CMS CY 2025 Physician Fee Schedule Final Rule Reminder
CMS finalized a 2025 PFS Conversion Factor (CF) of $32.3465. The CY 2024 conversion factor is $33.29, the CY 2025 Conversion Factor will result in a decrease of 2.8% or $0.93.
To make this information more meaningful to providers, CMS has published the Estimated Impact on Total Allowed Charges by Specialty on page 2,326 of the Final Rule.
Medicare Beneficiary Eligibility Not Offered on the IVR
To help protect Medicare beneficiaries against fraud, the Centers for Medicare & Medicaid Services (CMS) is instructing all Medicare Administrative Contractors (MACs) to remove beneficiary eligibility information from our interactive voice response (IVR) systems. Starting 11/18/2024, you won’t be able to obtain beneficiary eligibility information from our IVR.
This includes beneficiary eligibility that was obtained under Option 1, Eligibility, such as:
- Part A and Part B entitlement dates
- Current/prior year Part B deductible information
- Current/prior year physical therapy and occupational therapy limit amount used
- End-stage renal disease (ESRD) coverage dates, dialysis and/or transplant date
- Home health and hospice (HH+H) name, National Provider Identifier (NPI), address and effective/termination dates
- Preventive care details
Eligibility information can only be obtained by utilizing the online portals. NGS is offering several webinars to provide an overview of their portal, NGSConnex.To view the webinar times, click here.
Digital-only authorization case status for Wellpoint New Jersey
Medicare Advantage and Medicaid plans from Wellpoint New Jersey can now receive authorization notifications digitally through Availity Essentials.
Here’s a quick recap on how to navigate Availity Essentials for your authorization cases.
Authorization cases status and digital authorization decision letters on Availity Essentials:
- Through Auth/Referral Inquiry, you can retrieve cases submitted by your organization via both digital and non-digital methods. You can also use the Pin to Dashboard feature to keep these cases on Auth/Referral Dashboard, saving you from repeating the search in the future.
- Get the most recent status of cases submitted by your organization on Auth/Referral Dashboard and view the case details including decision letters via View Details in the Actions menu. For pinned cases, select the case card to view the latest status and case details.
Visit the Wellpoint October Provider Newsletter for more information.
Excellus BlueCross BlueShield Update to Telemedicine and Telehealth
Effective November 1, 2024, services that are billed inappropriately with telehealth service modifier G0 (Telehealth services for diagnosis, evaluation, or treatment of symptoms of an acute stroke) in telehealth Place of Service 02 or 10 (CMS-1500) will be returned for an invalid modifier in the place of service that billed.
This policy is in line with Centers for Medicare & Medicaid Services, Current Procedural Terminology (CPT), and Healthcare Common Procedure Coding System (HCPCS) guidelines. It will apply to all participating and non-participating practitioners and to the Commercial (HMO, PPO, POS, ASO/ASC and Indemnity), Medicare Advantage, Medicare HMO-Dual Special Needs Program (D-SNP), New York State Government Programs (Medicaid Managed Care, Health and Recovery Plan (HARP) and Special Programs (Healthy NY and Essential Plan) lines of business.
For further details, click here.
United Healthcare Update on Prior Authorization Resources for Outpatient Therapy and Chiropractic Services
On Sept. 1, 2024, we began requiring prior authorization for physical, occupational, speech therapy and chiropractic services for UnitedHealthcare® Medicare Advantage members. Optum Physical Health has been delegated to review the prior authorization request for medical necessity using CMS Chapter 15 criteria, applicable local coverage determinations (LCDs) and InterQual® criteria to render a determination. Medical necessity reviews are conducted by licensed medical professionals, including physical therapists, occupational therapists and speech-language pathologists.
Reviews are conducted after the member’s initial consultation and evaluation and consider the specific circumstances of the individual member to approve a course of treatment supported by the clinical evidence…
Exclusions
The below plans and provider types are not required to submit for authorization:
- Out-of-network providers
- UnitedHealthcare® Dual Complete plans
- UnitedHealthcare Nursing Home and UnitedHealthcare Assisted Living plans
- Preferred Care Network and Preferred Care Partners of Florida
- UHCWest (specific plans in California and Arizona)
- Peoples Health Plan
- Rocky Mountain Medicare Advantage Plans
- Erickson Advantage
…Prior authorization is required for services rendered in the following places of service. If your claim is submitted indicating procedures were performed at one of these places of service and an authorization has not been obtained, your claim will be denied:
- 11 Office
- 19 Off-Campus Outpatient Hospital
- 22 On-Campus Outpatient Hospital
- 24 Ambulatory Surgical Center
- 49 Independent Clinic
- 62 Comprehensive Outpatient Rehabilitation Facility