July 29, 2022  

Note: New Content Noted with Asterisks** and Highlighted

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Clinical Considerations for Monkeypox in Children and Adolescents**

The Centers for Disease Control and Prevention (CDC) has released considerations for the clinical management of monkeypox in children and adolescents younger than 18 years old. These considerations are intended to help U.S. clinicians and health systems develop a plan for managing children and adolescents with exposure to monkeypox, suspected monkeypox, or confirmed monkeypox.

Please note that most people, including children, infected with monkeypox virus have a mild, self-limiting disease course in the absence of specific therapy. If you want to discuss a situation or concern with a member of the Children's Pediatric Infectious Disease service, please reach out through Doc on Call or call 404-785-7778.

Key Points:

• Monkeypox should be considered when children or adolescents present with a rash that could be consistent with the disease, especially if epidemiologic criteria are present.
• Young children, children with eczema and other skin conditions, and children with immunocompromising conditions may be at increased risk of severe disease when they contract monkeypox.
• Treatment should be considered on a case-by-case basis for children and adolescents with suspected or confirmed monkeypox who are at risk of severe disease or who develop complications of monkeypox. Tecovirimat is the first-line medication to treat monkeypox, including in children and adolescents.
• Children and adolescents with exposure to people with suspected or confirmed monkeypox may be eligible for post-exposure prophylaxis (PEP) with vaccination, immune globulin, or antiviral medication.

In addition, Children's has developed a tip sheet for community practices with guidance on identifying the symptoms of monkeypox, how to protect healthcare workers, and who to inform should a patient be identified with suspected monkeypox.

DCH has also released a letter to all Georgia healthcare providers with guidance on standard infection prevention and testing availability.

Please continue to monitor the CDC page on monkeypox for healthcare workers as well for updated information.

Bilirubin Level Testing and Phototherapy Vendors**

We are aware of recent challenges with procuring phototherapy for patients with high bilirubin levels due to lack of supply and/or access. We have compiled some instructions and resources to help you guide your patients to the care they need.

Bilirubin Level Testing

Children’s provides STAT bilirubin level testing 7 days a week. The requisition must be submitted either through accessCHOA or on a Children’s lab requisition form.

The main registration staff will alert the lab regarding the bilirubin patient so that a phlebotomist can walk in the patient. There is a lab manager on call that can be contacted to assist. Staffing challenges may result in some delays.

Local Phototherapy Vendors

We have identified four local vendors who are currently providing phototherapy services. We encourage you to please contact each vendor first to verify pricing and insurances accepted.

• Contact Medical (770-807-8910): Phototherapy Available. Limited supply of Bili Blankets. Family must pick-up from Lawrenceville, GA location. No bedside delivery offered. Out-of-pocket expenses required. Medicaid & CMOs and most major insurances accepted. Kaiser not accepted. Breast pumps available for purchase only.
• Neb Doctors / Pumps for Mom (770-394-5330): Phototherapy available but as a closet DME Vendor. Medicaid & CMOs and major insurances accepted. Breast pumps available for purchase only.
• Apria Healthcare (888-492-7742): Phototherapy can only be provided for Kaiser patients. Limited stock of Bili Blankets. Breast pumps available for Kaiser patients only. Breast pumps will have to be ordered.
• Analia Homecare HM (678-695-7896): Phototherapy available. Limited supply of Bili blankets. Initially accepting only straight Medicaid as they are currently working on acquiring contracts with CMOs and major insurances. Bedside and home delivery offered. Also, will require a PCP or provider to follow lab work. Breast pumps not currently available.

Direct Admission

If you have a bilirubin patient needing a higher level of care, please admit them directly rather than sending them to the ED. Please contact the Children’s Transfer Center at 888-785-7778 for assistance with admitting the patient.

At the July 13th Professional Staff Town Hall, an update was shared regarding the Children's Urgent Care locations, hours of operations, and scope of services which are summarized below:

Urgent Care Locations:

• 8 locations in the Atlanta MSA
• ~190,000 patients/year
• Open 365 days/year
• Monday through Friday: 11am to 9pm
• Saturday and Sunday: 9am to 9pm
• Holidays: 9am to 7pm
• Hamilton Creek Urgent Care opens on July 26, 2022
• Cherokee Urgent Care opens on September 7, 2022

Hours of Operation Change:

So that we may provide the best care for our patients, Children’s will adjust weekend hours at all Urgent Care locations and holiday hours at some locations

• Hamilton Creek will open on July 26th, with new weekend hours of 9 a.m. to 7 p.m.

As of September 1

• All Urgent Care locations will adjust weekend hours on Saturday and Sunday from 9 a.m. to 9 p.m. to our new hours of 9 a.m. to 7 p.m.
• We are altering the number of open Urgent Care locations on the holidays (New Year’s Day, Martin Luther King Day (MLK), Memorial Day, 4th of July, Labor Day, Thanksgiving and Christmas)
• Children’s at Chamblee-Brookhaven, Hudson Bridge, Forsyth, Town Center and Satellite Boulevard Urgent Care locations will be open on holidays.
• Children’s at Cherokee, Hamilton Creek, and North Point Urgent Care locations will be closed on holidays.

Urgent Care Scope:

• All patients until 21 years of age
• Patients over 18 years of age requiring a higher level of care (ED, hospitalization) are directed to adult hospital of choice
• Standardized scope of care at all locations
• Laboratory: In-UC, Moderate complex lab
• Radiology: Supervision by Radiology at CHOA 
• Fracture Care:
• Splinting
• Simple reductions
• Urgent management of open fractures
• Lacerations
• Single layer, Double layer, Anxiolysis
• Other procedures: (not comprehensive)
• Foreign Body Removals
• Simple dental trauma
• Burn Care

Outside of Scope: 

• Prolonged observations
• Behavioral and mental health crisis
• Routine IVF
• Complex fractures
• Possible ingestions
• Acute sexual abuse
• Procedures requiring sedation
• Advanced imaging (CT, Ultrasound, MRI)

2-Week Data Submission Requirement

Dear TCCN Members,

As participants in the TCCN network, we recognize the benefits of active and effective use of information technology by each of you in operational and performance measures. Since 2018, we have successfully collected claims data for all patients and providers through a defined process. In doing so, we have met the requirements of a clinically integrated network while improving accuracy of scorecards and recall lists, thus improving overall care to our patients. In addition, our actions support contract management, which is key to our financial success, as well as to maintaining clinical integration across the Network. 

While we have successfully performed this requirement in submitting data to our population health management tool (PHM Tool) in a “manner and timeframe as proscribed by the agreement between the TCCN network and the Network Participants,” we have not required a specific timeframe for submitting such data, but rather a suggested submission of claims data within 14 days of the encounter date.

In March 2022 we reviewed the current frequency by which all Network Participants are submitting claims data and found the following information:

• 60% of all PCP TCCN practices submit data within 14 days/less
• 14% submit data between 15-21 days
• 7% submit data between 22-28 days
• 19% submit data more than 28 days after the encounter

With 40% of practices falling outside of the recommended 14 day period for submission, we must institute a submission requirement for all practices. As stated previously, this new requirement should result in improved accuracy of scorecards and recall lists, aid transition to the Innovaccer PHM Tool, support our contract management efforts, and lastly, reduce the amount of time and resources spent in managing non-compliant practices.

After a review of the above information, the TCCN Board of Directors met on May 18, 2022, and revisited the initial recommendation made in 2018. At this time, by vote of the BOD (as allowed by the TCCN agreement with Network Participants), the TCCN BOD requires all practices to submit claims data to the PHM Tool within 14 calendar days of the most recent encounter date. This requirement will take effect beginning August 1, 2022.

If you have any questions regarding this revised requirement, please don’t hesitate to reach out to Laura Baldwin at laura.baldwin@tccn-choa.org.

We appreciate your continued support and collaboration with The Children’s Care Network.

COVID-19 Vaccine Toolkit Update

We have updated our COVID-19 Vaccine Toolkit to account for the recent expansion of vaccine eligibility for ages 6 months to 5 years under the EUA. For specific information on vaccine dosage and other clinical guidance, please refer to the CDC website and the AAP Pediatric COVID-19 Vaccine Dosing Quick Reference Guide. The Toolkit will no longer contain dosage information which may change periodically, but it will remain a resource for vaccine ordering, administration, and storage.

Click here to download the TCCN COVID-19 Vaccine Toolkit

CDC Healthy Alert Network (HAN) Health Advisory on Parechovirus

The CDC HAN Health Advisory notified clinicians and public health departments that Parechovirus (PeV) is currently circulating in the US. Multiple states have reported the infections in neonates and young infants since May 22, 2022. Clinicians are encouraged to include PeV in the differential diagnosis of infants presenting with fever, sepsis-like syndrome, and neurologic illness. Click here for more information.  

Due by August 12th: New CMO Entrant Delegations**

As the State begins its CMO bidding process for contracts that are planned to start in 2024, you have likely noticed communications being sent to your practice by entities that are interested in entering our market with their CMO product. We are in discussions with a couple of these entities regarding potential contracting through TCCN, and to that end we would like to know which of you would be willing to participate in a new CMO contract should one or more of these entities be selected by the State. 

TCCN, through a “black box” analysis, has developed an aspirational fee target to be achieved in order to bind your practice to a contract with each specified payor. Each TCCN CMO payor contract will be based on the aspirational fee target, with a guarantee that aggregate reimbursement will not be less than what is represented by this schedule, and could be more, depending on negotiations.

To make sure we have your decisions in time for our response to the potential new entrants, it is critical that you complete your TCCN Form of Delegated Authority Exceptions Notice and return it to Sahdeja Serieux via email (sahdeja.serieux@choa.org) or fax (404-785-9140) by Friday, August 12th. Please note that your delegation decisions will be effective for two years.

If you have any questions about this process or need a reminder of your previous delegation decisions, please reply to this email or call us at 404-785-0101. Click here to view the full version of this communication.

Completion of Amerigroup Value-Based Agreement

The Children’s Care Network is pleased to let our members know that TCCN has recently signed a new value-based contract with Amerigroup. TCCN member providers currently provide services to over 80,000 Amerigroup covered lives. This arrangement will allow for opportunities in shared savings and improvement in quality metrics for the Amerigroup population. Further details on quality initiatives will be forthcoming.

Claims Resolution & Escalation - Updated July 22

When contacting Anthem for help to resolve a denial, please follow these steps:

Review the EOB to confirm that the denial was received in error.

• Call the member services number on the back of the I.D. card.
• At the beginning of the call, request the rep’s name, and reference number and document the time of the call.
• If the call is dropped, please call back presenting the reference number from the previous call and ask that they pull up that call.
• If you feel the conversation is not being resolved, ask to speak to a supervisor. Please record the supervisor’s name, date, and time you spoke to them. You can submit this information to your TCCN rep to research with our Anthem representative. 
• Initiate a claim inquiry using Availity.
• Record the confirmation/tracking number of your Availity interaction.
• You can submit this information to your TCCN rep to research with our Anthem representative. 

NEW!! Anthem Claims Issue Escalation Spreadsheet

If your practice has exhausted the claims escalation process with no resolution (see above), you may submit escalated issues to your TCCN rep for assistance. Please add your escalated claims to the Anthem Claims Issue Escalation Spreadsheet and complete all required fields. Be sure to include thorough details that will assist with the resolution efforts.  All spaces must be completed to be submitted to the Anthem Escalation team. Please also submit supporting documentation such as EOB, letters, etc. If you have any questions please contact your TCCN representative.

Completion of Base Agreement and Delegated Credentialing

TCCN is pleased to announce we have now completed the full base contract with Anthem. The TCCN rate structure negotiated earlier this year will be attached to this agreement. Additionally, a Delegated Credentialing agreement is in final stages of operational development. Please continue the current process of direct credentialing with Anthem until we announce the new delegated credentialing process in the coming weeks.

Please make sure your CAQH profile is updated and that it is set to “Allow payors to view profile”. Anthem will credential based on what is in the profile. More details on CAQH profile maintenance are provided in the Credentialing Update section below.

As a reminder, the new provider application is located here, or you can click "Begin Application" on the Provider Maintenance Form. Once the application is completed you will receive a confirmation number letting you know that the application has successfully been completed. Please keep the confirmation for your records. Provide your TCCN representative with the confirmation number so the TCCN representative can work with Anthem to track the progress of the application. Anthem Credentialing Team requests that we allow 45 days for them to successfully load the member into the TCCN contract. Please respond to any email you receive from Anthem regarding credentialing as not responding can result in a delay in loading your provider to the Anthem contract.

Anthem Enhancing Claims Attachment Processes in Digital Applications

Submitting attachments electronically is the most efficient way for you to receive your claim payments faster — that’s why Anthem has been hard at work making the digital attachment process easier, more intuitive, and streamlined.

Anthem is preparing to launch an enhancement to the Claims Status Inquiry application that will enable you to submit claims attachments directly to the claim from Availity.com.

Didn’t submit your attachment with your claim? No problem!

If you submitted your claim through EDI using the 837, and the PWK segment contains the attachment control number, there are three options for submitting attachments:

• Through the attachments dashboard inbox: 
• From com, select the Claims & Payments tab to access Attachments – New and your Attachments Dashboard Inbox
• Through the 275 attachment: 
• Important: You must populate the PWK segment on the 837 with your document control number to ensure the claim can match to the attachment.
• Through the Availity.com application: 
• From com, select the Claims & Payments tab to run a Claims Status Inquiry to locate your claim. When you have found your claim, select the Send Attachments button: 
• If you submitted your claim through the Availity application, simply submit your attachment with your claim
• If you need to add additional attachments, to add a forgotten attachment, or for claims adjustments: 
• From com, select the Claims & Payments tab and run a Claims Status Inquiry to locate your claim. When you have found your claim, use the Send Attachments button.

Click here for more information

Reimbursement Policy Update:

Distinct Procedural Service, Modifiers 59 and XE, XP, XS, and XU

Beginning with dates of service on or after October 1, 2022, Anthem Blue Cross and Blue Shield will implement the following:

• 96365, 96369, 96372, 96373, 96374, 96379 will deny when reported with 78265, 78830 or 78835.
• 95957 will deny when reported with 95700 on the same day: 
• The reference to subsequent dates of service was removed from this code pair.

Use of Modifier 25 Policy Update – Effective July 1, 2022

The following is an update for the use of modifier 25 when billing for visits that include preventive services and problem-oriented evaluation and management services.

Beginning with claims processed on or after July 1, 2022, Anthem will implement additional steps to review claims for evaluation and management (E/M) services submitted by professional providers when a preventive service (CPT codes 99381 to 99397) is billed with a problem-oriented E/M service (CPT codes 99202 to 99215) and appended with modifier 25 (for example, CPT code 99393 billed with CPT code 99213 to 99225).

According to the American Medical Association (AMA) CPT Guidelines, E/M services must be “significant and separately identifiable” in order to appropriately append modifier 25. Based on review of the submitted claim information, if the problem-oriented E/M service is determined not to be a significant, separately identifiable service from the preventive service, the problem-oriented E/M service will be bundled with the preventive service.



Providers that believe their medical record documentation supports a significant and separately identifiable E/M service should follow the Claims Payment Dispute process (including submission of such with the dispute) as outlined in the provider manual.

Anthem Alert: Stat Labs

Just a reminder to please refer stat lab when administering in-house labs.

Please let your TCCN representative know if you have seen any claim adjustments prior to the TCCN fee schedule paying out correctly. 

Anthem Alert: Claims Reprocessing Update

We met with our Anthem rep and have key updates to share: 

Claims Reprocessing

Please check EOBs for after January 15 dates-of-service for potential adjustments. Claims adjustments will be within the EOBs and will show what was originally paid; a reversal, and then the new amount paid with the difference in payment on the check. This will include an adjustment reason code.

Reverse Roster Audit

We are reviewing the reverse roster audit to ensure all providers and locations are connected to the TCCN fee schedule. We will provide more information soon.

Claims Down-coding Appeals

Our Anthem rep will be providing more documentation on down-coding appeals. Appeals at a claim level must have proper documentation. A significant number of successfully appealed claims will lead to a reduction in claims flagged for coding. 

Anthem Resources: Policies, Guidelines and Manuals

Member Services

Please make sure providers are going to member services prior to coming to their Anthem Rep. When calling, ask for a reference number at the beginning of the call.

Anthem publishes their reimbursement policies as well as clinical practice guidelines on their website. The reimbursement policies provide insight on claim processing and editing guidelines. 

Policies include modifier usage, bundling, etc. and may be valuable when understanding claims processing. The Clinical Practice Guidelines (CPGs) provide guidance on medical conditions, citing their source and give links to supporting documentation.  

Click this link to access Anthem's available resources including policies and guidelines.

If you have any questions, please contact us at contact@tccn-choa.org.

Anthem PCP Assignment Requirement

Anthem confirmed the HMO, Open Access and Pathways Network plans require PCP assignment. Please ensure patients are assigned to a PCP within your practice for their appointment. This will ensure claims process and pay according to their plan requirements.

If you have any questions, please contact us at contact@tccn-choa.org.

• Click here to review FAQs and details about the TCCN/Anthem agreement

CAQH Profiles 

Providers are responsible for updating their CAQH profile and keeping their credentialing file up- to-date. 

Please remember the importance of completing the attestation on the CAQH website every quarter and respond to any attestation request in a timely manner to prevent any disruption in payment from payors. This needs to be completed every 90 days. 

If you fail to respond to Anthem’s re-credentialing requests or fail to keep your profile up-to-date, Anthem could drop you from the contract.

If you are experiencing out of network claims or denials it could be that your provider needs to update their CAQH application and have not completed Anthem’s re-credentialing requests. You may update the CAQH application by visiting their website at https://proview.caqh.org/ or by calling 888.599.1771.

Please also ensure that you have granted Anthem Blue Cross Blue Shield permission to access your CAQH application by checking the box in the application. Failure to complete this step will result in Anthem’s inability to reload the affected providers.

Once you have completed the CAQH process, you will need to return to Availity to complete a new application for this provider. Credentialing timeline is 15-30 days once submitted if everything is correct on CAQH.

Announcement of New Malpractice Broker**

TCCN is excited to announce that we have engaged Sterling Seacrest Pritchard “SSP” as our new insurance consulting firm for the TCCN Malpractice Program effective July 1, 2022. Alongside the TCCN team, SSP will be assisting in the management and coordination of our professional liability program as we approach the 2022-2023 insurance renewal. We are very pleased about this new partnership and the intellectual capital SSP brings to TCCN members through their depth of experience in the professional liability marketplace both locally and nationally.

SSP is one of the largest insurance brokerage and consulting firms in the Southeast and brings over 30+ years of experience in physicians’ and surgeons’ professional liability insurance to TCCN members. SSP’s Healthcare Practice includes over 30 team members. TCCN members will have access to the SSP team and the additional services they provide their clients.  

TCCN’s hiring of SSP will not have any impact on your practice’s current insurance with MAGMutual Insurance Company. Click here for a list of services offered by SSP and contact information.

MAGMutual Risk Mitigation Report

MAGMutual has developed a Risk Mitigation Report for Pediatrics to highlight trends in losses and what pediatric providers and practices can do to mitigate these risks. Please share with your staff and discuss at your next practice meeting.

MAGMutual has released two 1-hour CME courses on “Sexual Misconduct” that fulfills the new GA license requirement for HB458 which became effective January 1, 2022, and requires that each Physician complete a course in “professional boundaries and sexual misconduct in medical practice” before renewing their GA medical license. Please see below for the links to the 2 classes.

• Sexual Misconduct: Strategies to Minimize Risk (Part 1)
• Sexual Misconduct: Strategies to Minimize Risk (Part 2)

If you are not with MAGMutual, then you should reach out to your malpractice carrier and see if they have a similar course. If they do not, then MAG and GPPA have a program as well – please see link below. 

https://gppa.memberclicks.net/hb485   

Link to register for the recording and get CME credit. Non-members cost $100.

Please contact your carrier, legal advisor or the Georgia Composite Medical Board with any questions. TCCN does not monitor all changes to legal requirements and does not provide legal advice.

Keep an eye out for our August Quality Steps newsletter coming soon. 

The Children’s Care Network is pleased to sponsor the 2022 Children’s Annual Professional Staff Meeting on Thursday, September 22nd at 6:00 PM at the Children’s Support Center. This meeting replaces the TCCN Fall Clinical Quality Forum, so your attendance at the event will count towards your 2022 meeting attendance requirement.

As this will be the first opportunity for many of you to network with your primary care and subspecialist colleagues in some time, we have coordinated to make tables available for subspecialty physicians to connect with pediatricians and other physician attendees. In addition to this networking opportunity, there will be TCCN and Children’s updates presented along with awards recognizing physician leaders. We strongly encourage all TCCN practices to attend!

If you have not sent your RSVP and are planning to attend, please respond to the calendar invite that you should have received from Physician Communications or complete this online registration.

Updates in Pediatric Emergency Medicine Conference**

September 10-11, 2022 (MOC Credit Available)

Event Details:

Saturday, September 10, 2022, 7:45 a.m. – 4:45 p.m. 

    *Optional reception to follow.

Sunday, September 11, 2022, 7:45 a.m. – 12:15 p.m.   

Course Description:  

The purpose of this course is to have an open discussion with clinicians interested in common pediatrics emergencies. This years course will include dermatological, endocrine and rheumatological emergencies among others. The course will use both didactic lectures and hands on workshops to garner discussion of the most important topics and take-home points. 

Target Audience:

Physicians, advanced practice providers, nurses, residents, and medical students are all invited to attend.

Click here for more details and to register

Click here to download the conference postcard

Behavioral and Mental Health Project ECHO – Learning Disabilities Cohort**

(MOC Credit available)

Utilizing the Project ECHO platform, Children's has been providing Behavioral and Mental Health education in multiple cohorts since March 2021. The Learning Disabilities Cohort will meet every other Thursday at lunchtime starting September 1st for six sessions and will cover multiple facets of caring for patients with Learning Disabilities. Upon the conclusion of our Learning Disabilities cohort, we will offer additional cohorts which will cover topics including ADHD/Oppositional and Disruptive Behaviors, Anxiety, and Autism.

Project ECHO uses the online platform, Zoom, and participation in Project ECHO is free of charge. Registration is open to primary care providers in the state of Georgia only. Active participation is required and participants are expected to present at minimum one case during the series.

Event Details:

All Learning Disabilities Cohort sessions will take place from 12:30pm – 1:30pm

• September 1: Learning Disabilities in Early Childhood
• September 15: Learning Disabilities and School Aged Children
• September 29: Learning Disabilities in Adolescence
• October 13: Assessment and Intervention for Learning Disabilities
• October 27: Health Literacy and Transition to Adult Health Care and Learning Disabilities
• November 10: Working with the School System

This series will be limited to 25 participants due to the time constraints of case presentations. There will be an active waitlist so please add your name if the course is full and you will be contacted if you are able to join.

To register for this series, click here.

Slots still available! Adverse Childhood Experiences (ACEs) in Practice Cohort

Participation in the ACEs Project ECHO series is still available through August 11th, so please register if you are interested in that cohort. For more information and to register for the ACEs series, click here.

Project ECHO (Extension for Community Healthcare Outcomes) is a lifelong learning and guided practice model that revolutionizes medical education and exponentially increases workforce capacity to provide best practice specialty care and reduce health disparities through its hub-and spoke knowledge sharing networks.

As we near completion of the second year of the BMH Project ECHO series at Children’s, we are evaluating the topics for 2023 and beyond.

• Call to Action: Complete the BMH Needs Assessment/Survey
• Purpose: To better understand what the most critical behavioral health topics are for your practice
• Duration: Approximately 5 minutes

Pediatric Oral Treatment Study

Emory University School of Medicine is conducting a phase 2/3 clinical trial on the use of Paxlovid oral treatment in children and teens. You can find more information on the study here. 

In Case You Missed It (please use the links below to review)

• Formula Shortage Resources
• June 2022 TCCN State of the Union Recording and Attestation
• Spring 2022 Clinical Quality Forum Recording and Attestation
• Endocrinology Referral Guide
• Children's Physician Group - Nephrology Referral Guideline
• TCCN COVID-19 Diagnosis and Isolation Algorithm

We are here for you. Please reach out to contact@tccn-choa.org with any questions you may have.