Tag: #Medicareadvantage

Find medical billing and coding guidance for Medicare Advantage Plans (various insurance payers)

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

UHC Colorado: Rocky Mountain Health Plan-BH prior auth updates

Posted on by KR2Medical Billing

If you are a provider that accepts the following Rocky Mountain Health Plan types, then this blog post is for you:

  1. D-SNP: dual eligible special needs plan
  2. Child Health Plus
  3. Medicare Advantage
  4. Individual and Family plans
  5. Medicaid: RAE/PRIME

The following update will take affect for any DOS 7/1/25 and thereafter:

1.HCPCs – H2033, T2022- Multisystemic Therapy (MST), Enhanced MST: Requires pre-service notification, authorization necessary for services provided more than 90 days

2.H0036, T2022-Functional Family Therapy (FFT), Enhanced FFT: Requires pre-service notification, authorization necessary for services provided more than 90 days

3. G0137, H0015, Rev code 906- Substance use disorder intensive outpatient programming (SUD IOP): Requires pre-service notification, authorization necessary for services greater than 15 sessions

4. HCPCs code S9480, Rev code 905-Behavioral health intensive outpatient programming (BH IOP): Requires pre-service notification, authorization necessary for services greater than 15 sessions

5. Rev. code 0911-Psychiatric Residential Treatment Facility (PRTF): Requires prior authorization

6.H0019-Psychiatric Residential Treatment Facility (PRTF): Requires prior authorization

8. CPT codes: 6132, 96133, 96136, 96137, 96138, 96139, 96146, 96130, 96131-Neuropsychological and psychological testing (and related codes): Requires prior authorization

7. H0017- All services associated with H0017, including Acute Treatment Unit (ATU): Requires prior authorization

9. CPT codes- 96116, 96121- Neurobehavioral status exam: Requires prior authorization

To access the full list of codes, please click here: https://www.uhcprovider.com/en/prior-auth-advance-notification/adv-notification-plan-reqs.html and find the BH section

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

Aetna: Reimbursement for evaluations with G2082 and G2083 codes…

Posted on by KR2Medical Billing

According to Aetna, effective for DOS 3/1/24 and thereafter, evaluation codes 99212-99215, 99415–99417 will no longer be reimbursed separately when billed on the same DOS for the same member by the same provider.

This change will apply to Commercial and Medicare Advantage Plans.

Modifier 25 will not be able to override this claim edit and the payment for the E/M codes will be included in either code G2082 or G2083

G2082-temporary code for 2024- office or outpatient visit for evaluation and management of already established patient that requires physician or other qualified health care professional supervision up to 56 mg of esketamine nasal self- administration, includes 2 hours post-administration observation.

G2083-temporary code for 2024- office or outpatient visit for evaluation and management of already established patient that requires physician or other qualified health care professional supervision greater than 56 mg of esketamine nasal self- administration, includes 2 hours post-administration observation.

CTP codes 99415, 99416 are used to report the total amount of face-to-face time spent with the patient and/or family/caregiver by clinical staff in the office or
other outpatient setting, on a given date of service even if the time is not continuous. The
physician or qualified health care professional is present to provide direct supervision of the
clinical staff. Codes 99415, 99416 should not be used for prolonged services of less than 30
minutes total duration on a given date.

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MVP: Home Health Auth and Concurrent Review Process changes

Posted on by KR2Medical Billing

The change to the prior authorization process and concurrent review process will affect the Medicare Advantage and DualAccess (D-SNP) Members in New York and Vermont.

As of Jan 1 ,2024 the process for Home Health Services and Concurrent Review will be handled by naviHealth, Inc. d/b/a Optum Home and Community Care.

Important things to remember:

  • Start of Care (SOC) visits will not require prior authorization
  • Providers should submit the notice of initiation of start of care for home health services to Optum Home and Community Care within the 5 days after the Start of Care visit: the provider will receive an Authorization Id, AND MVP Authorization ID- for the FIRST 30 days of the services. The MVP Authorization ID will allow the member to receive services without the need for an authorization.
  • Prior to day 30, Provider must request prior authorization for days 31-60, by discipline, and provide documentation to Optum Home and Community Care.
  • For each subsequent 60-day period, Provider must request prior authorization, by discipline, and provide documentation to Optum Home & Community Care during the 56-60-day recertification window.

If you would like more information, please visit mvphealthcare.com/policies and select Provider Policies, Effective October 1, 2023 (PDF) and review the Utilization and Case Management section.

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