Month: November 2020

Posted in Insurance, My services, Training, Updates

Aetna: New Medicare Advantage Plans in North Carolina, South Carolina and Tennessee- 01/01/2021

Posted on by KR2Medical Billing

As of 01/01/2021- there are 2 new HMO plans that will be available in NC, SC and Tennessee: These plans are Aetna Medicare ValueSM Plan (HMO) and Aetna Medicare Value Plus Plan (HMO)

These plans will require to choose a PCP. However, they will NOT require a referral to see a specialist. This information will be on the member cards, as indicated by the red arrow below:

The following is the list of the plan types:

Supplemental Benefits: NOT all plans will have these available

  • Dental (preventive and comprehensive)
  • Over-the-counter (OTC)
  • Hearing Aids
  • Post hospital discharge meal delivery
  • Telehealth

Additional Information:

  • All members must select a primary care physician.
  • There is no referral requirement for specialty care.
  • Participating providers can submit pre-authorization requests through our provider portal, or they can also fax the request or call it in to the Provider Service Center.
  • These plans include pharmacy Part D coverage.

Note: No out-of-network benefits exist for these plans unless the member follows the approval process. They can start this process by contacting Member Services directly.

Posted in Insurance, Training, Updates

1199 SEIU Benefits Fund-Vitamin D testing – 09/01/2020

Posted on by KR2Medical Billing

In order to ensure that 1199 SEIU Benefits Fund members get the proper medically necessary care, 1199 SEIU has implemented a new Vitamin D testing policy.

This policy will become effective 09/01/2020- 1199 SEIU Benefits Fund will pay for VITAMIN D testing for the following indications:

  • Medical Diagnosis associated with Vitamin D deficiency
  • Documented Vitamin D deficiency
  • Known or suspected excessive Vitamin D blood levels

Vitamin D testing is NOT considered medically necessary for the following:

  • Routine Preventative Screening test
  • All other indications

Coding and Billing:

The following Codes will be accepted:

82306- vitamin D; 25 hydroxy, includes fractions, if performed

82652- Vitamin D; 1,25 dihydroxy, includes fraction (s), if performed

Claims that are submitted with BOTH codes in combination, on the same day, are considered not medically necessary and will be denied.

In addition, code 0038U is currently not covered.

If providers have any questions regarding this policy, they can contact the 1199 SEIU Benefits Fund Provider Relations Department at 646-473-7160, Monday through Friday, from 9:00 AM to 5:00 PM.

Posted in Insurance, Training, Updates

EmblemHealth (NY) – Pharmacy Utilization Management Update for 2021

Posted on by KR2Medical Billing

As of 01/01/2021-there are two main changes that will take effect:

  1. Express Scripts will take over utilization management for drugs (medication) – this will apply to ALL lines of business including Medicaid and Medicare plans. The utilization management will include: prior authorizations, quantity limits and step therapy.
  2. New Century Health (NCH) will authorize most oncology related chemotherapy drugs and supportive agents, when these services are performed (delivered) in physician’s office, outpatient hospital, or ambulatory setting.

Note: #2 Change DOES NOT APPLY to Montefiore CMO, EmblemHealth Inc. (formerly GHI), members managed by HealthCareParners, or members under 18 years of age.

For complete list of formulary: EmblemHealth, GHI, HIP and Vytra Commercial benefit plans please click here.

For complete list of drug formulary: Medicare Plans, click here

Note: Updates to the Commercial formulary apply to EmblemHealth, GHI, HIP and Vytra benefit plans. Updates to the Medicare formulary apply to EmblemHealth and ConnectiCare benefit plans. Exceptions will be noted.

#EmblemHealth, #HealthCarePartners, #Expressscripts, #NCH