InforMED

FLASH: What’s the “Advantage” of Medicare Advantage Plans?

October 9, 2017

The Annual Enrollment Period is almost here! We can help you be prepared to field patient questions about Medicare. Providers and their office staff members are invited to join one of our upcoming webinars to learn more about our Medicare Advantage plans. 

We’ll discuss original Medicare and Medicare Advantage plans, how they differ, and the benefits Medicare Advantage plans offer both members and providers. Our Provider Relations staff will also be available to answer your questions. 

Choose the webinar you’re interested in to register:

Note: All times are Central.

FLASH: New Process for New Therapy Preauthorization Requests through eviCore

September 20, 2017

For the first therapy request received during a patient’s episode of care, these are the minimum numbers of visits you can expect:

Pediatric Cases

  • Will receive a minimum of 12 visits over 90 days

Post-Surgical Cases

  • Will receive a minimum of 12 visits in 45 days

All Other Cases

  • Will receive a minimum of 6 visits over 30 days

Providers should continue to send eviCore basic information, like member information and provider information, to create a case through Your Health Alliance for providers or on the phone.

eviCore will then ask a few questions to figure out if you’re seeking a pediatric, post-surgical, or other type of preauthorization. It will also ask 3 to 5 questions in the clinical portion of the case to determine if more visits are appropriate and to help streamline the process for future visits.

You aren’t required to submit any additional clinical information or any specific answers to any of these questions in order to receive the minimum number of approved visits above.

This process is for new requests only and works best for cases submitted online or on the phone. Cases started by fax will not be processed quickly.

There are no changes to the way eviCore will handle subsequent therapy requests at this time. Providers may receive additional visits immediately online or on the phone. They may still be required to submit clinical information for therapist review.

If you have any questions, contact your provider relations specialist.

Requesting Split-Night Sleep Studies

There have been a few questions about requesting split-night sleep studies, so we’ve put together the details for you to review:

  1. When you start a preauthorization for a split-night study on eviCore through Your Health Alliance for providers, request CPT 95811.

  2. While you’re building the case, eviCore will ask if this is a planned split-night study. Choose Yes.

  3. Don’t be alarmed if you receive authorization for 95810 instead of 95811. If the case meets eviCore’s guidelines, approval will be granted for 95810 instead of 95811 because the member might not actually need a split-night study once the test begins.

  4. If you end up performing only 95810, bill CPT 95810. If you end up performing the split-night, bill CPT 95811.

  5. Our claim system will pay for the CPT code you’ve billed on the claim, regardless of the code that was approved on the eviCore preauthorization.

We hope this answers all of your questions. If you still have concerns, contact your provider relations specialist.

FLASH: eviCore Spine Surgery Clinical Criteria Update

September 11, 2017

Starting September 15, preauthorizations for spine surgery will no longer require documentation of patient-reported outcome measures, including the modified Japanese Orthopaedic Association (mJOA), Short Form Health Survey Score/Mental Component Summary (SF-36 MCS) or the Oswestry Disability Index (ODI).

Any cases currently in the appeal process that were denied based solely on these requirements will be overturned and approved.

We still recommend that providers identify and help patients with reasonably modifiable medical and behavioral health co-morbidities improve before elective spine surgery.

If you have any questions, contact your provider relations specialist.

Understanding eviCore’s Therapy Approval Letters

eviCore lists both the number of visits and the number of service units approved on the therapy approval letters sent to members and providers. Some providers have asked us how they should manage care based on units when their services are visit-based. We want you to know that we manage claims based on visits only, not units.

Even though we aren’t using them, we’ve decided to leave the units on the approval letters since some providers might use that information in internal processes.

If you have any questions, contact your provider relations specialist.

Eliminating Antiemetics Preauthorizations

Preauthorizations for antiemetics will no longer be required. When members need these drugs, we don’t want you to have to worry about getting a preauthorization from us first.

We have removed these codes from eviCore, so you can no longer try to get a preauthorization:

  • Akynzeo
  • Aloxi
  • Emend IV
  • Emend oral
  • Sustol

If you have any questions, contact your provider relations specialist.

FLASH: Hurricane Irma and eviCore

September 8, 2017

Because of the likely impact of Hurricane Irma on eviCore’s contact centers in Florida and South Carolina, they are enacting their disaster response plan. They expect this will impact their operations between Saturday, September 9 and Tuesday, September 12. Because of this, you may experience longer phone hold times than normal.

Please use eviCore online through Your Health Alliance for providers to start authorization requests and to check on a case’s status during this time. eviCore’s clinical staff is available to help with cases submitted online faster.

We appreciate your patience and understanding as eviCore works to ensure their employees are able to return to safe living and working conditions and to bring their company back to full operations as quickly as possible after the event.

FLASH: Atenolol Backorder and Shortage

August 24, 2017

We received notice that atenolol, a common blood pressure medication, is on a national backorder, and all manufacturers are having supply issues. As a result, pharmacies in our service areas have been running out of the medication and calling providers for substitutions.

Formulary alternatives include these cardioselective beta-blockers:

  • Acebutolol
  • Bisoprolol
  • Metoprolol

We are unsure how long this shortage is going to last, so we wanted to make providers aware so that patients aren’t left without medication. If you have any questions, contact our pharmacy department at 1-800-851-3379, option 4.

Eliminating Chiropractic Referrals with eviCore

Now that we have partnered with eviCore, members will no longer need a referral from their primary care provider (PCP) for chiropractic visits.

Members can go directly to their chiropractor to start their care. Their chiropractor will use the Request Preauthorization tab on Your Health Alliance for providers to submit the request online and provide medical documentation to eviCore. If the request meets medical necessity criteria, eviCore will review and approve the initial visit and future visits. This must be completed within 7 days after the initial visit.

The request can also be submitted up to 14 days before the first treatment visit, but eviCore requires medical documentation from the chiropractor or PCP that’s no more than 10 days old. Most chiropractors find it easiest to request preauthorization after the evaluation visit, since they can include their notes with the request.

If you have any questions, contact your provider relations specialist.