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 2023.
Effective March 1, 2023, we will require all post-service provider appeals to be submitted using
the Appeals application on Availity Essentials.
The only disputes and appeals that should not be submitted via Availity Essentials are:
- Pricing disputes, which are not appeals and are subject to a separate pricing dispute process
- Disputes that meet our Extenuating Circumstances criteria, which must be submitted via fax
Appeals that Availity cannot process because of file size limits, which may be submitted via our secure file transfer protocol
Providers must submit all other provider appeals via the Availity Essentials Appeals application. Provider appeals sent via an improper method will be returned to the provider with directions to submit using the Appeals application on Availity Essentials.
The Appeals application is a more efficient way of receiving appeals and communicating determinations to providers. The application:
- Streamlines the appeals process by making it easy to submit appeals directly from the Claim Status screen
- Gathers all required information about the claim being disputed
Prevents duplicate appeals submission
The Appeals dashboard shows the status and history of submitted appeals, eliminating the need for providers to contact us for status information.
Appeals application and exception criteria
Learn more about the Appeals application and view our exception criteria.
Accessing the Appeals application
The Appeals application is available on Availity Essentials: Claims & Payments>Appeals. If you do not have access to the Appeals application, please contact your Availity Essentials administrator and request the Claim Status role.
Training resources
View guides on Availity Essentials: Help & Training>Find Help>Appeals. A recorded training demonstration is also available by searching for Appeals: Help & Training>Get Trained.
Listed below is a summary of medication policy additions and changes.
Revised medication policies effective March 1, 2023
- Medications for Hereditary Angioedema (HAE), dru535
CDK 4/6 Inhibitors for Breast Cancer, dru611
Read the December 2022 issue of our newsletter for details.
Effective March 1, 2023, we will add HCPCS A4611 to our non-reimbursable services (NRS) list for commercial, Medicare Advantage and UMP claims. This durable medical equipment (DME) code will be added to the Clinical Edits by Code List.
This change is supported by our Non-Reimbursable Services (Administrative #107) reimbursement policy.
Effective March 1, 2023, we will make the following reimbursement changes to durable medical
equipment (DME):
- HCPCS E0118 (crutch substitute) and K0891 (pediatric power wheelchair) rental reimbursement rates will be reduced.
The following HCPCS codes will no longer be reimbursable when billed with rental modifier RR: A4206-A4209, A4211, A4213, A4215, A4218, A4281-A4286, A4600, A4606, A4627, A4660, A4663, A4670, A6198, A6206, A6208, A6213, A6215, A6250, A6261, A6530, A6533-A6541, A6545, A9274, A9276-A9278, A9282, A9283, E0240, E0241, E0243-E0245, E0247, E0248, E0445, E0486, E0603, E2291-E2294, E2331, L3202, L3203, L3206, L3208, L3209, L3211, L3215, L3216, L3219, L3221, 3222, L3260, L3265, L8010, L8692, S1040, S8265, S8420-S8428, V5011, V5014, V5030, V5040, V5050, V5060, V5070, V5080, V5090, V5100, V5110, V5120, V5130, V5140, V5150, V5160, V5171, V5172, V5181, V5190, V5200, V5211-V5215, V5221, V5230, V5240-V5261, V5264, V5266, V5268-V5273, V5275, V5281-V5290 and V5336
Reimbursable ambulance services provided on or after March 1, 2023, will be limited to the base fee for transportation and mileage. Services including—but not limited to—oxygen, medications, additional attendants, supplies, electrocardiograms (EKGs) and night differentials will be denied when billed as part of an ambulance transportation service.
This change applies to claims for members with our commercial, Medicare Advantage and UMP plans.
More information
- Chapter 15 of CMS’ Medicare Claims Processing Manual
Our Ambulance Guidelines (Administrative #121) reimbursement policy.
For services delivered on or after March 1, 2023, we will conduct post-payment review of implanted devices, emergency department evaluation and management (ED E&M) and diagnosis-related group (DRG) claims for pricing and payment accuracy.
Our vendor, Performant, will contact your office if your claim is selected for this review:
- To validate the services billed on the claim
- To verify the pricing method applied is correct
To verify the payment rendered is appropriate to the member’s benefits
If you disagree with Performant’s findings, you can appeal to Performant. Their contact information is provided on the determination letter. We will request recoupment via adjustment of a future claim payment.
These reviews will be conducted for our commercial, Medicare Advantage and Uniform Medical Plan (UMP) plans.
Beginning March 1, 2023, Carelon Medical Benefits Management (Carelon) may request additional clinical information for radiology pre-authorization requests for commercial members. If requested, providers will need to submit documentation from the patient’s medical record to ensure services are clinically appropriate. Carelon will request this documentation only for select procedures when certain clinical indications are present.
Effective March 1, 2023, HCPCS J0219 and J9144 will be added to the pre-authorization lists for CHG Healthcare Services (group #70000004) and Alsco Inc. (group #70000002) members.