FLASH: Three Important Updates
April 6, 2021Coding Update Notice
As of January 1, 2021, the CPT code G0297 has been deleted and replaced with the new code 71271 for Low Dose CT for Lung Cancer Screening. Our claims system has already been updated to reflect this.
UM Provider Weekend Coverage
Our Utilization Management department will be changing our processes for prior authorizations for weekend immediate discharge needs, effective Saturday, May 1, 2021. Please follow the instructions below and utilize the checklists provided for Skilled Nursing Facility and Ambulance prior authorization requests. This update will streamline the referral process for our members and providers, helping us provide timely determination decisions for immediate discharge needs.
PROVIDER PROCESS FOR WEEKEND URGENT AUTHORIZATION REQUESTS
- This on-call service is limited to urgent immediate discharge needs for members in the emergency department or an observation bed, needing our authorization for ambulance or inpatient post-acute prior authorization on a Saturday or Sunday.
- One of our staff members is available each Saturday from 9 a.m. to 2 p.m. for urgent authorization needs as described above.
- All requests for prior authorization must be received by 12 noon to allow for research, physician contact (if needed for approval/denial) and entering the authorization into the UM software system.
- The hospital case management staff member or Post-Acute Care (PAC) facility case manager will submit requests via fax to us, utilizing the checklists provided (Skilled Nursing Facility/Ambulance).
- Please fax the completed and signed checklists to (217) 902-9712.
- Phone contact is available if needed for questions, by leaving a voicemail at (217) 902-8949. Our on-call staff member will then return the call before 2 pm.
- The checklists are specific to Medicare guidelines and our medical policies, which are used to evaluate for appropriateness of an approval or denial determination. It’s expected that the hospital or PAC case management staff complete the questions on the checklists to confirm validity of clinical and demographic information and sign it to confirm validity of the information.
Key Points:
- This weekend service is limited to urgent discharge needs only (for example, members in observation or ED status who require acute care treatment and then meet criteria for Skilled Nursing Facility services and are ready for discharge prior to Monday).
- The checklist must be completed in its entirety, including the name of the accepting facility and – most importantly – the confirmation that the member meets the skilled care requirement and the signature of the hospital/PAC case manager to provide confirmation of this.
- Please print and distribute the checklists to your staff for use:
- Please continue to obtain prior authorization for members who’ve been admitted to the acute care hospital during our regular business hours of Monday through Friday, 8 a.m. – 5 p.m.
Education and Training Programs
Effective March 1, 2021, our health plans are not covering these codes – we’re listing them as a provider write-off, so it’s also not billable to the member. This is applicable to all our product lines.
Education and Training Programs: In general, our plans do not cover group education and training programs. Similar to Medicare, Health Alliance™ does not cover S-codes. These (that we don’t cover) include, but are not limited to, those submitted with the CPT/HCPCS codes below:
CPT/HCPCS Code and Description:
98960 Education and training for patient self-management by a qualified, non-physician healthcare professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient.
98961 Education and training for patient self-management by a qualified, non-physician healthcare professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; 2 – 4 patients.
98962 Education and training for patient self-management by a qualified, non-physician healthcare professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; 5 – 8 patients.
99078 Physician or other qualified healthcare professional qualified by education, training, licensure/regulation (when applicable) educational services rendered to patients in a group setting (e.g. prenatal, obesity or diabetic instructions).
G0177 Training and educational services related to the care and treatment of patient’s disabling mental health problems per session (45 minutes or more).
S9140 Diabetic management program, follow-up visit to non-MD provider.
S9141 Diabetic management program, follow-up visit to MD provider.
S9441 Asthma education, non-physician provider, per session.
S9442 Birthing classes, non-physician provider, per session.
S9444 Parenting classes, non-physician provider, per session.
S9445 Patient education, not otherwise classified, non-physician provider, individual, per session.
S9446 Patient education, not otherwise classified, non-physician provider, group, per session.
S9447 Infant safety (including CPR) classes, non-physician provider, per session.
S9449 Weight management classes, non-physician provider, per session.
S9451 Exercise classes, non-physician provider, per session.
S9452 Nutrition classes, non-physician provider, per session.
S9454 Stress management classes, non-physician provider, per session.
S9455 Diabetic management program, group session.
S9460 Diabetic management program, nurse visit.
S9465 Diabetic management program, dietitian visit.
However, please note that diabetes training is covered under the codes below:
G0108 Diabetes outpatient self-management training services, individual, per 30 minutes.
G0109 Diabetes outpatient self-management training services, group session (two or more), per 30 minutes.
As always, if you have any questions, please contact your provider relations specialist. Thank you for all you do to take care of our members.