Loading...Loading...In addition to the summary of monthly changes below, please also review our monthly Bulletin for recent and upcoming changes to our medical and reimbursement policies, Clinical Position Statements and associated changes to pre-authorization requirements. The Medical Policy Manual includes a list of recent updates and archived policies. Monthly change summaries are added to our website within 10 business days of our newsletter publication.
Review other monthly changes for 2022.
The following changes were made to our pre-authorization lists effective July 1, 2022:
Uniform Medical Plan
Vagus Nerve Stimulation (#SUR74)
- 0720T
Medicare Advantage
Genetic and Molecular Diagnostics—Next Generation Sequencing and Genetic Panel Testing (#M-DME64)
- 0323U, 0326U, 0327U, 0329U, 0330U, 0331U
Please review our pre-authorization lists for all updates and pre-authorize services accordingly. You can submit standard medical pre-authorizations through Availity Essentials. Learn more about electric authorizations.
We publish updates to medical and reimbursement policies in our monthly publication, The Bulletin. Subscribe to receive an email notification when issues are published.
Medical policy updates
We provided 90-day notice in the April 2022 issue of The Bulletin about the following medical policies, which are effective July 1, 2022:
- Eating Disorder Inpatient Treatment (#BH25)
- Eating Disorder Intensive Outpatient (#BH26)
- Eating Disorder Partial Hospitalization (#BH27)
- Eating Disorder Residential Treatment (#BH28)
- Investigational Gene Expression and Multianalyte Testing (#LAB77)
- Psychiatric Inpatient Hospitalization (#BH29)
- Psychiatric Intensive Outpatient (#BH30)
- Psychiatric Partial Hospitalization (#BH31)
Psychiatric Residential Treatment (#BH32)
Reimbursement policy updates
We provided 90-day notice in the April 2022 issue of The Bulletin about changes to the Modifier 53; Discontinued Procedure (Modifiers #102) reimbursement policy, which are effective July 1, 2022.
We publish updates to medical policies in our monthly publication, The Bulletin. Subscribe to receive an email notification when issues are published.
We provided 90 day notice in the April 2022 issue of The Bulletin about the following medical policies, which are effective July 1, 2022:
- Eating Disorder Inpatient Treatment (#BH25)
- Eating Disorder Intensive Outpatient (#BH26)
- Eating Disorder Partial Hospitalization (#BH27)
- Eating Disorder Residential Treatment (#BH28)
- Investigational Gene Expression and Multianalyte Testing (#LAB77)
- Psychiatric Inpatient Hospitalization (#BH29)
- Psychiatric Intensive Outpatient (#BH30)
- Psychiatric Partial Hospitalization (#BH31)
Psychiatric Residential Treatment (#BH32)
We publish updates to reimbursement policies in our monthly publication, The Bulletin. Subscribe to receive an email notification when issues are published.
We provided 90-day notice in the April 2022 issue of The Bulletin about changes to the Modifier 53; Discontinued Procedure (Modifiers #102) reimbursement policy, which are effective July 1, 2022.
Our behavioral health utilization management team will complete telephonic concurrent and discharge reviews for some services delivered on or after July 1, 2022.
We will require telephonic reviews for cases involving the following member and diagnostic groups:
- Child and adolescent—all levels of care and diagnoses
- Eating disorder—all levels of care
- Residential substance use disorder (SUD)
After a provider submits the inpatient form—required beginning May 1, 2022—our staff will contact the requestor to schedule a review.
Excluded services: Applied behavior analysis (ABA) and transcranial magnetic stimulation (TMS) services are excluded from the telephonic review requirement.
Effective for dates of service on and after July 1, 2022, we will implement Change Healthcare’s bundling edits for outpatient facilities n/a BSH: for all lines of business except Medicare Advantage. These outpatient code pairs will be used to supplement the CMS Outpatient Code Editor Correct Coding Initiative (OCE CCI) code pairs.
Read more about ClaimsXten sourced edits in our Coding Toolkit.
Listed below is a summary of medication policy additions and changes. Links to all medication policies, medication lists and pre-authorization information for our members, including real-time deletions from our pre-authorization lists, are available on our provider website.
Archived medication policy effective July 1, 2022
High Cost Epinephrine Autoinjectors, dru484
Revised medication policies effective July 15, 2022
- Enjaymo, sutimlimab, dru716
- Fyarro, nab-sirolimus, proteinbound sirolimus, dru700
- Kimmtrak, tebentafusp-tebn, dru701
Opdualag, nivolumab-relatlimab-rmbw, dru718
New medication policies effective July 15, 2022
- Chimeric Antigen Receptor (CAR) T-cell Therapies, dru523
- Enhertu, fam-trastuzumab deruxtecan, dru623
- Keytruda, pembrolizumab, dru367
- Medications for Sickle Cell Disease, dru628
- Monoclonal antibodies for asthma and other immune conditions, dru538
- Non-preferred pegfilgrastim products, dru563
- Products with Therapeutically Equivalent Biosimilars/Reference Products, dru620
Provider-administered drugs for chrinic inflammatory disease (for Uniform Medical Plan), dru900
Read the April, August and October 2022 issues of our newsletter for details.
To align with CMS guidance, we will begin denying Medicare Advantage ambulatory surgical center (ASC) claims submitted with modifier 50 effective for dates of service on or after July 1, 2022.
Bilateral procedures should be billed on two separate claim lines with one unit for each service.