Tag: #Medicareadvantage

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

Posted in #Medicareadvantage, #reimbursement, MVP (NY/VT) Insurance Payer, Training

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.

Do you find this type of information useful? Follow my blog for more updates. #medicalbilling #medicalcoding #reimbursement

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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…

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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!

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Posted in MVP (NY/VT) Insurance Payer, NY Providers, Payer Updates, Payers and CPT reinbursement

MVP (NY/VT)- Reimbursement sick visit and Preventative Care on the same day.

Posted on by KR2Medical Billing

Effective 5/1/23 MVP insurance payer will start to reimburse 50% for the E&M code that represents the sick visit and is billed on the same day as the preventative E&M code.

The providers should expect this reduction to apply to the code even if the modifier 25 is appended on the sick E&M code.

This update in reimbursement applies to both NY and VT providers.

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

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

Posted on by KR2Medical Billing

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).

Find this type of content useful, then follow my blog for more medical billing and coding guideline updates, reimbursement policy changes, and more!

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