2011 New England Insurance Company Updates

 CT – Community Health Network of Connecticut (CHNCT)

CHNCT has contracted with Care to Care (CtC) to manage outpatient advanced imaging services.  The program will include CT, MR, PET and nuclear cardiology studies and is available to CHNCT’s HUSKY A, HUSKY B and Charter Oak members.

Contracted providers should receive a CtC Provider Form that once completed will initiate a provider enrollment package.

 CT & RI -  AmeriChoice

Effective January 1, AmeriChoice® will be managed under United Healthcare’s brand name, UnitedHealthcare Community PlanTM. This new brand name will be used on their member ID cards, member and provider handbooks, clinical materials and any promotional or advertising materials.

MASS – MA Blue Shield

MABCBS made a number of changes to their Medicare Advantage products, Medicare HMO Blue and Medicare PPO Blue and Medicare Prescription Drug Plans (Blue Medicare Rx).  MABCBS communicated the changes to their members and in December, most Medicare Advantage members received their new ID cards which reflect updated office visit copayments.

MABCBS will also update their Medicare Advantage fee schedule according to the changes made by CMS for 2011.

You can find all of the Medicare Advantage changes on their website in the F.Y.I. newsletter dated December 1, 2010.  Their web address is www.bluecrossma.com.  You may need a password to view the newsletter.

Revised Radiology Privileging Requirements for Cardiac CT Studies (CTT)

Effective Date: April 1, 2011

Currently, MABCBS requires radiologists to perform at least 50 CTT studies per year to maintain CTT privileging status.  Effective April 1, 2011, MABCBS will change the requirement to

75 studies over 36 months to maintain privileging status.  This is in alignment with the American College of Radiology’s criteria.

MA – Fallon Health Care

Beginning January 1, 2011, any member who does not meet Fallon’s criteria for a home sleep study will be directed to their preferred network of free-standing sleep labs.  FCHP will use clinical and financial quality standards in addition to geographic access standards to support physicians in directing their members to appropriate facilities.

Gastroenterology Services

Fallon has updated their gastroenterology payment policy. A complete listing of covered and non-covered services as well as Information concerning prior authorization for procedures and use of anesthesia with upper and lower GI endoscopic may be viewed by clicking on the following Fallon policy.

Gastroenterology Services Payment

Prior Authorization

Effective Date:  January 1, 2011

The following codes will require Plan Authorization as of 1/1/2011.

58570 – Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less

58571 – Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) or ovary(s)

58572 – Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g

58570 – Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) or ovary(s)

2011 CPT & HCPCS codes

A listing of all new 2011 CPT and HCPCS codes and whether they are covered by Fallon Health Care are listed on their website by clicking below.

Fallon Jan 2011 Supplement

Deletion of Consultation Codes

Effective January 1, 2011, for providers who are contracted in accordance with the current Medicare Physician Fee Schedule, Fallon Community Health Plan will no longer reimburse consultation codes 99241-99245 and 99251-99255. Providers should bill with the corresponding

Evaluation and Management visit codes.

Senior Plan Changes

On October, 1, 2010, Fallon began to market their Senior Plan offerings for 2011 and patients had to make a change between November 15 and December 31, 2010.  Although CMS will not be increasing payments to Medicare Advantage plans in 2011 and plans to cut payments beyond 2011, Fallon states they are making a significant effort to keep costs down.  Depending on where patients live, premiums will either stay the same or will increase.  A complete listing of senior plan changes is listed in their November newsletter.  You may view this newsletter by clicking below.

Fallon November 2010 Newsletter

MASS – MA Medicaid

MA Medicaid has deleted consultation codes for services as of January 1, 2011.  As with Medicare last year,  E & M visit codes must be substituted for the consult codes.

MA, NH, RI - Harvard Pilgrim – HPHC

Reminder:  HPHC’s Medicare Supplement Plan will go into effect on January 1, 2011.  This plan replaces the First Seniority Freedom plan and is available to non-group Medicare beneficiaries.  ID cards will bear “Medicare Supplement” in the upper right corner and the member-number prefix will begin with HPK.

Members may see any Medicare participating providers in the USA without referrals or authorizations.  The plan covers many deductibles, coinsurance, and co-payments not paid by Original Medicare.  Part D drug coverage will be offered as an additional option through a partnership with HPHC and Coventry First Health.

Members in Massachusetts will be entitled to all state-mandated benefits.

Harvard Pilgrim HMO & PPP Tiered Network Products

Effective Date:  July 1, 2011

Effective July 1, 2011, HPHC will begin offering a tiered network version of its Best Buy HMO and PPO products to employer groups in Massachusetts and New Hampshire (pending regulatory approval in NH).  Under this plan, members will be responsible for cost sharing as determined by the provider’s tier assignment, when applicable.

Hospitals were tiered based on quality and cost performance.  All directly contracted physicians were assigned to a medium cost sharing level (Tier 2) due to a lack of sufficient data to evaluate quality and cost-efficiency performance.  Direct contracted, non-physician providers were not tiered.

A description of the Tiered Network products will be available on HPHC’s website once regulatory approval is received.  If a physician does not want to participate in the Harvard Pilgrim’s Tiered Network products (in MA), he/she must notify their Contract Manager in writing no later than January 20, 2011.

HPHC Care Network

Effective Date:  January 1, 2011

HPHC’s NetOption New Hampshire HMO will expand to include all of HPHC’s contracted providers.  The expanded network applies to the standard and Best Buy NetOption HMO plan designs.  Upon 2011 plan renewal, the tertiary deductible will apply to all tertiary hospitals and all services provided at them.  The current HPHC Provider Manual should contain all information on these plans.

HPHC November Newsletter

 Health New England

On December 1, 2010, HNE partnered with MedSolutions, Inc.(MSI) for radiology management.  MSI replaces their former management vendor, National Imaging Associates (NIA).  Services under management are CT, MR, PET and nuclear cardiology studies.

BMC HealthNet Plan

Effective Date: March 1, 2011

Effective March 1, 2011, BMC HealthNet Plan will require prior authorization for visits to certain Plan-contracted specialists unless the specialist and the member’s primary care provider (PCP) are affiliated with the same hospital, or if the member is going to Boston Medical Center for specialty care.

Specialty care, as listed in this Network Notification, refers to the following specific set of

Evaluation and Management (E&M) CPT codes and related HCPCS codes.

• 92002-92004: New Patient Ophthalmology Services*
• 92012-92014: Established Patient Ophthalmology Services*
• 99201-99205: New Patient Office or Other Outpatient Visit
• 99211-99215: Established Patient Office or Other Outpatient Visit
• 99241-99245: New or Established Patient Office or Other Outpatient Consultation
• G0245-G0246: Initial or Follow-up Physician Evaluation and Management of a Diabetic
• Patient with Diabetic Sensory Neuropathy Resulting in Loss of Protective Sensation
• G0247: Routine Foot Care by a Physician of a Diabetic Patient with Diabetic Sensory Neuropathy Resulting in Loss of Protective Sensation

Prior authorization from BMC HealthNet Plan is required when specialty care is administered by specialists affiliated with any of the following Plan-contracted hospitals unless the specialist and the member’s PCP are both affiliated with the same hospital.

• Beth Israel DeaconessMedicalCenter – all locations
• Carney Hospital
• Children’s Hospital – all locations
• Mount Auburn Hospital
• Saint Elizabeth’s MedicalCenter
• Tufts Medical Center
• Women and Infants Hospital of Rhode Island

Specialty care prior authorization will only be granted:

• When this care is not available from a specialist affiliated with BostonMedicalCenter or
• From a Plan-contracted specialist affiliated with the same hospital as the PCP.

Prior authorization is not required when:

• The service rendered is one of the first 12 outpatient visits to a Behavioral Health provider
• A member goes to any in-network obstetrician, gynecologist or certified nurse midwife for certain OB-GYN care.

MA – MVP HealthCare

Effective Date:  January 1, 2011

On January 1, 2011, USA Care is changing from a PFFS (Physician fee for service) to a PPO plan.

Many of the same benefits are included in the new plan:

• In and out of network benefits are identical
• The PPO plan reimburses Medicare providers at the Medicare limiting charge
• There is no contract required to see a USA Care member
• There are not referral/prior authorization requirements for medical services

Members will have a new ID card with a new claims address. Providers may only collect copayments or coinsurance amounts from Care USA members.  They may also collect payment from the members for non-covered services.

For more information, visit their website at:  www.mvphealthcare.con/usacare

Back To Top 

MA – Network Health

 

Network Health (NH) is implementing a new referral requirement for specialty services for members in the Cambridge Health Alliance (CHA) Accountable Care Organization beginning with service dates of January 17, 2011.

The Network Health member’s PCP must notify Network Health when specialty care is needed from a contracted specialist.  NH will then issue a referral number to the PCP.  Network Health will not pay for specialty services that do not have a PCP referral.  Members can not be billed for these services.

MA, NH, RI – Tufts Health Plan

Tufts will differ from CMS:

• by allocating a higher proportion of funds to Pathology codes and ER visits, with emphasis on the lower-level codes
• by continuing to reimburse consultation codes

Tufts will be revising some procedure codes which it considers non-reimbursable for physicians (NR list).  Some codes will be added and some taken away from the list.

Preventive Services for Tufts Medicare Preferred: Many preventive care services will be covered in full with no copayment.  Medicare guidelines will apply in most cases and an office visit copayment cannot be charged unless a non-preventive service is provided during the same visit as a Medicare-covered preventive service.

Some of the preventive services performed by our clients that are covered in full are:  bone mass measurement, cardiovascular screenings, colon cancer screening, diabetes screening, EKG screening, Flu vaccination, breast cancer screening, and pneumococcal vaccination.

Observation Services:  There is no member copayment for members seen in observation. (99218 – 99220).  Billing an office visit code in conjunction with an observation service is not appropriate.

Tufts – Commercial Plan Benefit Changes

New Prior Authorization Programs

Effective Date:  January 1, 2011

Tufts will require prior authorization for the following procedures:

Sinus Endoscopy:

• 31256 – Nasal/sinus endoscopy, surgical, with maxillary antrostomy
• 31267 – Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal from maxillary system
• 31276 – Nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal sinus

for Diagnosis

• 473.0 – Chronic sinusitis, maxillary
• 473.1 – Chronic sinusitis, frontal
• 473.8 – Other Chronic sinusitis (pansinusitis)
• 473.9 – Unspecified sinusitis (chronic)

Cholecystectomy Open and Laparoscopic

• 47600 – Cholecystectomy
• 47605 – Cholecystectomy with cholangiography
• 47562 – Laparoscopy, surgical; cholecystectomy
• 47563 – Laparoscopy, surgical; cholecystectomy with cholangiography

Procedures for the Treatment of Benign  Prostatic Hypertrophy

• 52450 – Transurethral incision of prostate
• 52601 – Transurethral electrosurgical resection of prostate
• 52630 – Transurethral resection
• 52648 – Laser vaporization of prostate

Changes to Existing Prior Authorization Programs

Arthroscopically Assisted Surgery:

The following services will be added to the current list of shoulder arthroscopy codes requiring prior authorization.

• 29825 – Arthroscopy, shoulder, surgical with lysis and resection of adhesions with or without manipulation.

Upper GI Endoscopy – Guidelines have been revised to include coverage criteria for members with increased risk factors for gastric cancer.

The following services are not covered by Tufts Health Plan as they are considered experimental/investigational.

• 95012 – Inhaled Nitric Oxide for Acute Respiratory Distress in Adults

Copayments for High-Tech Imaging Services

Effective:  January 1, 2011

Beginning January 1, 2011 and effective upon a member’s plan renewal, copayments for high-tech imaging services (MRI/MRA, CT/CTA, PET, and nuclear cardiology) will increase by $25 on the following plans:

HMO Premium               Select Network HMO plans                      HMO Choice Copay

HMO Value                    HMO Basic

PPO and POS products for small groups

This change applies to Massachusetts groups only.

Changes to Sleep Management Program

Effective Date:  January 1, 2011

Tufts has selected Sleep Management Solutions (SMS), in conjunction with CareCore National (CCN) to provide sleep diagnostic and therapy management services.    Effective January 1, 2011:

• Providers must request prior authorization for sleep studies and related PAP therapy through CCN rather than through Tufts Health Plan’s Precertification Department.
• Providers may no longer fax authorization requests for those services to Tufts after that date.

These changes apply to Massachusetts and Rhode Island commercial and Tufts Medicare Preferred HMO plans with the exception of Tufts Medicare Complement, Tufts Medicare Supplement Plan, commercial PPO plans with the PHCS network, and CareLink.

RI – Blue Shield of Rhode Island

Blue Cross & Blue Shield of Rhode Island (BCBSRI) revised their radiology management program to make certain their members receive only clinically appropriate testing. Effective January 1, 2011, the ordering provider is responsible for obtaining prior authorization for high-tech imaging studies for patients who are BCBSRI members. Radiology facilities may no longer obtain prior authorization for high-tech imaging studies on behalf of ordering providers.

MedSolutions administers BCBSRI’s radiology management program and will conduct on-line webinars in the coming weeks to help prepare for this change.  Click below for their training schedule:

MedSolutions Training

RI – Neighborhood Health Plan (NHP)

RI NHP published back in November that they would convert to their new HealthRules system by 12/6/2010.  This did not occur and the date has been pushed back to early 2011.  Providers and other partners will have at least 30 days notice prior to “Go Live.”

 United HealthCare

74176 – CT ABD & PELVIS W/O CONTRAST

74177 – CT ABD & PELVIS W/CONTRAST

74178 – CT ABD & PELVIS W/O CONTRST 1+ BODY

C8931 – MR ANGIOGRAPHY W/CONTRAST SPINAL CANAL CONTENTS

C8932 – MR ANGIOGRAPHY W/O CONTRST SPINAL CANAL CONTENTS

C8933 – MR ANGIO NO CONTRST FLW W/CONTRSTSP CANAL CNTN

C8934 – MR ANGIOGRAPHY WITH CONTRAST UPPER EXTREMITY CARDIOLOGY NOTIFICATION

C8935 – MR ANGIOGRAPHY WITHOUT CONTRAST UPPER EXTREMITY

C8936 - MR ANGIO W/O CONTRST FOLLOWED W/CONTRST UP EXT

Cardiology Notification Program – New codes added for 2011

Effective January 1, 2011, the following new codes were added to the notification and prior authorization list.

Diagnostic Catheterization

93452 – Diagnostic left heart catheterization (ventriculography only)

93453 – Combined right and left heart catheterization (ventriculography only)

93454, 93455 – Coronary Arteriogram (no ventriculography)

93456, 93457 – Coronary Arteriogram and right catheterization (no ventriculography)

93458, 93459 – Coronary Arteriogram (with ventriculography)

93460, 93461 – Coronary Arteriogram and right catheterization (with ventriculography)

Botox® for Chronic Migraine Headaches

Effective:  November 17, 2010

Recently, the U.S. Food and Drug Administration has expanded the labeled indications for Botox® (onabotulinumtoxinA) to include prophylaxis of adult patients (18 years or older) with chronic migraine headaches that occur 15 or more days per month and last four or more hours per day.

As a result of this change, the United Healthcare National Pharmacy & Therapeutics Committee has approved revisions to their botulinum toxin drug policy to include chronic migraine headache as a proven indication.

For additional information please refer to UnitedHealthcareOnline.com > Tools &

Resources > Policies and Protocols > Medical & Drug Policies and Coverage Determination Guidelines > Botulinum Toxins A and B.

The complete policy may be found by clicking below on UHC’s Network Bulletin – January 2011 Supplement – pages 13-15.

UHC Network Bulletin – Jan 2011 Supplement

 

United Healthcare & Medicaid Products

United Healthcare covers the Medicaid population through several products and this year UHC will continue to move all Medicaid products to a single brand.  They have begun the transition with Medicaid companies in several states.  In most states, the AmeriChoice brand will become United Healthcare Community Plan. This transition will occur over a 24 month period.

United Healthcare Fee Schedule Changes

United Healthcare will perform their annual fee schedule update when they receive CMS’ January 2011 Physician Fee Schedule file that contains the 2011 relative value units and conversion factor.  This fee update will comply with their contractual and regulatory requirements for in-network physicians, out-of-network physicians who render services to members of UHC, Secure Horizons, Evercare and United HC Community Plans.

Claims will be paid at the 2010 conversion factor until UHC loads their system with the

new 2011 fee schedule.  They will not hold claims until this is accomplished.  Providers who hold claims until the 2011 fee schedule is implemented will still need to abide by the filing limits.  Waivers will not be granted.

If physicians are not tied to Current Year or 2011 Medicare rates, their existing fees are not affected by the conversion factor change.

United Healthcare 2011 CPT Code Changes

United Healthcare has updated their system to accept all 2011 CPT, HCPCS and ICD-9-CM code edits and additions.  System updates have also occurred for their affiliates Oxford Health and United Healthcare of the RiverValley.

Other information that may be of interest to you is contained in the UHC Network Bulleting below:

Oxford Health

• Preventive Medicine & Screening Codes
• Credentialing Guidelines – Radiology Network
• Radiology Privileging List
• Varicose Vein Treatment
• Wireless Capsule Endoscopy for Commercial Plans

UHC Network Bulletin Jan 2011