Posted in #aetna, Training, Updates

Aetna: Non participating provider New Timely filling frame

Recently, while I was preparing for my Denials Management Made Easy Webinar (Physician Services), coming soon, I researched the 8 most common denial types.

One of those common denials is timely filing.

Picture via Performance Adjusting

Timely filling frame is the time given to providers to send their clean claims to the insurance payer. Each insurance payer has different timely filling time frames. These time frames also differ for In and Out of network providers.

Training your staff on keeping current with timely filling changes will help you avoid unnecessary denials and ensure that claims are submitted on time and paid.


In this article, as you see by the title of it, we will look at the timely filling requirements change for AETNA Out of network providers.

As per Aetna, for all claims submitted on or after DOS 01/01/2022 the new timely filling will be 12 months. Down from 27 months.

Aetna is doing this to match Centers for Medicare & Medicaid Services (CMS) standards. The change will apply to medical procedures.

Dental Out of network providers will continue to have 27 months timely filling frame for their claims.


According to Aetna the denials will start showing up in 2023 and all policy exceptions to timely filing today will apply after this change and will be supported as they are today.


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Posted in #Medicareadvantage, #unitedhealthcare, Training, Updates

Dialysis Billing Update: UHC Medicare Advantage

If you have patients with UHC Medicare Advantage Plan? Then this blog post is for you.

Starting October 1st 2021 UHC Medicare Advantage Plan updated their billing information in order to avoid Denials.

Modifiers: UHC Medicare Advantage Plan requests that providers bill the dialysis treatment with the following modifiers: CG or KX for dialysis treatment

Revenue Codes: 821 and 881

CPT code: 90999

Coverage: Dialysis treatments that exceed 14 treatments in a calendar month will be reviewed per CMS Frequency of Hemodialysis (A55703) LCD

If you would like to read the whole CMS Frequency of Hemodialysis (A55703) LCD please click here.


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Posted in BCBS Empire NY, Training, Updates

BCBS (NY): Proper coding for INR In-home patient monitoring

This following policy is part of BCBS (NY) administrative policy guidelines (07/01/2021)


This blog post is for providers that need to meet the INR (in-home) monitoring quality measure.

What you will learn?

  1. What is INR monitoring Quality measure?
  2. Proper coding for in-home INR monitoring
  3. Documentation requirements to meet the INR in home monitoring measure

What is INR (International normalized ratio)?:

International normalized ratio (INR) is blood-clotting test. It is a test used to measure how quickly your blood forms a clot, compared with normal clotting time.


Background:

International normalized ratio is part of the 2021 Quality Measure Set (Pharmacy Quality Alliance (PQA) measures.

The QRS measure set is comprised of clinical quality measures, including the National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) measures and Pharmacy Quality Alliance (PQA) measures.


Previously, patients taking warfarin (brand name Coumadin) were heading off to the lab or clinic every few weeks for an international normalized ratio (INR) blood test. However, currently there is a small, portable device that patients on warfarin, can now self-test with a finger prick drop of blood.


Is there a provider type restriction for this quality Measure?

No, there is not provider type restriction.


As a provider, which proper codes should I use for INR in-home patient monitoring?

Below please see the proper codes that providers should use for INR in-home patient monitoring.

Meeting INR monitoring Quality Measure:

Definition: The percentage of members 18 years of age and older who had at least one 56-day interval of warfarin therapy and who received at least one international normalized ratio (INR) monitoring test during each 56-day interval with active warfarin therapy.

INR quality measure requirements.

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If you are looking for more insightful breakdown of the medical coding and billing/reimbursement guidelines? Please check out my services page for more information.


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