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Midwest April Newsletter

Infertility Preauthorizations Move Back to Your Health Alliance

We will be reverting back to how infertility was preauthorized prior to eviCore, so you should submit requests on Your Health Alliance for providers and office personnel.

Any ultrasounds ordered to establish a diagnosis of infertility should be submitted through eviCore, as these fall under the patient’s medical benefit until the diagnosis of infertility has been made.

If you have questions about this information, contact your provider relations specialist.

Preauthorization Updates

We will be sharing regular updates about functionality changes to our preauthorization tools – Clear Coverage, eviCore, and Health Alliance preauthorization forms.

eviCore

Finish Later and Attach Clinicals Later

  • This has been updated so provider offices can choose Finish Later to come back to an authorization within 2 business days. This also allows you to attach the clinicals before submitting a preauthorization.

OB Ultrasounds

  • At this time, multiple OB ultrasounds cannot be batched into one authorization request.
  • Submit separate authorizations when multiple exams are requested.
  • We’re working with eviCore for a solution, and we will keep you updated as changes occur.

Breast Ultrasounds

  • Do not require preauthorization.

OB/GYN Codes Flipped

  • From time to time, users experienced changes to CPT codes within the eviCore system. This issue has been corrected, and OB/GYN offices should no longer be seeing this problem.

Can’t Choose Rendering Provider

  • As of March 13, we’ve corrected the issue that you could not choose providers, including physicians, hospitals, and imaging centers, as the rendering provider or site. (You will no longer receive the message, “not certified for this program” when you make this selection.)

Rendering Provider vs. Ordering Provider

  • Rendering provider and ordering provider are the same as long as the rendering provider is not a hospital or imaging center.

Don’t Use the Enter Key on Your Keyboard

  • eviCore requires you to choose select, continue, or submit on a preauthorization. If you use the Enter key on your keyboard, the preauthorization will be lost, and it will take you back to the beginning.

Clear Coverage

Call with Inpatient Home Health Discharges Preauths

  • Preauthorizations for patients being discharged from an inpatient setting to home health will be handled by calling our medical management department. Use Clear Coverage for all outpatient home health preauthorizations.

Missing CPT Codes

  • The missing CPT codes for home health have been updated and can now be selected.

2017 Commercial Provider Manual Available

You can find the commercial provider manual for all of our plans in the Forms & Resources section of Your Health Alliance for providers. In it, you’ll find more information about:

  • Our Quality Improvement program, including its purpose, goals, objectives, scope, structure, key personnel, and technical resources and systems
  • Our complex case management program and how to refer a member
  • How to access and request our utilization management and pharmaceutical management criteria
  • Affirmative statement about incentives related to UM decision making
  • When decision timeframes begin for non-urgent pre-service requests received after 
business hours
  • How to use our pharmacy management procedures and processes, including our 
formulary, pharmaceutical classes, tier information, preauthorization, managed dose limitations, step-therapy, generic substitution, pharmacy savings programs, and how to request a medical exception
  • Our disease management programs, including what we do and how you and your patients can access program services
  • A comprehensive list of clinical guidelines, including non-preventive and preventive, as well as behavioral health
  • Preventive care guidelines for all age groups
  • Members’ rights and responsibilities

Meet with a Coding Specialist

The risk adjustment coding consultants are continuing to request meetings with high-volume participating provider offices. These meetings are designed to share member-specific examples of coding and quality measure needs and to update providers on the latest efforts to educate on risk adjustment. Along with member specific examples, there is information on yearly risk adjustment data validation (RADV) audits, and how provider practice participation is essential in this process.

A member of the coding consultant team is willing to meet with you to discuss any coding or quality questions you may have, or to provide member-specific examples from your panel of members. If interested, contact us at CodingCounts@healthalliance.org.

New Provider Relations Specialists

We’re excited to welcome Abby Klitzing to our provider relations specialist team. She’s responsible for the local service area to the West, which includes Macon, Moultrie, Shelby, Dewitt, Fayette, Effingham, McLean, and Woodford counties, and all regional dialysis and home infusion providers.

If you’re a provider in one of these areas, you can reach Abby at 217-383-8240 or Abby.Klitzing@healthalliance.org.

We’re also excited to welcome Kelly Cagle to our team. She’s responsible for the local service area to the North, which includes Champaign, Clark, Coles, Crawford, Cumberland, Douglas, Edgar, Jasper, and Vermillion counties in Illinois, and Warren, Fountain, Parke, Putnam, Vigo, Clay, Sullivan, and Vermillion counties in Indiana, and all regional DME/orthotics and prosthetics providers.

If you’re a provider in one of these areas, you can reach Kelly at 217-255-4730 or Kelly.Cagle@healthalliance.org.

Pharmacy Updates

Commercial

Tier Changes – Effective April 1, 2017

  • Zortress – Moved from Tier 2 to Tier 5 (Non-Preferred Specialty)
    • Must be ordered through CVS Specialty

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