RCM eNews – May 2024

On March 22, 2024, the FDA released an emergency use authorization for the PEMGARDA monoclonal antibody product for pre-exposure prophylaxis of COVID-19.

• New Product Code – Q0224
• Administration Code – M0224

Click here for further details.

In March, we gave notice that as of February 8, 2024, Horizon BCBS of NJ, Braven Health, and Horizon NJ Health had joined the Availity Essentials Provider Portal but that access to Navi Net was still available.

Now, starting May 31, 2024, Navi Net will no longer work with Horizon BCBS of NJ, Braven Health, and Horizon NJ Health. You must register with Availity Essentials to check eligibility, benefits, claims, and authorizations.

Refer to the resources on availity.com/horizon for additional help.

For registration help or a status update, call Availity Client Services at 1-800-AVAILITY (282-4548).

Effective April 1, 2024, access was expanded to the Essential Plan (now known as Essential Plan 200-250) by increasing income qualifications from 200% of the Federal Poverty Level to 250%. Excellus BCBS has issued new member cards to eligible members.

UHC follows a two-step claims reconsideration and appeals process for UnitedHealthcare commercial and Medicare members. Under this policy, you’re allowed one reconsideration. If that reconsideration is denied, you can then file an appeal. Claims reconsideration does not apply in some states, based on applicable state law.

Familiarize yourself with the two-step reconsideration and appeals process by viewing their Claims Interactive Guide.

When submitting a reconsideration, be sure to include all pertinent documentation. Your reconsideration request may be denied if the necessary documentation is not included, and you will not be allowed to file another reconsideration request.

Effective February 15, 2024, the Florida Agency for Health Care Administration (AHCA) is changing the taxonomy rules. This includes a new Taxonomy Master List (TML) and updates to some of the National Provider Identifier (NPI) Initiative tools and resources.

Please review the updated TML to make sure your taxonomy codes are accurate and up to date.

Remember to include the following information when submitting claims:

• NPI number, as enrolled with Florida Medicaid
• Taxonomy code for your services provided in accordance with your enrolled provider type and specialty
• Address with ZIP+4 code, as enrolled with Florida Medicaid

The new TML will be used to authenticate billed taxonomy codes on claims to valid provider/specialty type. The TML works with the existing NPI Master List to ensure valid provider type/specialty type combinations.

New York State:
The NYS DFS has released guidance regarding suspension of timely filing and utilization review timeframes due to the Change Healthcare breach in order to ensure that there are no delays in healthcare services provided to Medicaid, Medicaid managed care, Child Health Plus, the Essential Plan and managed long term care plan members.

• Suspension of Preauthorization Requirements: Issuers should suspend statutory and contractual preauthorization requirements for providers that use or rely on Change Healthcare for prior authorization upon receipt of a provider’s signed certification that such suspension is needed because the cyber incident had an adverse impact on the provider’s ability to submit prior authorization requests. Issuers should not penalize the provider for a failure to request preauthorization due to the cyber incident for dates of service on and after February 21, 2024.
• Timely Submission of Claims: Insurance Law §§ 3216(d)(1)(G), 3221(a)(9), 3224-a(g), 4305(m), and 4306(n) state that providers have 120 days to submit claims under a health insurance policy or contract. Issuers should toll the statutory and contractual timeframes for providers to submit claims upon receipt of a provider’s signed certification that such tolling is needed because the cyber incident had an adverse impact on the provider’s ability to comply with these timeframes.

To read the complete guidance, click here.

New Jersey:
For impacted providers who cannot submit claims electronically, the State of New Jersey would like to remind providers that after verifying member eligibility through the secure area of www.njmmis.com (eMEVS) or through the IVR line (REVS) 1-800-676-6562, they have the option to bill the claim later once the CHC network is restored.

As an alternate vendor, Relay Health is approved to process NJ Family Care claims.

Follow www.njmmis.com for additional updates and guidance.

North Carolina:

• Extension of Timely Filing Requirements: NC Tracks will waive timely files for all claims submitted on or after Feb. 21, 2024, for 60 calendar days. NC Medicaid will continue to monitor the evolving situation and will provide updated guidance if the timely filing waiver is extended further.
• Providers Needing Hardship Payments: If a provider is not able to successfully submit claims to NCTracks after attempting all the flexibilities above and is at risk of not meeting financial obligations, the provider may request a hardship advance to offset business cost due to unpaid claims due to the Change Healthcare disruption.

To read the entire release from NC Medicaid, click here.

In a report, the Office of the Inspector General found that Medicare providers who billed for advance care planning (ACP) services in an office setting did not always comply with federal requirements. Review yjr Advance Care Planning (PDF) fact sheet, and learn how to:

• Document discussions.
• Follow time-based coding requirements.

Advance Care Planning (ACP) is a voluntary, face-to-face discussion between a physician or other qualified health care professional (QHP) and your patient, their family member, caregiver, or surrogate (as appropriate) to discuss the patient’s health care wishes if they become unable to make their own medical decisions.

Documentation Requirements
You must document your ACP discussion with the patient and their family member, caregiver, or surrogate (as appropriate). In your documentation, include:

• The fact that the visit was voluntary
• An explanation of advance directives
• Who was present
• The time spent discussing ACP during the face-to-face encounter
• Any change in the patient’s health status
• The patient’s health care wishes if they become unable to make their own decisions

ACP Services are billed with CPT codes 99497 and/or 99498 and are time-based.

ACP Minutes	CPT Code and Units
15 or less	Don’t bill any ACP services
16-45	99497 (1 unit)
46-75	99497 (1 unit) AND 99498 (1 unit)
76-105	99497 (1 unit) AND 99498 (2 units)