September 2024

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The Payor Issue Database is found in the Members section of the Kids Health First (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.

CURRENT TRENDS

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

PAYOR UPDATES

Anthem


Advancing digital efficiency by discontinuing paper remittances

Advancing digital efficiency by discontinuing paper remittances - Provider News (anthem.com)


Incident To Services Update Effective October 1, 2024

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

CareSource


Quality Enhancer (QE) Recoupments

CareSource (TCCN contract), sent recoupment letters to a subset of TCCN practices. The recoupment letters are for the Quality Enhancer (QE) Program. CareSource changed the QE codes and modifiers in 2023 from what they were in 2022. Practices who billed 2022 QE codes and modifiers on 2023 claims are subject to the recoupment of the QE incentives for the incorrectly billed codes. Not all TCCN practices are impacted. 


PeachCare for Kids – Copay Reinstatement

ga-med-p-3106946-peachcare-for-kids-copayment-network-notification.pdf (caresource.com)

Cigna


Cigna to Decommission OHP

providernewsroom.com/cigna-healthcare/cigna-healthcare-ohp-decommission-brandcigna-healthcare/

Humana


Humana is exiting the commercial market on 12/31/2024. Kids Health First is creating an FAQ/Checklist to assist practices with this transition. If you have specific questions about Humana exiting commercial insurance, please email payorconcerns@khfirst.com.

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


KHF is monitoring an ongoing issue with Peach State. On 2/21/2024, DCH released a message on GAMMIS on health Check reimbursement for E&M Codes and Preventative Visits (Provider Messages (georgia.gov). The Peach State rep for KHF confirmed on 8/6/2024 that Peach State had not removed the claim editing in their processing system. Claim examples were submitted to Peach State with an inquiry asking when Peach State will remove their claims edit. KHF is pending a response from Peach State. Status updates will be posted to the KHF Payor Issue Database once received

BEST PRACTICES & QUICK TIPS

Tips for escalating an Anthem claim to TCCN:​

TCCN can escalate Anthem claims practices feel were denied or underpaid in error. 

 

All claims must be disputed/appealed and a reference number obtained before escalating to TCCN.

  • Obtain reference number for all claims ​from Availity or by calling Customer/Provider Services.
  • Anthem will not accept an escalation from TCCN without a reference number​.

 TCCN can submit claim processing errors related to provider issues only. 

  • Examples include out of network claims, denials for incorrect addresses/data, and fee schedules inconsistencies.

For out of network denials, confirm the front office staff is verifying the PCP on the date of service. If a member sees a provider within the same practice (same Tax ID), but different than their listed PCP, Anthem should cover the claim because they are under the same practice (Tax ID).

  • Confirm the patient’s PCP is documented as a provider in your practice on the date of service. You may be asked to provide proof.
  • If the patient’s listed PCP is not in the practice, the member should call Customer Service, change their PCP, and initiate the claim to be reviewed. The member has 90 days to initiate the correction.
  • TCCN cannot have the PCP updated for a claim already processed. This must be completed by contacting Customer Service.
  • The practice can also appeal by providing the reference number or proof of provider portal documentation showing the PCP was correct on the date of service.
  • Anthem will not reprocess claims with a PCP outside of your practice when asked by TCCN. 

 Member benefit disputes cannot be resolved through TCCN. 

  • Practices must resolve benefit issues with the members benefit plan or the patient’s employer group, if needed.

Use the enclosed claim template when submitting an escalated claim to your TCCN Rep. The following information is required: ​

  • rendering provider and service location
  • member information, including practice's patient account number​
  • reference number​, detailed summary of concern

Anthem Practice Claims Template


If a refund is required, a refund notification is sent to the provider on their Remittance Advice.  

  • Out of state plans require a full refund of the initial claim payment to make claim adjustments and pay corrected rates. This can take up to 90 days. 
  • For Georgia plans, Anthem send an “add pay” for any additional payment and does not require full refund. This can take 7-10 business days. 

For additional resources, please review the Anthem Georgia Facility and Professional Provider Manual, page 54-57 PM_GA_0124.pdf (anthem.com).

 

There are several options to file a Claim Payment Dispute:

  • Online through Availity
  • Call the number on the back of the Member ID Card
  • Mail all required documentation to:

Anthem Claim Payment Dispute

P.O. Box 105449

Atlanta, GA 30328-5449

 

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


BILLING FOR HEDIS COMPLIANCE

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. 

TCCN Quality Performance Measure Definitions


TCCN publishes educational coding documents for contracted HEDIS measures. The Quality Performance Measure Definitions document is important to billers to ensure all applicable services and codes are billed. 


TCCN Quality Performance Measure Definitions

 

Measures included in the document:

  • Adolescent Immunizations: Combo 2
  • Asthma Medication Ratio
  • Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis
  • Childhood Immunization Status: MMR
  • Childhood Immunization Status: Combo 7
  • Childhood Immunization Status: Combo 10
  • Chlamydia Screening
  • Follow-Up Care for Children Prescribed ADHD Medication (ADD) – Continuation & Maintenance
  • Lead Screening in Children
  • Well Child Visits in the First 30 Months of Life
  • Well Child Visits Ages 15-30 Months
  • Child & Adolescent Well Care Visits – 1 or More Visits 3-21 Years
  • Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents

If you identify the need for a process change or improvement, collaborate with your practice's 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.

RESOURCES

Kids Health First Intranet Page