December 2016 - In this issue

What's new for 2017?

CMS rule for providers prescribing Medicare Part D drugs, now effective in 2019
Recent provider headlines

What's new for 2017?

Here's a recap of information you need to know about policies and changes effective Jan. 1, 2017, plus updates on pharmacy, coding and product changes.

Newly designed ConnectiCare ID cards for all members

Claims processing information for Medicare Advantage members

We told you last month that we are issuing newly designed ID cards as members renew their commercial and Medicare Advantage plans after Jan. 1. (Review the article.)

We're also issuing new ID numbers to Medicare Advantage members. To avoid any delays in your claims payments, please use the new member ID numbers when submitting Medicare claims for services after Jan. 1, 2017. Claims for 2017 services with old member ID numbers may be denied and returned for resubmission.

How to submit Medicare claims for services that start in 2016 and extend into 2017

If you are submitting claims for:

  • Inpatient claims that start in 2016 and end in 2017, you only have to use the old Medicare member ID number.
  • Outpatient claims that start in 2016 and end in 2017, please split your submission into two separate claims:
    • Services before Jan. 1, 2017, use the old Medicare member ID number; and
    • Services on or after Jan. 1, 2017, use the new Medicare member ID number.

New "Passage" referral plans for commercial and Medicare members

We are launching new plans called "Passage" for some of our commercial and Medicare Advantage members on Jan. 1, 2017. Passage plans will require members to get primary care provider (PCP) referrals to see any specialists in our ConnectiCare network.

Members with Passage plans have to:

  • Designate a PCP from one of three participating physician groups ─ CliniSanitas, Connecticut State Medical Society ─ Independent Practice Association (including Starling physicians) and ProHealth Physicians.
  • Get PCP referrals to see any specialists in the ConnectiCare network.

As we announced earlier, we are limiting participation in the plan's PCP network to three primary care groups in 2017, our pilot year.

Our new member ID cards will clearly indicate members who have Passage plans and who will need referrals for specialists' care. See illustrations below:

Medicare Advantage Card

Medicare Advantage Member ID Card

Exchange Card

ConnectiCare Exchange Member ID Card
(commercial)

Group Card

ConnectiCare Group Member ID Card
(commercial)

PCPs: What you need to know about Passage
If you do not belong to one of three participating physician groups, you should not provide primary care services to members with Passage plans. If you do provide such services, we will unfortunately have to deny the claims and tell members they are responsible for the costs. (For Passage members with individual plans through Access Health CT, the Connecticut insurance exchange, the claims will be paid under their out-of-network benefits.)

Specialists: What you need to know about Passage
Referrals are needed for specialist care of any member with Passage plans. Passage members will be able to see any specialist in the ConnectiCare provider network as long as they have valid referrals from their Passage PCPs. Without referrals, we will deny claims for specialists' consultation services and tell members they are responsible for the costs.

You will be able to find out if a member has a proper referral by calling one of our provider services representatives. You can also check with the member's Passage PCP for verification.

Referrals will not be required when Passage members need hospital and/or ancillary care services, such as radiology and lab work.

Breast tomosynthesis screening, 3-D mammography, will be covered by fully-insured commercial plans starting Jan. 1

We will cover breast tomosynthesis screening, a three-dimensional mammogram, for all our fully-insured commercial members in 2017. The member's cost-share will depend on his or her benefits plan.

Preauthorization will not be required for this service, which the state of Connecticut mandates be included in all fully-insured individual and employer-sponsored plans that are new and renewing after Jan. 1, 2017.

Our coverage of this service, identified with a procedure code of 77063, will be as follows:

  • For employer-sponsored large group plans, we will cover the service as preventive as long as it is coded and meets the same age and frequency requirements as a routine, preventive annual mammogram:

    Procedure code: 77063
    Frequency: Once a year*
    Other requirements: women age 40 and older
    • The member will have no cost-share if these guidelines are followed.
    • If these guidelines are not followed, then the member will have to pay any applicable non-advanced radiology cost-share listed in his or her benefits plan.
    • Coverage will begin only after a large group renews on or after Jan. 1. So if one of your patients has a plan that will renew on Feb. 1, 2017, we will only cover the service if the claim was submitted with a date of service on or after Feb. 1, 2017. Any claims submitted prior to the renewal date will be denied.
  • For Connecticut small group and individual plans, which include ConnectiCare SOLO and ConnectiCare plans sold through AccessHealth CT, the state insurance exchange, we will cover the service, and the member will have to pay the applicable non-advanced radiology cost-share as listed in his or her benefits plan.
    • Coverage will begin only after the plan renews on or after Jan. 1. So if one of your patients has a plan that will renew on Feb. 1, 2017, we will only cover the service if the claim was submitted with a date of service on or after Feb. 1, 2017. Any claims submitted prior to the renewal date will be denied.

*Please note: employer-sponsored plans for municipalities do not have visit limitations.

Payment of Part D vaccine claims, starting Jan. 1 – Medicare only

Starting Jan. 1, 2017, Medicare Part D vaccines must be submitted under the member's Part D prescription drug benefit — not under the member's Part B medical benefit.

Part D vaccines include, but are not limited to the following:

  • Human papillomavirus (HPV)
  • Measles, Mumps and Rubella (MMR)
  • Meningitis
  • Shingles
  • Varicella

This means we will not pay claims for Part D vaccines administered in a physician's office and submitted under the Part B medical benefit. This is consistent with guidance from the Centers for Medicare & Medicaid Services (CMS).

Register on TransactRx for free
If you wish to continue administering these vaccines in your office, please use TransactRx, an electronic claims adjudication portal that allows physicians to electronically submit vaccine claims under their patient's Part D benefit. TransactRx will send payments directly to you twice a month for your submitted claims.

TransactRx can also help your patients minimize their upfront, out-of-pocket costs for vaccines. Go to www.transactrx.com/physician-vaccine-billing for details.

If you do not want to submit vaccine claims through TransactRx, please send your patients to a pharmacy to get the vaccines.

EmblemHealth to include ConnectiCare providers in one of its networks in 2017 ─ Commercial only

Our parent company, EmblemHealth in New York, will expand one of its commercial provider networks to include ConnectiCare network providers in Connecticut as of Jan. 1, 2017.

This means EmblemHealth Prime members will be able to get medical care and services under their in-network benefits from ConnectiCare providers like you.

Some EmblemHealth members will present ID cards that include a ConnectiCare logo as of Jan. 1, 2017, but others will not. EmblemHealth will update member ID cards throughout the year.

What to expect and resources available
Your name, address, hours and other information will be included in the EmblemHealth provider directory. EmblemHealth members may contact your office or organization for treatment. EmblemHealth may auto-assign you as a primary care provider for some members living close to your office.

If you treat members of EmblemHealth, please refer to emblemhealth.com/providers for EmblemHealth's medical and pharmacy policies, eligibility requirements and claims submission processes. Register on the EmblemHealth website so you have the information and resources you need.

It's always best to check a patient's eligibility on EmblemHealth's website before providing care. You can also call EmblemHealth's provider services at 1-866-447-9717 for assistance.

New 2017 codes

Each year billing codes are updated by the American Medical Association. Please refer to the 2017 manuals for Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) as resources.

We're in the process of updating our system for new 2017 codes. Claims submitted with new codes for covered services will be noted on the explanation of payment (EOP) statements with an explanation code of Z0 that states "New code, rate not yet established, will be adjudicated by March 31, 2017." This applies to commercial and Medicare plans.

We will automatically adjust claims with new, covered codes that are submitted between January and March 31, 2017. Providers do not need to resubmit the claims. When the adjustments are made and claims paid, an EOP will be generated to inform providers that the payment includes adjustment of the new codes that paid $0 upon initial submission.

Changes to the Medicare Advantage payments process

We will, on Jan. 1, 2017, begin processing our Medicare Advantage electronic payments to providers through the Bank of America, the same bank we use for our commercial providers. This will affect Medicare providers who have opted into electronic fund transfers (EFTs) and 835 electronic remittance advices (ERAs).

As a result, Medicare providers who have opted into electronic payments will:

  • Continue to receive payments through PNC for services on or before Dec. 31, 2016. This also means providers who want to access their 835 ERAs for any dates of service in 2016 will need to check PNC Bank's Remittance Advantage.
  • Get EFT payments deposited directly to the provider's bank account for any payments of services on or after Jan. 1, 2017. This means providers who want to access 835 ERAs for any dates of service in 2017 will need to check their own clearinghouses for the information.

CMS rule for providers prescribing Medicare Part D drugs, now effective in 2019

Earlier this year, we told you that the Centers for Medicare & Medicaid Services (CMS) will require all providers who prescribe Medicare Part D drugs to either be enrolled in an approved status with CMS or have filed an opt-out affidavit as of Feb. 1, 2017. That effective date has since been moved to Jan. 1, 2019. Here's the original October 2016 Office Visit article for your reference. We'll keep you updated as we get more guidance and news from CMS.

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