Tag: #Medicareadvantage

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

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

UHC Medicare Advantage Plans: DME changes in certain States

Posted on by KR2Medical Billing

For any DOS April 1st 2026 and thereafter the new company that will manage DME ordering and fulfillment will be Synergy Health.

This change will apply to Medicare Advantage Plans in certain states:

Individual HMO and PPO plans:

Via UHC website

Chronic Special Needs Plans (C-SNP)

Via UHC website

Dual Special Needs Plans (D-SNP):

  • North Dakota
  • South Dakota
  • West Virginia

DME providers would need to join Synapse Health network. Synapse will contact you, however you can also reach out to them via email: JoinOurNetwork@synapsehealth.com

To which DMEs does this change apply?

  • Diabetic supplies
  • Enteral
  • Home ambulatory
  • Hospital beds
  • Insulin therapy
  • Mobility aids 
  • Negative pressure wound therapy
  • Ostomy
  • Oxygen
  • Respiratory
  • Respiratory vest
  • Sleep
  • Urological
  • Ventilators
  • Wheelchairs

The DMEs that this change does not apply to?

  • Bone growth stimulators
  • Cancer treatment
  • Cardiac defibrillators
  • Complex rehab
  • Optune device
  • Oral devices
  • Orthotics
  • Parenteral nutrition, vision, and hearing
  • Prosthetics

Authorizations:

Providers would need to request an auth from Synapse Health for DOS of April 1st 2026 and there after, via their portal https://connect.synapsehealth.com/authorization/login

As a provider you can also go on their web to request a personalized training http://www.synapsehealth.com/welcome

Which plans are no affected by this change? Medicare Advantage-

Institutional Special Needs Plans (I-SNP)
Institutional Equivalent Special Needs Plans (IE-SNPs) 
Group retiree plans

Find this type of content useful? Follow my blog for more payer updates: medical coding, billing, reimbursement, prior auth.

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

If you find this type of content useful? Subscribe to my blog where I bring you the latest payer updates including medical billing and coding.

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.

Want to stay current with the up-to date medical billing and coding information? Follow my blog. #medialbilling #medicalcoding #reimbursement

Recent Blog Posts

Tufts Health One Care: New Plan name and ID cards

Does your provider accept Tufts Health One Care insurance? Then this blog post is for you- don’t leave money on the table and waste precious administrative time! As of Jan 1,2026- Tufts Health One Care became Tufts D-SNP – with such change members will receive new ID cards and member numbers. New ID cards: Authorizations…

KR2Medical Billing's avatar by KR2Medical Billing

Fidelis MMC: healthy nutrition benefit

Fidelis (NY) has partnered up with Foodsmart vendor to offer the Managed Medicaid Members nutrition services- “fully covered by the plan”. The services include a personalized telenutrition from registered nutritionist. Foodsmart services include: For more information, providers should contact: Paula West, Director of Provider Relations, at Paula.West@foodsmart.com. Ready to refer a member? Find this information…

KR2Medical Billing's avatar by KR2Medical Billing

UHC Medicaid: Idaho: diabetic DME coverage change-benefit

Starting for DOS 4/1/26 and thereafter the following codes will be covered through the patient pharmacy benefit and no longer will be covered under patient medical benefit. For DOS 1/1/26 through 3/1/26- providers can still bill either through medical benefit or pharmacy benefit. Find this type of content useful? Follow my blog!

KR2Medical Billing's avatar by KR2Medical Billing