Payor Issue Database

The Payor Issue Database contains a current list of payor and claim issues Kids Health First is tracking on behalf of the practices. The issues were identified by your KHF network peers and escalated to KHF for research. In the Payor Issue Database, you will find:

• Key dates (issue identified, most recent update, resolution date)
• Claim issue descriptions
• Current action
• Resolution (when received)
• Practices impacted

The Payor Issue Database is found in the Members section of the KHF Intranet under the Financial menu. If you need access to the KHF Intranet, please contact us via

e-mail. 

When you identify a claim issue during your explanation of benefits (EOB) review, check the Payor Issue Database for known issues and their status. This may decrease your research time and offer next steps. Please encourage all billing staff to reference this helpful resource.

If your issue is not found on the Payor Issue Database, you can add your practice to an existing issue or submit a new issue for research by contacting us via e-mail. 

Reminder

Please submit your PHI and claims examples securely. KHF can provide a secure email for you if needed.

Sanofi Influence Vaccine Portfolio

CPT’s 90662, 90673, 90656, 90657, 90658

Flu Season is right around the corner!  This year’s flu is a trivalent (vs. previous years quadrivalent) per the CDC and WHO guidelines. KHF staff is monitoring and checking with payers to make sure codes are updated. We will send out a more comprehensive grid once information is available.

Sanofi Flu Vaccine Portfolio

Webinar for Coding, Coverage, and Reimbursement for Beyfortus

Registration Details and Dates

Anthem

Incident To Services Update Effective October 1, 2024

Reimbursement policy update: Incident to Services — Professional - Provider News (anthem.com)

Frequency Editing Update Effective October 1, 2024

Reimbursement policy update: Frequency Editing — Professional - Provider News (anthem.com)

Adopting Digital ID Cards

Adopting digital member ID cards - Provider News (anthem.com)

Timely receipt of other carrier EOB or rejection helps avoid timely filing denials

Timely receipt of other carrier EOB or rejection helps avoid timely filing denials - Provider News (anthem.com)

Cigna

Claim Appeals Reminder

providernewsroom.com/cigna-healthcare/appeals-reminders/?brand=cigna-healthcare

E&M Recoding

Cigna recoded E&M codes briefly in March 2024. Claims adjusted with earlier dates of service were also recoded during the same period. The payments processed correctly at the rate of the original code, but on the recoded line.

Cigna confirmed on 7/11/2024 their claims system was corrected. All affected claims will be reprocessed, though there is no ETA at this time. No action is required by practices. 

Medicaid

Save the Date for Face-to-Face Medicaid Fair

Provider Messages (georgia.gov)

DCH and Gainwell Technologies encourage you to save the date for our Face-to-Face Medicaid Fair!

Atlanta Marriott Northwest at Galleria

Thursday, October 31, 2024

200 Interstate N Pkwy E SE, Atlanta, GA 30339

The Medicaid Fair will offer important updates on emergent issues by DCH leadership and several break-out sessions covering a variety of topics. Registration information will be posted soon.

PeachCare of Kids Copayments

Provider Messages (georgia.gov)

Collection of PeachCare for Kids® Co-Payments will resume on October 1, 2024, for all non co-pay exempt PCK enrollees. Premium Payment collection will resume on October 1, 2024, for new enrollees and for renewals completed on or after October 1, 2024.

Peach State Health Plans

Sports Physical and Well Visit

HA Modifier for Catch-Up Preventative Visits

The HA modifier is used to identify a catch-up preventative visit for children ages three (3) years and younger.

In the Georgia Medicaid EPSDT manual, linked below, Table B provides an explanation of when and how the HA modifier should be used. It also provides clear instructions on the use of the EP and 25 modifiers in conjunction with the HA modifier.

https://www.mmis.georgia.gov/portal/Portals/0/StaticContent/Public/ALL/HANDBOOKS/EPSDT%20Services%20Health%20Check%20Program%20Manual%20revised%2020240626133453.pdf

For practices that accept Medicaid, it is recommended for billers to know how to use the HA modifier.

Remember to check the KHF Intranet for fee schedules updated in 2024.

What is HEDIS? 

The Healthcare Effectiveness Data and Information Set (HEDIS) is a widely used set of performance measures in the managed care industry, developed and maintained by the National Committee for Quality Assurance (NCQA). HEDIS was designed to allow consumers to compare health plan performance to other plans and to national or regional benchmarks.

Billers and coders play a vital role in ensuring a practice meets their HEDIS quality measures. This newsletter section will offer billing insight into HEDIS guidelines. If you identify a code or process change that can improve your practice, please discuss them with your Practice Administrator and/or Quality Champion.

When a patient completes a service and a provider documents the visit, it is important that all associated CPT and diagnosis codes are billed on the claim. If codes are left off or not billed with the correct specificity, a patient may be identified as non-compliant for the care they received. 

Weight Assess and BMI Counsel – BMI – All Ages

This HEDIS measure looks at patients 3 to 17 year of ages who had one or more outpatient visits with their PCP or OB/GYN during the year and documented evidence of the following:

• Height, weight, and BMI percentile
• Z68.51 – Body Mass index (BMI) pediatric, less than 5^th percentile for age
• Z68.52 – Body Mass index (BMI) pediatric, 5^th percentile to less than 85^th percentile for age
• Z68.53 – Body Mass index (BMI) pediatric, 85^th percentile to less than 95^th percentile for age
• Z68.54 – Body Mass index (BMI) pediatric, greater than or equal 95^th percentile for age

How Billing Analysis May Improve HEDIS Compliance

If you see patients on your recall list that are non-compliant for Weight Assess and Counsel – BMI – All Ages and they had a date of service this year, the billed claim needs to be reviewed. 

Double check the appropriate BMI percentile diagnosis code was included on the claim submission. If the correct diagnosis was left off or incorrectly coded, a corrected claim should be submitted.

Q: What if the claim is past timely filing?

A: The payor will still pick up the diagnosis code and mark the patient as compliant even with a timely filing denial. 

If you identify the need for a process change or improvement, collaborate with your practices Quality Champion and/or Practice Administrator.

You can also utilize the TCCN Quality Team and/or your Provider Relations Representative if additional advice or resources are needed. We are here to help!

We Want To Hear From You!

Do you have billing topics, best practices, claim questions, or good news to share? Email KHF at PayorConcerns@khfirst.com.