Month: May 2021

Posted in #aetna, Updates

Aetna Louisiana Better Health: Peer Support Specialist Requirements

Posted on by KR2Medical Billing

Below are listed the requirements for the Peer Support Specialists, as per Louisiana Department of Health (LDH) and Substance Abuse and Mental Health Services Administration (SAMHSA) guidelines.

Lived Experience – has lived experience with a behavioral health (BH) diagnosis (can
include a diagnosis with mental health challenges, addiction challenges, or co-occurring
disorders).
• Education – has a minimum of a High School diploma or a GED.
• Age – is at least eighteen (18) years of age.
• Time in Recovery – has at least twelve (12) months of continuous, demonstrated
recovery as indicated by SAMHSA’s working definition of recovery.
• Training – has completed all required training.
• Credentials – is credentialed in the state of Louisiana.

Peer Support Specialists must provide ABHLA with their education (diploma or transcripts) and
registered NPI for billing.

In order to receive payment remember to bill age and education modifiers in accordance to
the Louisiana Medicaid Specialized Behavioral Health Fee Schedule.

Questions and Support:
For questions, please contact LAProvider@AETNA.com or call 1-855-242-0802 and follow the
prompts.

Posted in Cinga Insurance, Updates

Cigna Update: Change to Shoulder Arthroplasty Coverage Review, 06/01/21

Posted on by KR2Medical Billing

The following policy is effective 06/01/2021 and applies to Cigna Fully Insured and Self-Funded Plans.

Background: CMS and an evidence-based guidelines from MCG Health designate shoulder arthroplasty procedures (CPT codes 23470 & 23472) as outpatient, when medically appropriate.

Picture via Mayo Clinic 2014.

Starting 06/01/2021- Cigna may deny CPT 23470 & 23472, when requested for inpatient level of care. (inpatient setting).

eviCore will review the inpatient level of care requests for medical necessity and level of care. eviCore will base its review of medical necessity based on MCG Health criteria.

Denials will include the medical necessity appeal rights.

The above policy is basically the site-of-care policy for Cigna Fully Insured and Self-Funded Plans.

Possible Solution to avoid unnecessary Denials: Make sure you review the Cigna Shoulder Arthroplasty Policy and CIGNA Site-of-Care Policy. Site-of-Care policy will give you the criteria for the patient to qualify for the inpatient setting and receive inpatient level of care as oppose to outpatient setting (ASC).

(Shoulder Arthroplasty Policy is updated for 07/01/2021) Please visit the links above for the FULL CIGNA POLICIES.

Posted in #unitedhealthcare, Updates

UHC Commercial Plan New Reimbursement Policy Alert: Physician Billing (facility) 08/01/21

Posted on by KR2Medical Billing

According to UHC Commercial Plans May Reimbursement Policy Update:

Starting 08/01/2021 the new reimbursement policy will apply to E/M (99202-99215) codes. This policy applies to services billed on professional (HCFA-1500) form and UB 04 (facility) form.

This policy applies to services that are performed in POS 19 (Off Campus Outpatient Hospital) or POS 22 (On Campus Outpatient Hospital) without any additional medical surgical service on the same day of service by the same provider.

The E/M codes will be only reimbursed when billed with a POS (place of service) 11.

For Provider Based Facility Clinic visit with revenue code 051X:

Facility Claim (UB04) – provider based facility clinical visit services with a Revenue code 051X will not be separately reimbursed IF a coinciding Professional Claim (HCFA-1500) is billed and reported with POS 11 and/or billed with the same E/M codes (99202-99215).

When will this policy NOT apply?

When a provider performs E/M codes AND a medical surgical service ON THE SAME DOS, the professional and facility claim (if applicable) WILL NOT BE SUBJECT TO THE ABOVE POLICY.

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