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 email PayorConcerns@khfirst.com.

The Payor Issue Database contains a current list of payor and claim issues KHF 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

When you identify a claim issue during your 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!

Is your issue not found on the Payor Issue Database? Let us know! You can add your practice to an existing issue or submit a new issue for research by emailing PayorConcerns@khfirst.com. 

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

CareSource Recoupments

CareSource, contracted through TCCN, completed a recoupment project in March/April 2024 resulting in recoupment letters sent to practices. The recoupments impacted 2023 claims recouping approximately 2% on payments. CareSource confirmed recoupments were processed in error.

• Practices can disregard recoupment letters​.
• CareSource will not recoup money from future payments. ​
• Practices do not need to send in recoupment checks. ​
• A retraction letter is being drafted by CareSource for distribution to practices. 
• If your practice sent a recoupment check to CareSource, please notify your PR rep.

Anthem – Wellstar Health Plan’s Employee Plan

Preventative Care Processed to Deductible in Error

Wellstar Health Plan’s three employee plans were processing preventative care to the deductible in error. Anthem updated the plan benefits on 4/12/2024 to pay at 100%.



• Claims processed before 4/12/2024 are being adjusted during May 2024 to pay preventative care at 100%.
• Claims processed after 4/12/2024 should pay correctly.

If your practice still has claims processing in error, please contact your PR rep.

Anthem – Wellstar Health Plan’s Employee Plan

EPO Benefit Plan

If a provider needs to verify which Tier they will fall into for Wellstar benefits, the TPA (Luminare) can confirm this for them if the provider calls the WHP Provider Concierge Line at 1-833-932-3912.

Group # L08317

• If you are a WellStar provider, Tier 1 benefits will be applied.
• If you are not a WellStar provider, but you are an Anthem/BlueCard PPO DME, Independent Lab, Behavioral Health & Substance Abuse, or Pediatric Specialist provider, Tier 1 benefits will be applied.
• If you are a not a WellStar provider, but you are an Anthem/BlueCard PPO provider, Tier 2 benefits will be applied. 
• Member level exceptions may be applied which can result in Tier 1 benefits being applied. (Contact 1-833-932-3912 for the exception review)
• If you need to confirm a provider’s network status, please contact 1-833-932-3912.

Anthem

Anthem – Wellstar Health Plans Employee Sample ID Cards

Cigna

Cigna + Oscar exiting market effective 1/1/2025

Coming Q2: New digital correspondence on the Cigna for Health Care Professionals Website

CareSource

Well Visit Provider Education Flier – Completing a Well Visit During a Sick Visit

Humana

Q2 2024 Provider Newsletter

Resource Sheet for Providers (Quick Guide)

Claim Payment Inquiry Resolution Guide

Medicaid

Provider Messages 4/26/2024: Eliminate Attestation and Reimbursement All Eligible Providers at Enhanced Rates

Provider Messages (georgia.gov)

Provider Messages 4/19/2024: Secondary Claims Submission Workshops held in May 2024. Register to participate.

Provider Messages (georgia.gov)

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

Recent Updates to Medicaid E&M Visit Reporting:

• EPSDT reporting of sick and well visits. 

The Georgia Chapter of the AAP published a notice about the Georgia Medicaid updates to EPSDT reporting of sick and well visits. 

https://www.gaaap.org/advocacy-win-for-peds-ga-mcd-updates-epsdt-reporting-sick-well-visits/

• GAMMIS Provider Messages 2/21/2024: Health Check Reimbursement for E&M Codes and Preventative Visits

Provider Messages (georgia.gov)

30 Month Well Check

Don’t forget to complete the 30 Month Well Check with your patients. This well check is part of the Bright Futures periodicity schedule and will ensure your patient is compliant with their preventative care.

• Bright Futures Periodicity Schedule

• Coding for Pediatric Preventative Care – Bright Futures (AAP)

G2211 – Letter from the AAP

Click here to view

Definition: Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient's single, serious condition or a complex condition. (add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established).

From AAP:

• G2211 is an add-on code to Office and other outpatient services, 99202-99215.
• Used by primary care and other specialties who treat a single, serious condition or a complex condition with a consistency and continuity over a long period of time.
• CMS is emphasizing the longitudinal relationship between the practitioner and the patient.
• CMS will not allow G2211 to be used with an E/M service if modifier 25 is appended.

Tips:

• Be sure to document the medical record to support usage of G2211.
• Evaluate usage of G2211 to ensure utilization is accurate.
• Concerns on tendency to overuse the code.

Fee Schedules:

• Payors that currently have G2211 on their fee schedule: Anthem, Humana, United Healthcare.

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.