RCM eNews – June 2023

Are you using all the appropriate anatomical modifiers to get your claims paid? Your insurance company may be looking for more than a RT/LT modifier, here is the complete list of anatomical modifiers:

Effective July 1, 2023, Allegany County members with prefix AGU will be covered under the BlueChoice Advantage plan with a Preferred Provider Network (PPO) overlay.

What does this mean?

All Commissioners of Allegany County members with prefix AGU can go to a PPO provider and receive in-network benefits within the CareFirst service area. This also means that these members with prefix AGU have the flexibility to use a PPO lab and radiology providers without restrictions of the BlueChoice product.

Cigna Healthcare announced that it is delaying the implementation of the policy requirement that would require medical documentation be submitted with E&M CPT codes 99212, 99213, 99214, and 99215 and modifier 25 when a minor surgical procedure is billed for dates of service on or after May 25, 2023. Cigna will provide additional details and a new implementation date at a later time. Click here to read the letter regarding the delay of this implementation.

If you are having E&M claims down coded when processed by insurance companies and would like an analysis of your coding, contact your ASM for a free Bell curve analysis.

Per the AMA, “An increasing number of payers are down coding claims automatically using software algorithms, without first requesting and reviewing clinical records. Inappropriate down coding by payers can significantly reduce revenue for physician practices, especially when it becomes routine or when a physician becomes subject to global prepayment review.”

With proper documentation and claim appeals, down coded claims can be corrected and paid at the correct rate.

The AMA has provided a resource with tools and tips to recognize down coding and to take action: https://www.ama-assn.org/system/files/payer-em-downcoding-resource.pdf.

Novitas Solutions previously announced the introduction of Smart Edits to our electronic billing systems. This enhancement will alert providers of any claims that can be repaired prior to a denial. The messages will display on the 277CA electronic claims acknowledgement response report and may require the claim to be resubmitted. Smart Edits is being introduced in two phases:

See how much time these Smart Edits will save with a comparison example of the electronic claim flow (JH) (JL) with and without Smart Edits.

Do you receive the 277CA report after submitting your electronic files? If not, you will need to start retrieving them or find out who in your office is retrieving them for you now. This report information is essential to understanding and tracking the electronic claim billing process. A training module is available on their website: Understanding the 277CA Claims Acknowledgement.

Continue to monitor your email and the Smart Edits (JH) (JL) web page for more information on Phase 2 Implementation.

Effective Aug. 1, 2023, Optum®, an affiliate of UnitedHealthcare, will manage prior authorization requests for non-oncology injectable medications that are covered on the medical benefit for UnitedHealthcare Community Plan New York.

The prior authorization request process for oncology-related medications will remain unchanged.

You’ll continue to submit your requests for injectable medications online. To support their review, clinical requirements will be documented within the request submission. You can also attach medical records, if requested.
To submit your requests:

Authorizations active before Aug. 1, 2023, will remain in effect. You’ll see the new process when you request a prior authorization starting Aug.1, 2023.

You won’t need to submit a new request until the existing authorization expires or you change the therapy.

Changes in therapy include:

• Dose
• Frequency of administration
• Place of therapy

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UHC Digital Claim Letters

• Document Library in the UnitedHealthcare Provider Portal:
• From any page on UHCprovider.com > Sign In
• Sign in to the portal with your One Healthcare ID and password
  • If you don’t have a One Healthcare ID, visit UHCprovider.com/access to get started
• In the menu, select Documents & Reporting > Document Library. Then, select the Claim Letters folder.
  • In preparation, please familiarize yourself with the Claim Letters folder, which contains many document types, including claim responses and requests for additional information. Note: Provider remittance details can be found in the Payment Documents folder.
• Notifications: When new letters are available in Document Library, an email notification will be sent to the address on file, which is typically the Primary Access Administrator. Only the Primary Access Administrator can change who receives these notifications.
• Need to notify multiple staff members? Document Library notifications are limited to 1 email address per letter type. If multiple staff members require notification, the Primary Access Administrator can consider using a group email address.
• There’s no need to wait for a notification. Although UHC will let you know when a new letter is available, make it a part of your regular process to check Document Library for new letters and actions needed.