Tag: #priorauthorization

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 #reimbursement, NY Providers, Prior Authorization Insurance Carrier Updates, Training

FidelisCare-concurrent prior auth update for family and group therapy services.

Posted on by KR2Medical Billing

This update will apply to any dos of Jan 1, 2026 and thereafter.

This update does not apply to SUD services/ providers that are certified as Article 32.

29-I providers are also excluded from the concurrent prior authorization requirenments.

Services affected:

Family Psychotherapy – CPT Code 90847

Group Psychotherapy – CPT Code 90853   

FidelisCare members have 30 visits per code/per calendar year.*

*Calendar year is defined as Jan 1st to Dec 31st

After the initial 30 visits the provider will have to submit a concurrent authorization request using the Family and Group Psychotherapy Form along with additional required information: (partial list)

1.Member and provider information, such as Member Full Name, ID and Date of Birth, Provider ID/TIN and Servicing Address
2. Type of service requested & CPT codes (Family Psychotherapy 90847 or Group Psychotherapy 90853)
3. First service date
4. Duration and intensity of requested services
5. Clinical goals, objectives, and rationale
6. Place of service (e.g. office)

7. A treatment plan with measurable goals
8. Recent progress notes
9. Recent psychiatric evaluation/biopsychosocial

In addition, please include the following:

1. How well does the individual cope with adversity, use supports, and community resources? 

2. Treatment & Recovery History

3. Engagement in Services and Recovery Status: Is member engaged in treatment?

How soon should the providers submit the concurrent authorization request?

Up to 30 days in advance of the 30th visit.

For a full list of required information please visit click here for FAQs.

Find this type of information useful? Follow my blog for more!

Posted in #aetna, #Medicareadvantage, #reimbursement, NY Providers, Prior Authorization Insurance Carrier Updates, Training

Aetna Medicare Advantage: reminder- certain post acute, skilled nursing and home health require pre- approval

Posted on by KR2Medical Billing

This change applies to the providers located in the following states:

NJ, NY, PA, VW

The pre-apporoval applies to some post-acute , skilled nursing, and home health services.

The following HCPCS are affected:

  • G0151: Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes.
  • G0153: Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes.
  • G0155: Services of a clinical social worker in home health or hospice settings, each 15 minutes. 
  • All the codes until G0162

As well as the following codes:

G0299- Direct skilled nursing services of a Registered Nurse (RN) in the home health or hospice setting, each 15 minutes.

G0300-Direct skilled nursing services of a Licensed Practical Nurse (LPN) in the home health or hospice setting, each 15 minutes.

G0463- Skilled services by a Registered Nurse (RN) for observing and assessing a patient’s condition.

G0496- Skilled services by a Licensed Practical Nurse (LPN) for training or educating a patient or family member.

Inpatient Revenue code:

128- daily medical management, skilled rehab services, and regular physician (MD/NP/PA) oversight for intensive rehab patients

Skilled Nursing levels: 1,2,3,4.

Pre-auth process:

1. Go to EviCore.

2.Call 1-888-622-7329 during normal business hours.

3.Fax a request form to 866-705-3574 (Aetna Home Health), 855-633-8631 (AETNA PAC Initial) or 877- 502-0810 (AETNA PAC Concurrent)

For any urgent requess, when  member requires services in less than 48 hours, please call eviCore.

Find this information useful? Follow my blog for more information about current medical billing, coding and reimbursement policies.