RCM eNews – September 2023

Effective Oct 1, 2023, CareFirst will only cover audio-only calls where mandated by law. Audio-only coverage will end for members in Virginia, while members in Maryland and DC will retain coverage.

Providers may choose to engage in electronic messaging to communicate with patients. Such messages are part of normal patient/physician interaction, and therefore part of services already payable under the terms of your contract. Claims for CPT codes 99421, 99422, and 99423 will be denied. Your contract does not allow direct billing of CareFirst members for these messages.

Coverage for audio-visual telemedicine visits remains unchanged. The expanded medical policy enacted during the public health emergency is still in place, allowing providers to deliver more services virtually now than before the COVID-19 pandemic.

Click here for further details.

Medicare Part B payment allowance limits for seasonal influenza vaccines (the vaccine product) are 95% of the Average Wholesale Price (AWP). In hospital outpatient departments, payment is based on reasonable cost.

Part B deductible and coinsurance amounts don’t apply for flu vaccine products or their administration. With respect to the vaccine product, all providers and suppliers must accept assignment on the claim.

To view the complete list of 2023-24 Flu Vaccine codes and payment allowances, click here.

CMS is working on the roll-out of PECOS 2.0, an upgraded enrollment and revalidation system, which will have these enhanced features:

• A single application for multiple enrollments.
• Data pre-population and an application that’s tailored to you.
• Enhanced capability to add or delete group members.
• Real-time processing checks and status updates.
• Revalidation reminders.

  For further details, click here. And to learn more about PECOS 2.0, watch this 2-minute video, or read these FAQs (PDF).

Medical records requests may be sent to your office from Ciox Health, LLC on behalf of Excellus Bluecross Blueshield. This will apply to Medicare Advantage members only as part of the annual CMS requirement. The records requests will apply to dates of service from Jan 1, 2022 through Dec 31, 2022.

Additionally, the Health and Human Services Risk Adjustment Data Validation (HHS-RADV) audit for the 2022 calendar year will launch in the next few weeks. This audit is required under the Affordable Care Act and will apply only to ACA Commercial lines of business. You may receive medical records requests from Health Data Vision, Inc (DBA “Reveleer”).

Click here for further details.

Certain edits are being implemented on/after 8/1/2023 to ensure you are billing your provider-based locations correctly. The edits are FISS reason codes 34977, 34978, 34984, 34985, 34986, 34987 apply to claims submitted by OPPS providers with multiple service locations and will be permanently activated to edit your claims on/after 8/1/2023 according to the following implementation schedule:

Date	Jurisdiction	Region
8/1/2023	J6	California and Wisconsin
8/1/2023	JK	Maine
8/15/2023	J6	Minnesota
8/15/2023	JK	Massachusetts
8/29/2023	J6	Illinois
8/29/2023	JK	New Hampshire and Vermont
9/12/2023	JK	New York, Connecticut and Rhode Island

Click here for further details.

Annual cultural competency training is a requirement for Medicaid providers in New York State. Fidelis Care NY and The United Healthcare Community Plan of New York have provided details on how to attest to its completion.

UHC Community Plan is requiring its Medicaid health care professionals to complete the Think Cultural Health training by Oct 1, 2023.

How to verify your training completion:

• Download the Roster, fill out the requested information, and then email it to UHC’s Cultural Competence team.
• Email your name, National Provider Identifier (NPI) number, address, and the date you completed the training to UHC’s Cultural Competence team with the subject line: Think Cultural Health training.

  You only need a single point of contact to verify that you, and other health care professionals at your practice, have completed the training.

Fidelis Care New York is requiring participating providers to complete the training by Dec 31, 2023. Once completed, providers need to verify completion of the program by emailing the Cultural Competency Attestation Form to:
CulturalCompetencyTrainingAttestation@fideliscare.org.

Beginning Nov 3, 2023, claim letters will no longer be mailed to healthcare professionals and facilities for UHC Community Plans (Medicaid) in Minnesota, New York, and North Carolina.

Do note that many documents have already gone digital, and these can be found in the Document Library in the UHC Provider Portal or an Application Programming Interface (API).

For further details, click here.

Starting Sept 1, 2023, UHC will begin a two-phased approach to eliminate the prior authorization requirement for many procedure codes. These code removals will account for nearly 20% of United Healthcare’s overall prior authorization volume. Authorization requirements will be eliminated as follows: Sept 1 and Nov 1: UHC Medicare Advantage, UHC Commercial, UHC Oxford, and UHC Individual Exchange plans. Nov 1 only: UHC Community Plan. To view the list of codes being eliminated from prior authorization, click the applicable link for the specific plan:

• for Commercial Plans
• for Oxford Plans
• for Individual Exchange Plans
• for Medicare Advantage Plans
• for Community Plans

  In 2024, United Healthcare will implement a national Gold Card program for provider groups that meet eligibility requirements. Qualifying provider groups will follow a simple administrative notification process for most procedure codes, rather than the prior authorization process. More information will be provided about the Gold Card program later this year.

In the performance of some of the services provided by STI RCM, we may at times contract with U.S. based third party companies, some of whom utilize overseas resources, typically to assist STI RCM’s staff with time-consuming functions. These companies are thoroughly vetted and sign a BAA with STI RCM and/or the U.S. based third party company. All communications with Provider and Provider’s patients are conducted by STI RCM employees who are US citizens and located within the United States.