RCM eNews – July 2024

On June 17, 2024, CMS announced that payments under the Accelerated and Advance Payment Program for the Change Healthcare/Optum Payment Disruption (CHOPD) will end on July 12, 2024. When this program launched in early March, the CHOPD payments were designed to ease cash flow disruptions experienced by some Medicare providers and suppliers, such as hospitals, physicians, and pharmacists, due to the unprecedented cyberattack that took health care electronic data interchange Change Healthcare offline in February.

To read the full press release, click here. For additional information on preparing for and safeguarding against cyberthreats see the Healthcare and Public Health Cybersecurity Performance Goalswebpage.

Aetna released an update for both their commercial and Medicare members regarding E&M denials for non-physician provider types.

Currently, they do not pay Evaluation & Management codes (99202–99499) for certain non-physician provider types. There are specific CPT® and HCPCS codes designed to more accurately identify the services performed.

Effective October 1, 2024, they will not allow payment for E&M codes (99202–99499) from these provider types:

• Addiction Counselor
• Athletic Trainer
• Case Management Child Psychology
• Clinical Nurse Specialist, Psychiatric/Mental Health***
• Doctor of Naprapathy
• Early Intervention
• Hearing Instrument Specialist
• Home Health Aide
• Home Health Care Agency
• Home Infusion
• Homemaker
• Homeopath
• Licensed Vocational Nurse
• Neuropsychology
• Nurse, Registered
• Pastoral Counselor
• Psychoanalyst
• Psychologist, Clinical
• Social Worker, Clinical

Effective June 19, 2024, you can easily complete UHOne/Golden Rule eligibility and claim services in the UnitedHealthcare Provider Portal. Previously, you performed these tasks in the UHOne provider portal or by sending materials to UHOne. As a result of this change, you’ll be able to:

• Access all your data in one place
• Search and get results under the UHOne Payer ID dropdown (37602)
• View member ID cards
• Review claims status for claims received after March 1, 2023
• Submit claim reconsiderations

New to the UnitedHealthcare Provider Portal?
The portal is the secure place where you’ll access patient- and practice-specific information 24/7. To access, you’ll need a One Healthcare ID. To get started and learn more, visit UHCprovider.com/access.

Digital claim correspondence is now available on the Cigna for Health Care Professionals website (CignaforHCP.com).

• As of June 20, 2024, registered users with the Claim Search entitlement have access to digital claim correspondence via the Messaging Center on CignaforHCP.com.
• Digital correspondence notifies users when claim letters are available, or when action is required to continue processing.
• Designate the following communication preferences by logging into CignaforHCP.com > Settings and Preferences > Communications Settings:
  • The type of correspondence you want to receive (e.g., emails and/or alerts) when digital correspondence is available.
  • Email notifications and frequency to alert you when new digital correspondence is available.

• Learn about digital claim correspondence by reviewing the frequently asked questions.

From From Highmark Blue Shield:

Starting Aug 23, 2024, providers will make corrections directly on the Replacement Claim- rather than the Adjustment Claim- when submitting a Frequency Type 7 claim or Type of Bill that ends in 7. This change only applies to the following lines of business: Commercial and Medicare Advantage.

NOTE: this change does not apply to Medicaid products, including Highmark Wholecare, Highmark Health Options Delaware, or Highmark Health Options West Virginia.

In Health Insurance Portability and Accountability Act (HIPAA) 837I and 837P claim transactions, the Frequency Type 7 claim is reported in the 2300 Loop, CLM05-3 element. The original claim number is reported in Loop 2300, as “Orig Clm No.”

For transactions via Availity^®, corrected claims can be submitted within the claim entry screen by selecting Frequency Type 7 and providing the original claim number.

Current Process

Here’s how the current correction or adjustment claims process works:

1. Provider submits a claim for services.
2. Identifies an error on the original claim.
3. Provider then submits a Frequency Type 7 claim or Type of Bill that ends in 7 (Replacement Claim) to correct the original claim.
4. The Adjustment Claim appears in the reference field of the Replacement Claim.
5. The Claims Processing System makes the changes on the original claim.

What Is Changing

The Replacement Claim will now process as the new claim and any future reference to the changes would be made on the Replacement Claim. The Adjustment Claim will serve as a notification to providers that a correction has been made; the Replacement Claim will document the actual correction(s).

From CMS:

The Departments are aware that Change Healthcare—a unit of UnitedHealth Group—was impacted by a cybersecurity incident in late February. The Departments recognize the impact this attack has had on health care operations across the country, including certain parties’ ability to initiate open negotiation, the initial stage of the Federal independent dispute resolution (IDR) process.

The Departments have received reports from providers, facilities, and providers of air ambulance services that they are unable to initiate open negotiation because they have not received necessary payment information or disclosures from plans or issuers due to disruptions to claims processing resulting from the Change Healthcare cybersecurity incident. In “FAQs About Affordable Care Act And Consolidated Appropriations Act, 2021 Implementation Part 55 (PDF)” (FAQs Pt. 55), the Departments explained that if a plan or issuer fails to timely disclose the information it is required to with each initial payment or sending a notice of denial of payment,* providers, facilities, and providers of air ambulance services may request an extension to initiate the Federal IDR process by emailing a request for extension due to extenuating circumstances to FederalIDRQuestions@cms.hhs.gov.

However, the Departments recognize that payment for a very large volume of items and services was impacted by the Change Healthcare cybersecurity incident, making individual extension requests burdensome for disputing parties and for the Departments. Additionally, the Departments understand that it may be difficult to determine the date of initial payment or notice of denial of payment for an item or service impacted by the cybersecurity incident, as in some cases, disruptions to payment transmissions have made it difficult to match payments received to specific items or services furnished.

Therefore, the Departments are announcing that providers, facilities, and providers of air ambulance services whose ability to timely initiate open negotiation for any item or service furnished on or after Jan. 1, 2024, was impacted by the Change Healthcare cybersecurity incident may choose to initiate open negotiation for such items or services at any point during the 120-calendar-day period following the publication of this notice, beginning 6/14/2024 and ending 10/12/2024, regardless of when the payment or notice of denial of payment and disclosures were transmitted. Parties may take advantage of this exception period by attesting that their ability to initiate open negotiation timely for an item or service was impacted by the effects of the cybersecurity incident.

The Departments have published an attestation (PDF) that providers, facilities, and providers of air ambulance services must furnish to plans or issuers alongside the standard open negotiation initiation form, and that providers, facilities, and providers of air ambulance services initiating the federal IDR process must furnish to non-initiating plans or issuers and certified IDR entities alongside the standard IDR initiation form, in order to invoke this exception period. Parties seeking to invoke this exception do not need to request extensions individually via the Federal IDR Inbox, as outlined in FAQs Pt. 55 (PDF).

IDR entities will be responsible for adjudicating, as part of their eligibility determination, any disagreement as to whether the initiating party is eligible to initiate open negotiation during this 120-day exception period. Non-initiating parties who believe disputes should not be eligible for this exception should provide documentation to support that assertion to initiating parties through open negotiation, as well as to certified IDR entities via the certified IDR entity selection process. See section 5.5 of Federal Independent Dispute Resolution (IDR) Process Guidance for Disputing Parties (PDF).

The Departments will continue to monitor the progress toward the restoration of normal clearinghouse operations and will timely reevaluate whether it is necessary to provide additional time beyond the 120-calenday-day exception period, providing additional guidance as appropriate.

*See 26 CFR 54.9816-6T(d)(1) or (2), 26 CFR 54.9816-6(d)(1), 29 CFR 2590.716-6(d)(1) or (2), and 45 CFR 149.140(d)(1) or (2).

From Commnunity Health Care Association of New York State:

Due to the cybersecurity incident that occurred with Change Healthcare/Optum on February 21, 2024, claims that exceed the timely filing limits may be submitted electronically using Delay Reason 15 (Natural Disaster). There is no additional documentation required to use Delay Reason 15; however, where particular claims require documentation, such as invoices for pricing, the claim and all necessary documentation should be submitted as a paper claim along with the delay reason form indicating delay reason 15. Providers should also maintain documentation that supports being affected by this incident.

Claims must be submitted by August 30, 2024, to be considered for payment. Claims that are payable using Delay Reason 15 are all claims that couldn’t be submitted timely due to the Change Healthcare/Optum cybersecurity incident only. Submitting claims that do not meet this purpose with Delay Reason 15 is not permitted and may be considered Medicaid fraud subject to review by the Office of the Medicaid Inspector General.

Claims for this incident submitted after August 30, 2024, with delay reason 15 will be denied.

General questions for claims submission should be directed to the eMedNY Call Center at 1-800-343-9000. Questions on specific claims that are pended for review should be directed to the Bureau of Medical Review, Pended Claims Unit at 1-800-342-3005 (option 3).