acupuncture and Chiropractic Clinical Policies

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

Medical Investigative List


  • Adrenal Mass Panel, 24 Hour Urine test
  • Afirma Xpression Atlas test
  • Caris Molecular Intelligence® Comprehensive Tumor Profiling /MI Tumor Seek test
  • Cxbladder™ Detect
  • Cxbladder™ Monitor
  • Decipher Bladder TURBT
  • DISCERN tests
  • HeproDX
  • Lymph2Cx test
  • MI Cancer Seek - NGS Analysis test
  • Molecular testing, gene expression profiling for idiopathic pulmonary disease
  • Microprocessor-controlled Knee-Ankle-Foot Orthoses
  • Molecular testing, gene expression profiling for indeterminate cutaneous lesions, pre-biopsy -
  • Nasal valve collapse repair with subcutaneous/submucosal lateral wall implant
  • NASH FibroSURE
  • Oncotype MAP™ Pan Cancer Tissue test
  • PlGF Preeclampsia Screen
  • PreciseDxTM Breast Cancer test
  • PredictSURE IBD test
  • PreTRM test
  • Robotic Lower Body Exoskeleton Suits
  • Vagus nerve stimulation for depression
  • Vestibular evoked myogenic potential (VEMP) testing, cervical and ocular
  • Vita Risk test


  • Arthroscopic lavage and debridement for osteoarthritis of the knee, except when used to alleviate symptoms due to loose bodies and/or meniscal tears
  • Breast gamma scans for all indications
  • Cervicography for routine screening and diagnosis of cervical cancer
  • Chelation therapy for all indications except
    • Aceruloplasminemia/Copper-storage disease (eg, Wilson’s disease or hepatolenticular degeneration)
    • Cardiac ventricular arrythmias/ heart block due to digitalis toxicity
    • Heavy metal poisoning (including arsenic, cadmium, copper, gold, iron, lead, mercury)
    • Hypercalcemia (emergency treatment)
  • Cryoablation/cryosurgery for the conditions listed (see List)
  • Combined Nucleoplasty and Percutaneous diskectomy/diskectomy into one entry and renamed as Decompression of nucleus pulposus by any method, using needle-based technique to remove disc material      
  • FES/NMES entries revised into the following two entries
    • FES of the upper extremities for all indications, including improvement of muscle strength, reduction of spasticity and atrophy, and facilitation of functional motor movement due to spinal cord injury, stroke (cerebrovascular accident/CVA), traumatic brain injury, or other upper motor neuron disorders (eg, Parkinson's disease)
    • FES and NMES for the following indications (see List) - Includes peroneal nerve stimulation. Examples include, but not limited to, WalkAide …
  • Hair analysis, excluding arsenic
  • High intensity focused ultrasound (HIFU) for all indications, except recurrence post-RT in the absence of metastatic disease
  • Hyperthermia treatment for cancer conditions…Hyperthermic administration of intraperitoneal chemotherapy (HIPEC) except…ovarian cancer
  • Molecular Testing, gene expression - to narrow scope of position to gene expression testing
  • Transcutaneous electrical joint stimulation device for all indications

Revisions, other

  • Annular repair after spinal surgery with use of surgical devices - Under Comments, added additional example of Barricaid
  • Cardioverter-defibrillator, implantable, with substernal electrodes - Added CPT 0614T
  • Cryoablation/cryosurgery - Under Comments, replaced current verbiage with a reference to the policy for use of this technology in oncology
  • Genetic testing, simultaneous RNA NGS for detection of variants of unknown significance in hereditary cancer
    • Deleted CPT 0131U, added CPTs 0101U, 0102U, 0103U, 0161U
    • Revised to now include by any method (eg, NGS [next-generation sequencing], Sanger sequencing, MLPA [multiplex ligation-dependent probe amplification], array CGH [comparative genomic hybridization])
  • Molecular testing, gene expression profiling cutaneous melanoma
    • Revised to include “post-biopsy for prognostication of…”
    • MyPath Melanoma removed from Comments - This specific test no longer falls into this position and is no longer considered investigative
  • Molecular testing, gene expression profiling and/or molecular testing for prostate cancer - NeoLAB Prostate liquid biopsy entry: addition of code 0011M
  • Nasal implant, stents, or spacers, steroid-eluting for chronic sinusitis without polyposis - Deleted HCPCS J7401 and C9122, added HCPCS J7402 and S1061
  • Non-invasive prenatal testing (NIPT) using cell-free DNA (cfDNA)
    • Added CPT 0060U
  • Obstructive Sleep Apnea (OSA) Treatments - Glossectomy, partial replaced CPT 42210 with 41120
  • Pharmacogenetic/pharmacogenomic testing
    • CPT codes removed from CPT/HCPCS column (listed next to investigative entry)
    • Correction of CPT 81213 to 81231
    • Addition of the following (previously reflected on pharmacogenetic/pharmacogenomic policy, only)
      • – ABCB1 genotyping to determine drug metabolizer status for all drugs
          • – ANKK1 genotyping to determine drug metabolizer status for all drugs
          • – BDNF genotyping to determine drug metabolizer status for all drugs
          • – FKBP5 genotyping to determine drug metabolizer status for all drugs
          • – GRIK4 genotyping to determine drug metabolizer status for all drugs
          • – HLA-A*31:01 genotyping to determine drug metabolizer status for all drugs
          • – HTR1A genotyping to determine drug metabolizer status for all drugs
          • – MC4R genotyping to determine drug metabolizer status for all drugs
          • – SLC6A4 genotyping to determine drug metabolizer status for all drugs
          • – SLCO1B1 genotyping to determine drug metabolizer status for all drugs
          • – TXNRD2 genotyping to determine drug metabolizer status for all drugs
          • – UGT2B15 genotyping to determine drug metabolizer status for all drugs
  • Whole genome sequencing (WGS) - Added CPTs 0209U, 0212U, 0213U

Deletions (including many services that are obsolete)

  • Bone conduction hearing systems, intra-oral
  • Co-culture of human embryos
  • Colonic hydrotherapy by colonic irrigation
  • Environmental Illness Therapy
  • FASIAR (follicle aspiration, sperm injection, and assisted follicular rupture)
  • Fetal tissue transplantation
  • Histamine Therapy
  • Impotence treatment – vascular surgery
  • Laser Bullectomy
  • Lipid associated sialic acid tumor marker for cancer screening
  • Lung cancer screening by any other imaging method beside low dose computed tomography (LDCT) (also known as helical or spiral CT)
  • Omental transposition to the spinal cord
  • Plethysmographic methods: inductance, capacitance, photoelectric, and mechanical oscillometry
  • Radiofrequency ablation of renal tumors
  • Red blood cell substitutes
  • ROSNI/ROSI (round spermatic nuclear injection)
  • Silicone injection
  • Spinal cord stimulation (SCS) /dorsal column stimulation (DCS), cervical
  • Spinal cord stimulation (SCS) /dorsal column stimulation (DCS),) for chronic pain from malignancy, other chronic non-malignant pain and spasticity
  • Sublingual antigen drops (sublingual immunotherapy)
  • Thoracic bioimpedance/impedance cardiography, electrical
  • Varicose Vein procedures, deleted Endomechanical or mechanicochemical ablation (MOCA)
  • Ventricular (heart) Reduction surgery

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

New to the Medical Policy Webpage

“Medical Policy and Pharmacy Policy Future Updates” link in the gray box under UPDATES & NEWS - This is a communication tool summarizing upcoming updates that may affect providers and members.

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Members Participating in Clinical Trials

Documentation related to each individual claim should be submitted simultaneously to aid in the validation process and to ensure coding and billing compliance.

Examples of Documentation Include: Visit notes, progress notes, orders for radiology, laboratory or other related testing.

A reminder regarding Clinical Trial Codes:

  • A modifier of Q0 or Q1 is appended to the CPT code.
  • An ICD -10-CM code Z00.6 “Encounter for examination of normal comparison and control in clinical research program” is reported as either a primary or secondary diagnosis.
  • If you have special circumstances for your clinical trials, review the full modifier list to determine if a more appropriate modifier would be applicable to your situation.

For Billing:

  • Report the clinical trial number
    It is mandatory to report a clinical trial number on claims for items and services provided in clinical trials, studies or registries, or under Coverage with Evidence Determination (CED) for claims with dates of service on or after January 1, 2014.
  • List Services as Separate Line Items
    You must enter clinical trial and non-clinical trial services on separate line items when billing both types of services on the same claim

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As a reminder, PreferredOne has implemented a pre-payment, post service claim edits program on specific medically administered medications. To find out more information about the Post-Service Claim Edits (PSCE) program, please visit the webpage below.


Rx Savings Solutions

PreferredOne offers eligible members a way to save on prescription drug costs. The program is called Rx Savings Solutions. It’s easy to use and available to eligible PreferredOne members through their member portal. This is an online pharmacy transparency service that analyzes members’ prescription drug claims and overlays clinical information to suggest equally effective, lower-cost alternatives to subscribers and their families. It empowers our members with the information needed to find the most cost-effective, yet therapeutically-conscious, prescription medication according to their PreferredOne pharmacy benefit. You may receive a phone call or fax from Rx Savings Solutions Pharmacy Support team member requesting to switch a member’s medication to a lower-cost alternative. Please know this is a partner of PreferredOne who is working to help lower the cost of care for your patients. This process usually takes a few minutes. The impact more affordable medications can have on your patient’s health is huge. Your eligible patients can access this valuable tool through their PreferredOne member portal at: PreferredOne.com/RxSS. Call 1-800-268-4476 or email support@rxsavingssolutions.com with any questions about Rx Savings Solutions.

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