Posted in NY Providers, Payer Updates, Payers and CPT reinbursement, Training, Updates

MVP Health Plans: reimbursement of sick E&M codes billed w/preventative codes -05/01/23

According to the latest announcement MVP Health Plan will change the reimbursement of sick E/M codes when they are billed on the same day as a preventative codes.

This policy applies to Primary Care Physicians.

According to the new reimbursement policy the sick E&M codes will be reimbursed at 50% of allowable amount if the codes are billed on the same date of service as the preventative codes.

The reimbursement will be applied with or without the modifier 25 present.

Policy applies to the following codes:

Preventive medicine services are represented in evaluation and management (E/M) codes 99381–99429. These E/M codes may be reported by any qualified physician or other qualified healthcare professional.

Preventative cpt codes 99381–99397 for comprehensive preventive evaluations are age-specific, beginning with infancy and ranging through patients age 65 and over for both new and established office patients.

E&M codes may include: 99202-99205, 99212-99215

For more information please refer to MVP Evaluation and Management (E&M) policy.

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Posted in #unitedhealthcare, NY Providers, Payer Updates, Training

UHC NY Community Plan Referral requirement change-effective immediately

As per UniteHealthCare- NY community Plan -members will no longer require referrals to see specialists (most specialties).

This change is made to help Primary Care Physicians with reducing administrative burden and make it easier for the members to see some specialists.

The specialists that do or do not require a referral still need to be In Network with UHC NY Community Plan.

Below are the specialties that still require the referral. The members will need to contact their PCP office in order to obtain a referral and ensure that the Specialist will get reimbursed for the services provided.

  • Allergy and immunology
  • Dermatology
  • Endocrinology
  • Gastroenterology
  • General surgery
  • Neurological surgery
  • Orthopedic surgery
  • Otolaryngology
  • Physical medicine and rehabilitation/physiatry
  • Plastic surgery
  • Podiatry
  • Pulmonary medicine
  • Sports medicine
  • Urology
  • Vascular surgery

I am a provider, where should I go in order to request a referral?

Providers can request a referral on the UHC provider portal ( ) Providers need to sign into the portal.

I am a provider and still have questions regarding the referral process, where should I go to find more infomation?

Provider can visit interactive guide in order to get more information regarding referral process.

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#NYMedicaid, #UHCCommunityPlan #UHC #referrals #specialists

Posted in BCBS (Various States), NY Providers, Training, Updates

HEDIS Measure: Update Colorectal Cancer Screening for 2022

Are you a primary care physician and is reporting HEDIS measures? Then this following blog post is for you.

In this blog post we will discuss the changes/updates that NCQA just released for HEDIS Colorectal Cancer Screening Measure.

Measure Description: Measures the percentage of members 45 to 75 years of age who had appropriate screening for rectal cancer. The Medicaid product was added to the administrative data collection method for this measure and the age range was changed to 45 to 75 years of age.

In order to meet this measure your patients need to fall in ANY of the following criteria:

  • Fecal occult blood test during the measurement year
  • Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year
  • Colonoscopy during the measurement year or the nine years prior to the measurement year
  • CT colonography during the measurement year or the four years prior to the measurement year
  • Stool DNA (sDNA) with FIT test during the measurement year or the two years prior to the measurement year

If you would like to report this measure via Electronic Clinical Data Reporting system you will need to select: Colorectal Cancer Screening (COL-E).

Reminder: please make sure to document all of needed information in the patient medical records.

#HEDIS #Cancer #primarycare #physicians #NCQA

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