We strive to make information readily available to your office. We understand that your office is affected by any changes to the contracts that you hold through Mercy Managed Care. In efforts to keep you updated, this section is designed to update you on contract information including: new contracts, contract terminations, rate updates, TPA changes, and miscellaneous other news.

Please be aware that not all rate changes or contract updates below will necessarily pertain to everyone. We are also not able to publish specific rate information online as that data is confidential. Please see the additional resources below that are available to you to confirm specific contract participation.

• Mercy Network LLC providers: If you are participating with Mercy via a contract with Mercy Network LLC (this would include providers in Southwest Missouri,  Northwest Arkansas, Oklahoma and select providers in St. Louis), please reference your online matrix for specific contract participation.
• Mercy PHO providers: If you are contracted with Mercy via the Mercy PHO (this would include the majority of providers in the St. Louis region), please reference your PHO contract and enrollment packet for a listing of the contracts you hold through Mercy.
• Mercy employed/integrated providers in the St. Louis region: Please continue to reference the Managed Care hub on Baggot Street, and the Sharepoint site as your reference for contract participation.
• All other Mercy employed/integrated providers: Please continue to use the Managed Care hub on Baggot Street as your reference for contract participation.

Provider Changes
As a contracted provider, it is important to notify us immediately of changes to your practice such as: a new provider joining the practice, changes in billing information, provider leaving the practice, or adding a new clinic location.  Notification may help avoid claim denials.  Please submit changes by fax 417-820-3821 or email. Please include a W-9 Form if the change involves a new billing address or tax identification number.

The full edition of the May Network News is available by following the link below

United Healthcare May Network News

The link below will allow you to access an overview of all policies updates, mandates, state-specific news, training and more Medicare Advantage, Medicaid and commercial plans.  You also have the option of accessing only Medical policy updates, Reimbursement policy updates, Specialty Medical Injectable Drug updates and Pharmacy and clinical update but following the links provided on the Network News.

May monthly overview | UHCprovider.com

There are also links provided for these items:

• A reminder regarding the UHC Provider Portal
• Review of Surest Medical injectable policy updates
• 2023 Quality Improvement survey results
• A link to medicaid.gov

The May edition of the Medica Connections is now available for review by following the link below.

May 2024 Medica Connections

*Reminder to verify the plan type and location listed

The following topics are covered in this edition.

General News

• Carelon updates:
  • A link to the Carelon provider portal is included
  • Prior auth list shows specific services, codes requiring submission of requests to Carelon.  A link to the full of services is provided
  • Correction and clarification of excluded services related to radiology and MSK.
    • Correction to information published last month:  Procedures performed in an inpatient setting (i.e., those services performed during an inpatient stay) or on an emergent basis (i.e., those services performed as part of being evaluated at the ER and prior to the patient’s discharge from the hospital) are not included in the Carelon cardiology and radiology programs.  Procedures performed on an emergent basis (as part of being evaluated at the ER an prior to the patient’s discharge from the hospital) are not included in the Carelon MSK program while certain non-emergent inpatient services are.

Pharmacy News

• Effective 07/01/2024 Medica will be making changes to their commercial drug formulary
• Effective 07/01/2024 Medica will update the step criteria for VEGH inhibitors to list bevacizumab as the preferred first-line treatment for AMD, DME and RVO indications.  More in-depth information and a link to their drug policy page can be found on the Newsletter.
• Effective 07/01/2024 new UM policies are available for Amtagvi, Lenmeldy and Tevimra

Network News

• Effective 07/01/2024 Medica will make quarterly updates to fee schedules

Administrative News

• A reminder that lab referrals need to be made to in-network providers
• A link to the Provider Manual and a reminder that updates may show up on this Newsletter prior to the changes being added to the Manual

Tips and Training

• Reminder that many answers to coding questions regarding a denied claim can be found in their reimbursement policies. A link is provided
• Training for May will be “Navigating Provider Resources” and will be held on May 9^th from Noon – 1pm CST. A link to the registration page is provided.

Summit Community Care Provider Newsletter – May 2024

Administrative

• Reminder: reimbursement for early elective deliveries
• Inaccurate laterality and diagnosis combination

Digital Solutions

• Ready, set, renew
• Coming soon — Submit behavioral health authorizations through the Authorization application on Availity
• Introducing new functionality for non-medical providers
• Roster automation update
• Digital Request for Additional Information is now available for all lines of business

Pharmacy

Notice of Material Amendment to Healthcare Contract

• Prior authorization updates for medications billed under the medical benefit

Quality Management

• Take action to improve adolescent immunizations rates

Anthem Provider Newsletter – Missouri May 2024

Featured Articles

• Digital Request for Additional Information is now available for all lines of business
• CarelonRx, Inc. Mail changed to CarelonRx Pharmacy on January 1, 2024

Administrative

• Carelon Post Acute Solutions, LLC will begin operating as Carelon Medical Benefits Management, Inc.
• CAA: Maintain your online provider directory information
• Inaccurate laterality and diagnosis combination
• Inaccurate laterality and diagnosis combination
• Coming soon — Submit behavioral health authorizations through the Authorization application on Availity
• Roster automation update
• Overview of the Preference Center on Availity Essentials
• Introducing new functionality for non-medical providers
• Personalized Match update

Education and Training

• Instructions for donor claim billing
• Rotary to ground educational message

Policy Updates

• Reimbursement policy update: Laboratory and Venipuncture Services — Professional and Facility

Products & Programs

Federal Employee Program (FEP)

• HEDIS tips: Adult Immunization Status (AIS-E)

Pharmacy

• Update on requirement to obtain certain specialty drugs from our contracted medical specialty pharmacy
• Specialty pharmacy updates — May 2024
• Pharmacy information available on our provider website
• Anthem expands specialty pharmacy precertification list
• Acquisition of Paragon Healthcare

Quality Management

• Take action to improve adolescent immunizations rates

You can follow this link to access the Q2 2024 Humana Physician News

Humana Q2 2024 Newsletter

Included is a brief rundown of what you will find in this edition.

A link to the new Preauthorization Lists (PAL) that will go into effect on 07/01/2024. This would apply to Medicare Advantage, Commercial and OK Medicaid.  This includes updates for both Medical and Medication.

A link is provider to access the current Medical an Pharmacy Coverage Policies.

A reminder that the new Provider Manuals that went into effect 03/15/2024 are available.

A link to the various educational webinars that Humana hosts monthly covering Quality and Stars-related topics.

Results of a study performed by the Humana Healthcare Research team related to increasing medication adherence in seniors.  The hope is that this information can used to encourage seniors to adhere to their medication schedule.

A review of the Peer to Peer process and it’s usage and application.  There also links provided to additional P2P documents.

Also included are links to various Provider Resources:  Information on Virtual Health classes for seniors, explanation of the Clinical Quality Validation (CQV) tool and it’s uses as well a link to guidelines related to reducing heart failure related hospitalizations with quadruple drug therapy.

Cigna Reimbursement Policy Update – E&M Codes Billed with ICD10 Clinical Modification Code 071424

As a result of a recent review, we will administratively deny the medical evaluation and management (E&M) code when billed with a preventive E&M code and only an International Classification of Diseases, 10th Revision, Clinical Modification Z diagnosis code on the claim. Denials will affect the claim line only and include administrative appeal rights.

We will update the Evaluation and Management (R30) reimbursement policy to reflect this change. This update is effective for dates of service on or after July 14, 2024.

Summit Community Care Provider Newsletter – 041524

Summit Community Care Provider Newsletter – April 2024

This month’s featured articles:

Education and Training 

• New digital learning platform for providers
• April is National Minority Health Month and Stress Awareness Month

Policy Updates

Notice of Material Amendment to Healthcare Contract

• Carelon Medical Benefits Management, Inc.updates

Medical Policy & Clinical Guidelines

Notice of Material Amendment to Healthcare Contract

• Clinical Criteriaupdates — December 2023

Quality Management 

• HEDIS^®2024 documentation for Colorectal Cancer Screening (COL-E)

Anthem Provider Newsletter – Missouri April 2024

This month’s featured articles:

Administrative

• Important reminder: The correct original claim number must be included if submitting a corrected claim
• Review your online provider directory information
• HCPCS to revenue code alignment for behavioral health
• Coming soon — digital-only authorization case status notifications
• Emergency department protocol for Special Investigation Unit review

Education and Training

• April is National Minority Health Month and Stress Awareness Month
• Blue High Performance Network
• Medical Policy & Clinical Guidelines
• Medical Policies and Clinical Utilization Management Guidelines update
• Medical Policies and Clinical Guidelines updates — April 2024

Prior Authorization- Medicare

• Prior authorization requirement changes effective July 1, 2024

Prior Authorization – Commercial

• Carelon Medical Benefits Management, Inc. genetic testing code updates
• Expansion of Carelon Medical Benefits Management, Inc. programs

Reimbursement Policies

• Reimbursement policy update: Virtual Visits — Professional and Facility

Pharmacy

• Expansion of specialty pharmacy precertification list

Quality Management

• HEDIS^®2024 documentation for Colorectal Cancer Screening (COL-E)

The April edition of the Medica Connections is now available for review by following the link below.

April 2024 Medica Connections

*Reminder to verify the plan type and location listed

The following topics are covered in this edition.

General News

• Eligibility, benefits functionality (270/271 transactions) now live on Availity Portal. If you are unfamiliar with Availity Medica provides a link to their microsite as well as live webinars once you are registered. Mercy would use Medica Individual and Family, Payer ID 124222
• Claim Status (HIPAA 276/277 transactions) will be the next to move to Availity
• Reminder that Beginning on or after May 2024 Medica will used Carelon to review prior authorization submissions for MSK, cardiology and radiology
• Medica is offering webinars for both radiology/cardiology and MSK through April.  Registration is required

Clinical News

• Effective May 20, 2024 Medica will update one or more UM policies, coverage policies and clinical guidelines. Specific details can be found by following the link in the notice.

Administrative News

• Effective on or after June 1, 2024 Medica will be implementing a new reimbursement policy related to Emergency Department Evaluation and Management Codes – Facility.
  • Medica will implement a new facility policy to provide reimbursement guidelines for the reporting of Emergency Department evaluation and management (E/M) codes. These codes are eligible for reimbursement when billed at the appropriate level. Medica follows interpretive guidelines sourced to Centers for Medicare and Medicaid Services (CMS) coding guidelines, American Medical Association (AMA) Current Procedural Terminology (CPT®) code descriptors, and specialty society guidelines for the reimbursement of Emergency Department E/M codes. This new policy will apply to outpatient facility claims reported on a UB-04 claim form or its electronic equivalent for all Medica members.
  • Medica will review level 4 and level 5 Emergency Department E/M codes using the Optum Emergency Department Claim (EDC) Analyzer tool. The Optum EDC AnalyzerTM tool determines E/M coding based on data received from the claim. The Optum EDC Analyzer will use the following claim data to recommend the appropriate level:
    • Patient’s presented health issues
    • Diagnostic services performed during the visit
    • Any complicating conditions the patient has
  • If the Optum EDC Analyzer tool determines a lower level of service should be submitted, Medica will deny the claim line, as the information submitted would not support the level of service. Facilities may submit an appeal for reconsideration of payment.
• Effective on or after June 01, 2024 Medica will update the reimbursement policy on Inpatient Hospital Readmissions.
  • This policy addresses the reimbursement of readmissions to the same hospital, billed on a UB-04 claim form or its electronic equivalent. Medica’s Inpatient Hospital Readmission reimbursement policy will be expanded to apply to readmissions to the same facility (i.e., same provider number) within 30 calendar days following discharge to include commercial and Individual and Family Business (IFB) plans in the following states: Iowa, Minnesota, North Dakota,South Dakota and Wisconsin.
  • Medica will not reimburse for more than one admission to the same hospital within 30 calendar days of discharge when the readmission is for the same, similar, or related condition and/or deemed a preventable readmission. The subsequent admissions will be denied and only the initial hospital stay will be reimbursed. This policy applies to all states and all of Medica’s products except Medicaid-only plans — Medica’s Minnesota Senior Care Plus (MSC+), Special Needs BasicCare (SNBC), Prepaid Medical Assistance Program (PMAP) and MinnesotaCare plans — which follow the Minnesota Department of Human Services (DHS) guideline of 15 calendar days.