Category: Insurance

Posted in #unitedhealthcare, Insurance, Payer Updates, Prior Authorization Insurance Carrier Updates

UHC Knee/Hip Surgery documentation requirenments.

Posted on by KR2Medical Billing

Effective for services performed on Nov 1,2024 and there after, there will be new requirements for the prior authorization documentation applied to the Knee/Hip surgeries.

These changes/updates apply to self insured and fully insured plans nationwide.

Codes affected:

27445,27447, 27130 and 27132 

Knee Surgery Documentstion requirenments:

  1. Complete diagnostic imaging Reports: -Documented closure of skeletal plates (age less than 18 years)
    -Presence or absence of focal full-thickness articular cartilage defect
    -Size and location of focal cartilage defect
    -Outerbridge grade
    -Joint space and alignment
    -Ligament tear location and grade
  2. Diagnostic Images: – show the abnormality- MRI, Xray, Bone scan.
  3. Prior treatment documentation (prior year): -NSAIDs or acetaminophen ≥ 3 weeks*
    -PT or home exercise ≥ 12 weeks
    -Activity modification ≥ 12 weeks

*For TJR Knee ≥ 1 intra-articular corticosteroid injection may be used in place of NSAIDs.

For more information please click visit: https://www.uhcprovider.com/en/resource-library/news/2024/documentation-requirement-updates-total-joint-replacements.html

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#medicalpolicies, #reimbursement, #medicalcoding, #medicalbilling

Posted in #reimbursement, EmblemHealth NY, Insurance, NY Providers, Training

EmblemHealth Commercial Plans: site of care change – adding 170 new injectable and infusion meds to the list

Posted on by KR2Medical Billing

Effective July 15, 2024- EmblemHealth will update their site of care policy and add 170 more injectable and infusion drugs to the list.

This change will apply to the commercial line of business and for all age groups.

The change is to help bring down the members’ cost sharing (out of pocket costs) and provide an access to the ongoing maintenance of infusion therapy.

The following is a partial list of these medications:

Via EmblemHealth

Note: for a full list of medications and the pdf version of site of care policy please visit – https://www.emblemhealth.com/providers/news/infusions-and-injectables-updates-policy-202404

These medications will still require prior authorization but will no longer be covered when administered in a hospital setting.

Instead the medications will be covered in the following place of service:

POS 11- Office

POS 12- Home

Ambulatory Infusion Suites- (POS 24, POS 49, or POS 12 with Modifier SS)

Exceptions for members that are receiving their first dosage may be requested with justifiable medical necessity.

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Posted in Insurance, Training, Updates

EmblemHealth (NY)-Care Management Program for Kidney Patients, 05/01/21

Posted on by KR2Medical Billing

Starting 05/01/21- EmblemHealth (NY) will offer the EmblemHealth Chronic Kidney Disease (CKD)/End Stage Renal Disease (ESRD) program.

What will this mean for your patients?

  1. EmblemHealth team of care managers, social workers, and pharmacists may be in touch with the physician’s office as they coordinate patient care.
  2. EmblemHealth is going to manage members affected by kidney disease

What will the EmblemHealth CKD/ESRD program do?

  1. The CKD/ESRD program will provide eligible members with holistic, seamless and, clinically robust wrap around support throughout all stages of their health care journey

What is the purpose of EmblemHealth CKD/ESRD Care Management Program?

  1. EmblemHealth’s CKD/ESRD program aims to slow the progression of illness and reduce unnecessary utilization. The program seeks to improve condition management and navigation of the healthcare system through a structured approach to person-centered assessment, care planning, and delivery of interventions.

Who will select the patents?

  1. EmblemHealth will identify members with complex needs and provide them with individualized care management interventions.

How to get in touch with EmblemHealth CKD/ESRD Care Management Program Staff?

  1. For more information or to make a referral, call us as at 800-447-0768, Monday through Friday, 9 a.m. to 5 p.m.