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.

HealthChoice Network News December 2022

In this issue

• Certification penalties
• Claim denials for medical records
• Credit balance resolution
• Dental maximum benefit
• HealthChoice direct data entry of claims and requests for additional information
• Overpayment notification
• New HealthChoice ID card for medical, dental and pharmacy
• HealthChoice is partnering with CARE
• HealthChoice EDI payer IDs and new group numbers
• Department of Corrections billing update
• HealthChoice Electronic Funds Transfer
• HealthChoice claim remittance vendor change
• Secure messaging through provider portal
• Timely filing and appeal deadlines for medical and dental claims
• New HealthChoice P.O. box addresses
• Certification portal update
• Contact information

For all states, Aetna is temporarily applying the following changes, effective through January 31, 2023:

Skilled Nursing Facility admissions from Acute Hospitals
• Initial Precertification/Prior Authorization for admission from acute care hospitals to Skilled Nursing Facilities (SNF) are waived for all Commercial and Medicare Advantage (MA) Part C plans.
• The SNFs will be required to notify Aetna of admissions within 48 hours. Providers may submit their request electronically though our provider portal on Availity or their preferred EDI vendor using the existing Precertification Request transaction. Providers can also submit their request by calling Aetna directly (refer to the back of the member’s ID cards for the correct telephone number).
• The Post-Acute care facility would also be required to send medical records for concurrent review within three days of the initial admission. Medical records can be uploaded directly through Aetna’s provider portal on Availity or sent to Aetna by fax to 1-833-596-0339. Please include the patient’s name and Member ID# on the cover sheet.

• Aetna requires:
o Hospital history and last two to three days of progress notes.
o Any information that demonstrates a need for Post-Acute care.
o Anticipated Discharge Plan with estimated length of stay.

Please click on the following link for the full announcement.

Aetna SNF waiver

Home State Health Authorization Update – Hospital Observation Services.

This notice is to inform you of changes to Authorization requirements for Hospital Observation Services/Hour (G0378). Home State Health will no longer require prior authorization for participating hospital observation services < 24 hours, effective December 1, 2022.

Please note: If services that require prior authorization are being provided during the observation stay, authorization requirements would still apply. In an emergency, facilities have up to one business day to request authorization. Hospital Observation services (G0378) exceeding 24 hours require notification of Inpatient admission within one business day.

For complete information regarding this update, click on the link at the top of this article.

Cigna – code editing update eff 03.12.2023

As a result of a recent review, we will update our existing code editing
logic to use diagnosis pointers at the Current Procedural Terminology
(CPT®) code level on some claims.

Medical necessity appeal rights will be available. This update is effective for dates of service on or after March 12, 2023.

The complete announcement from Cigna can be viewed by clicking on the above link.

Cigna – reimbursement policy updates eff 03.12.2023

As a result of a recent review, we want to make you aware that we will
make the following updates effective for dates of service on or after March
12, 2023.

Anesthesia claims submitted without modifiers AA, AD, QK, QX, QY,
and QZ

We will implement a new reimbursement policy, Anesthesia Services
(R39), to administratively deny the claim line on claims submitted without
modifiers AA, AD, QK, QX, QY, and QZ appended to an anesthesia
Current Procedural Terminology (CPT®) code, Denials will include
administrative appeal rights.

Anesthesia claims submitted .with multiple CPT codes

Additionally, as part of the Anesthesia Services (R39} reimbursement
policy implementation, we will administratively deny the anesthesia CPT
codes with the lowest base unit on claims submitted with multiple codes,
and reimburse the code with the highest base unit We will reimburse the ·
first code submitted if the base units are equal. Denials will include
administrative appeal rights,

Modifier QZ reimbursement for certified registered nurse anesthetist services

We will reduce reimbursement for claims submitted with modifier QZ for services rendered by a certified registered nurse anesthetist (CRNA) by 15 percent. Denials will include administrative appeal rights.

The complete announcement from Cigna can be viewed by clicking on the above link.

Effective December 31, 2022, the direct agreement between Mercy and CB Management Company will terminate.

Providers will need to continue to submit claims incurred prior to 1/1/2023 to MedPay. Since the Plan is terminating there is a 90-day filing limit.  Med-Pay will be administering the processing of the run-out claims.  However, any claims received after 3/31/2023 will be ineligible.

Please make sure that you request to see new identification cards when employees of this group present for care.

As 2022 comes to a close, here are several reminders to help your office prepare for 2023:

• All members will receive new medical and pharmacy ID cards in the mail.
• Prescriptions for over-the-counter (OTC) medications for heartburn, stomach acid and allergies will not be covered. Ascension Rx is offering a discount on 90- day supplies of these medications. For additional details, members can call 833 Meds-ARx (633-7279)
• The SmartHealth Well-being program will not continue. Ascension offers several valuable resources to associatbes and their families:
  • Ascension myCare
  • Ascension Wysa
  • Well-being sessions
• Standard cost sharing will apply for COVID-19 inpatient treatment. Mandated coverage will continue until the public health emergency is lifted
• Retrospective authorizations will no longer be accepted. This means if a service was rendered that required prior authorization (PA), and PA was not requested and approved, the claim will be denied (unless under extenuating circumstances, noted in the plan document).
• Kroger pharmacies will no longer participate in our Cigna pharmacy network. However, there are many local Ascension Rx pharmacy locations, plus home delivery on specialty and maintenance medications. Members can find an in-network pharmacy by visiting ascensionrx.com or Cigna.com.

Other Updates include:

• 2023 Provider Manual
• Prior authorization update
• Pharmacy care management now available
• Terms, adds and changes

Ascension Smart Health – Provider Newsletter Dec. 2022

Arkansas BCBS – Providers News December 2022

Click on the above link to view the latest news from Arkansas BCBS.

Authorization waiver for facility-to-facility transfers:  Commercial and Medicare

Cigna remains committed to offering accommodations to providers in critical times of need. Accordingly, in response to the surge of COVID-19, influenza, and RSV hospitalizations across the country – and in an effort to ensure providers have necessary accommodations to continue to treat their patients in a timely way – Cigna commercial and Cigna Medicare Advantage will waive the authorization requirement for facility-to-facility transfers from December 12, 2022 through March 15, 2023.

Important notes

• Cigna will allow direct emergent or urgent transfers from an acute inpatient facility to a second acute inpatient facility, skilled nursing facility (SNF), acute rehabilitation facility (AR), or long-term acute care hospital (LTACH).
• This waiver applies to all patients with a Cigna commercial or Cigna Medicare Advantage benefit plan.
• Routine and non-emergent transfers to a secondary facility continue to require authorization.

What the accepting facility should know and do

• The facility that the patient is being transferred to (e.g., SNF, AR, or LTACH) is responsible for notifying Cigna of admissions the next business day.
• Coverage reviews for appropriate levels of care and medical necessity will still apply.
• Concurrent review will start the next business day with no retrospective denials.
• Per usual policy, Cigna does not require three days of inpatient care prior to transfer to a SNF.
• When a claim is submitted by the facility the patient was transferred to (e.g., SNF, AR, or LTACH), the facility should note that the patient was transferred to them without an authorization in an effort to quickly to free up bed space for the transferring facility.

You can find this information on our websites.

Commercial:  Cigna.com and CignaforHCP.com

Medicare:  Medicareproviders.Cigna.com

Healthy Blue has recently identified several invalid modifiers that are currently causing encounter rejections
with the state. As a result, effective immediately, Healthy Blue will be implementing front end edits that will
no longer allow us to accept the submission of those invalid modifiers for any claims January 1, 2021, and after. Click the link below for more details.

Healthy Blue- Invalid Modifier Notification eff 1-1-23