Posted in Training, Updates

UHC Oxford- updated Prior Auth changes 01/01/2023

Starting 01/01/2023 Oxford will add and remove certain codes that require prior authorizations (commercial line of business).

According the Oxford this change helps align their processes with evidence-based clinical guidelines.

Some of the new codes that will be added are:

For a full list of new codes that will be added to the list of codes that require prior authorization, please click here.

In addition Oxford is also adding a new provider tool, the UnitedHealthcare Oxford plan Prior Authorization Requirements document, it will become available as of Dec. 1, 2022, on the Advance Notification and Clinical Submission Requirements page.

Providers are encouraged to use this tool where they will be able to find/research codes that require prior authorization as well as request an auth.

Would you like to learn more: please click here, for the Applicable Oxford Commercial policies.

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Posted in #Medicareadvantage, BCBS (Various States), Training, Updates

BCBS of MN: Reimbursement update (modifiers 52, CO, CQ)

Please note which type of providers will be affected by each reimbursement policy for specific modifiers and the effective date it begins.

The following reimbursement updates take effect as of July 1, 2022:

  1. Modifier 52- for services performed on 07/01/2022 and thereafter, Blue Cross will be begin reimbursing procedure codes billed with a -52 modifier at the lesser of 50% of the physician fee schedule allowance or charge submitted for the following lines of business: • Commercial• Federal Employee Program (FEP)
  2. The Reimbursement Policy, General Coding – 003 Coding Edits will be updated to reflect this change.

PT/OT/ST services reimbursement with modifiers CO, CQ for DOS 07/01/2022 and thereafter:

  1. Commercial plans-

Blue Cross will be implementing a 15% reduction in the allowed amount for services
modified with CO or CQ modifier for professional providers.

The following reimbursement Policy took affect for DOS 01/01/2022 and thereafter

1. Medicare Advantage Plans-

Blue Cross implemented a 15% reduction in the allowed amount for services modified with CO or CQ modifier for professional and facility providers to comply with requirements of the Centers for Medicare & Medicaid Services (CMS).

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Posted in #aetna, #Medicare, #Medicareadvantage, Training, Updates

Aetna Medicare Advantage: participating providers’ post-service appeals new address

Are you an Aetna Medicare Advantage participating provider and had issues with your post-service appeals? If your answer is yes, it is because as of Jan 1, 2022 there is a new address where the providers need to submit those appeals to.

There is also a NEW FORM that the provider needs to fill out.

Where to find the new form?

You can find this form, which is called the Medicare Provider Complaint and Appeal Request Form, by going to the forms for health care professionals page and scrolling to the “Dispute and appeals” drop-down menu.

The New form should be sent to the address below:

Medicare Provider Appeals PO Box 14835 Lexington, KY 40512 Fax: 1-860-900-7995


Provider Resolution Team PO Box 14020 Lexington, KY 40512 Fax: 1-800-624-0756

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