Tag: #physicaltherapy

Posted in MVP (NY/VT) Insurance Payer, Training, Updates

MVP Medicare Patients-KX modifier

Posted on by KR2Medical Billing

If you are a physician that provides PT/OT/ST services to MVP Medicare Patients, then this blog post is for you!

KX modifier should NOT be used when the member did not exhaust that member’s PT/OT/ST benefits.

Claims that require a therapy cap exception and are billed with the KX modifier must:
• Qualify for the therapy cap exception
• Be medically reasonable and necessary services that require the skills of a therapist
• Be justified by appropriate documentation in the medical records and would be available for review upon request

Providers: Please log on to the MVP website and verify member benefits to see that member met their annual PT/OT/ST visit cap.

If you find this type of information useful? Follow my blog for more medical billing and coding guidelines, medical policy/reimbursement policy changes and anything else healthcare related.

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#physicaltherapy, #occupationaltherapy #MVP #MVPmedicare #medicalbilling #medicalcoding

Posted in #unitedhealthcare, Training, Updates

UHC Community Health Plan: Maryland Medicaid PT/ST/OT prior auth req

Posted on by KR2Medical Billing

This blog refers to physical therapy, occupational therapy, and speech therapy that is done by Maryland Providers for Maryland Medicaid members that are 21 years and older.

As of May 1, 2022, all Maryland Medicaid (UHC community health plan) members will require a prior authorization in order to receive physical therapy, occupational therapy and/or speech therapy.

Important things to remember:

These requirements will apply whether a member is new to therapy or will continue receiving therapy

Prior authorization isn’t required for emergency or urgent services!

UHC community health plan (Maryland) will deny claims if prior authorization is not on file before the date of service, and you won’t be able to balance bill the member!

Medical necessity review
When the provider submits a prior authorization request starting May 1, 2022, UHC Community health plan (Maryland) will review your request for medical necessity. We will provide an authorization, if appropriate and send that determination to you and the member.

To help ensure members that are currently under your care do not experience disruption of services, providers may initiate a continuity of care request. UHC Community Health plan of Maryland will allow an approval for the current episode of care or 90 days, whichever is less, to continue upon receipt of the request and completed plan of care.

For the full list of therapy codes, reference the list of current prior authorization plan requirements for Maryland Medicaid.

Providers can submit requests for these services with dates of service on or after May 1, 2022, online using the Prior Authorization and Notification tool. Providers must submit a completed plan of care to prevent any disruption in services.

If you have any questions: please call 877-842-3210.

Find this blog post informative? Follow my blog for more prior authorization changes, medical coding and billing guideline updates, reimbursement/medical policy updates, various insurance payer general updates, and much more!

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Posted in #aetna, #Medicareadvantage, Training, Updates

Aetna Medicare Advantage: Home Health Program in KY, OH, MO

Posted on by KR2Medical Billing

Since 08/01/2021 Aetna has partnered with myNEXUS, a technology-enabled care management company, to manage the network, claims payment and precertification/prior authorization program for home health services.

Note the following changes for the Providers:

Prior approval changes:

  1. Effective for DOS 01/01/2022 and thereafter, myNEXUS will require advance approval for all home-health-related requests for in-home skilled nursing, physical therapy, occupational therapy, speech therapy, home health aide, and medical social work.
  2. If you would like to view the full home health care pre-auth list, please click here (insert link)

Claim Payment and Processing changes:

  1. Effective for DOS 01/01/2022 and thereafter, myNEXUS will pay claims for covered home health services, for Kentucky, Ohio and Missouri Medicare Advantage members
  2. Reimbursement rates will correspond to the rates and terms of your myNEXUS contract.

Important!

1.These above changes apply only to the Aetna Medicare Advantage Members that reside in the three states, and/or Aetna Medicare Advantage DSNP members, in the above mentioned 3 states.

2. These changes DO NOT APPLY TO THE FOLLOWING:

Medicare members residing outside of the states of Kentucky, Ohio and/or Missouri

Aetna and Coventry commercial fully insured HMO/POS/PPO plans • Aetna administrative services only (ASO) self-funded HMO/POS/PPO plans

Aetna Student Health℠

Aetna Global Business • Coventry Workers’ Compensation  

Cofinity®

First Health®, Meritain® Health, Traditional Choice®

Aetna Signature Administrators® 

Where do I order a prior approval?

  1. Online: myNEXUS portal to get started or

2. Fax the authorization request form to 1-866-996-0077

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