Buckeye Health Plan has chosen Availity Essentials as its new, secure provider portal. Starting January 20, 2025 you can validate eligibility and benefits, submit claims, check claim status, submit authorizations, and access Buckeye Health Plans payer resources via Availity Essentials.

If you are already working in Essentials, you can log in to your existing Essentials account to enjoy these benefits for Buckeye’s members beginning January 20, 2025:   

• Use Availity Essentials to verify member eligibility and benefits, submit claims, check claim status, currently submit authorizations, and more.
• Look for additional functionality in Buckeye’s payer space on Essentials and use the heart icon to add apps to My Favorites in the top navigation bar. Our current secure portal will still be available for other functions you may use today.
• Access Manage My Organization – Providers to save provider information. You can then auto-populate that information repeatedly to eliminate repetitive data entry and reduce errors. 

If you are new to Availity Essentials, getting your Essentials account is the first step toward working with Buckeye Health Plan on Availity.

Getting started: Designate an Availity administrator for your provider organization

Your provider organization’s designated Availity administrator is the person responsible for registering your organization in Essentials and managing user accounts. This person should have legal authority to sign agreements for your organization.

HOW DOES THIS IMPACT ME?	WHAT IS MY NEXT BEST STEP?
I am the administrator.   I am the designated Availity administrator for my organization.	Visit Register and Get Started with Availity Essentials to enroll for training and access other helpful resources.
I am not the administrator.   I am NOT the designated Availity administrator for my organization.	Your designated Availity administrator will determine who needs access to Availity Essentials on behalf of your organization and will add user accounts in Essentials.
I am not sure.   I am not sure who will be the designated Availity administrator for my organization.	Share this information with your manager to help determine who will be the designated Availity administrator for your organization.

Check out some of the time-saving tools that come with an Availity Essentials account: 

• Verify member eligibility and benefits, submit claims, check claim status, and currently submit authorizations.  
• Look for additional functionality in Buckeye’s payer space and use the heart icon to add apps to My Favorites in the top navigation bar.  
• Save provider information in Essentials and auto-populate it to save time and prevent errors.  

Join one of our upcoming free webinars, Availity Essentials Overview for Buckeye, to learn additional tips for streamlining your workflow. We’ll show you how to verify eligibility and benefits, submit claims, check claim status, submit authorizations, and more.   

We're excited to welcome you to Availity Essentials, helping you transform the way you impact patient care with Buckeye Health Plan. If you need additional assistance with your registration, please call Availity Client Services at 1-800-AVAILITY (282-4548). Assistance is available Monday through Friday, 8 a.m. – 8 p.m. ET. For general questions, please reach out to your Buckeye Health Plan Provider Relations Administrator.

Medicaid members are required to renew their benefits every year to keep their coverage. Buckeye Health Plan conducts outreach directly to our members to remind them when they need to renew and how they can complete their renewal. This process is called Redetermination through the Ohio Department of Medicaid. Members can renew their health care coverage online at www.benefits.ohio.gov, by calling the ODM Consumer Hotline at 1-844-640-6446 or by visiting their local Ohio Department of Job and Family Services (ODJFS) location. To help with this process, we have added each member’s Redetermination Date to Buckeye’s Secure Provider Portal. When you login, you’ll see the member’s Redetermination Date located just below their address on the Overview tab. See the sample image for reference. 

In a continuous effort to make it easier to do business with Ambetter from Buckeye Health Plan, we are introducing Availity Editing Services (AES). Starting Jan. 24, 2025, Centene is partnering with Availity to return rejection messages on its behalf via AES messages. These messages will show in your existing workflows. AES will give you an option, but not a requirement, to edit a claim.

AES can identify a claim error upfront and return a message to you for correction before sending the claim on to the plan to be adjudicated.

• You should review Edit Messages for potential corrections to the suggested claim line(s). If you make updates to the claim, this may help the claim process correctly the first time, preventing errors, improving payment accuracy, and claims adjudication turnaround time.
• If, after reviewing the message, you find it does not apply, please resubmit the claim “As-Is” to allow a bypass of the edit in cases where it may not be applicable.

This is not intended as a new method to deny a claim, nor does it bypass or replace downstream edits. If you choose to bypass an edit, it is possible that other downstream edits will still function as normal in our claims systems. Remember to “submit” your claim regardless of your choice to edit or bypass. This action is required for the claim to be processed in our systems.

If you have a Practice Management System (PMS), you can locate your edits report within your claims workbasket or que reporting. If you submit claims via the Availity portal, any of these rejections will show on your normal reports.

If you need assistance with registering for Availity Essentials, please call Availity Client Services at 1-800-AVAILITY (282-4548). Assistance is available Monday through Friday, 8 a.m. – 8 p.m. ET. 

If you choose to submit claims via Availity, join one of Availity’s free webinars to learn additional tips for streamlining your workflow:

• Send and Receive EDI Files – Training Demo
  This demo shows users where/how they can access reports in Availity Essentials. On these reports are where they would see edits. Please note: this demo does not say/call it AES however, this is the demo that would show the user how to locate the reports.
• EDI Reporting Preferences – Training Demo
  This demo shows users how to setup their EDI Reporting Preferences which needs to be done first by the user’s organization’s Availity Administrator to access the reports in the Send and Receive EDI Files application.

For general questions, please reach out to your Ambetter from Buckeye Health Plan Provider Engagement Administrator.

As of September 30, 2024, there is a change in the way Medicare covers antiretroviral therapy that is approved by the U.S. Food and Drug Administration (FDA) to prevent human immunodeficiency virus (HIV) infection in individuals at high risk of acquiring HIV. Use of these medications to prevent HIV infection is known as pre-exposure prophylaxis (PrEP).

Based on new Medicare coverage rules, medications prescribed for PrEP will be covered under Medicare Part B without cost sharing (i.e., deductibles or copays) as an additional preventive service. PrEP medications will no longer be covered under the Medicare Part D benefit. Medications for HIV treatment and HIV post-exposure prophylaxis (PEP) will remain coverable under Medicare Part D.

The table below lists the medications that are FDA-approved to be used as PrEP for HIV prevention. Please note that some of these medications are also FDA-approved to be used for HIV treatment.

As of September 30, 2024, Apretude will no longer be covered under Medicare Part D since it is only FDA-approved for PrEP for HIV prevention. In addition, Descovy, Truvada, and generics for Truvada will be covered only under Medicare Part B when used for PrEP for HIV prevention but will remain covered under Medicare Part D when used for HIV treatment.A diagnosis code should be included on all prescriptions if you are prescribing one of these medications for PrEP for HIV prevention.

Brand Drug Name	Generic Drug Name	FDA-Approved Use
Apretude®	cabotegravir	PrEP for HIV prevention
Descovy®	emtricitabine and tenofovir alafenamide	PrEP for HIV prevention HIV treatment
Truvada®	emtricitabine and tenofovir disoproxil fumarate	PrEP for HIV prevention HIV treatment
emtricitabine and tenofovir disoproxil fumarate (generic for Truvada)	emtricitabine and tenofovir disoproxil fumarate	PrEP for HIV prevention HIV treatment

As a valued member of the Buckeye Health Plan network, we are providing this important notification for you. 

Ohio Department of Medicaid (ODM) notified Buckeye Health Plan some 835 files from June of 2024 were not received by ODM and therefore some providers may not have received necessary remits.   If you were impacted and have not received every remit, those remits can be retrieved by logging into Payspan.  

If you should have further questions, please reach out to Provider Services, Monday through Friday 7am to 8pm at 866-296-8731.

Thank you again for being a valued provider for our members, your patients.

A New Program That Makes Rx Drugs  More Affordable by Allowing Medicare Members  to Spread Their Prescription Costs Over Time

Passed into law August 2022 by President Biden, H.R. 5376 — Inflation Reduction Act (IRA) includes policies on Medicare drug pricing. The IRA significantly reforms the Medicare Part D benefit design, including a new program, Medicare Prescription Payment Plan (M3P), which will be available to all eligible Medicare members¹, beginning Jan. 1, 2025.

Program Overview for Eligible Participating Medicare Members¹

• Financial benefits to all Medicare members¹ in 2025 include an elimination of the coverage gap and capping the maximum out-of-pocket (OOP) prescription costs at $2,000 annually — which beneficiaries can spread across the plan year.
• M3P participants will pay $0 at the pharmacy for covered Part D drugs and be billed monthly for any cost-sharing they incur while in the program. Importantly, this will help them manage prescription costs by enabling them to spread their monthly payments over time.
• Payment might change every month as additional prescriptions are filled.
• The program is voluntary, and eligible members can choose to opt-in to the program during the annual enrollment period and throughout the plan year. Members can conveniently opt-in via online, by phone, or mail.

o   Online: express-scripts.com/mppp

o   Phone: 833-750-9969

o   Mail:

Mail Express Scripts Medicare
Prescription Payment Plan
P.O. Box 2
St. Louis, MO 63166

• Existing members will receive additional information in their Annual Notice of Change.
• New members will receive additional information within 10 days of confirmed enrollment.

¹Excludes plans that solely charge $0 cost sharing for Part D covered drugs. See your plan’s Evidence of Coverage for more details.

Questions or Concerns?

As always, we encourage you to use the resources on Medicare.gov/prescription-payment-plan or contact your Provider Services team.

Earlier this month Buckeye Health Plan joined the World Health Organization (WHO) in recognizing and creating awareness of World Patient Safety Day. This day is as an opportunity to raise public awareness and foster collaboration between patients, health workers, policymakers and health care leaders to improve patient safety.

This year, the theme is “Improving diagnosis for patient safety” with the slogan “Get it right, make it safe!”, highlighting the critical importance of correct and timely diagnosis in ensuring patient safety and improving health outcomes.

According to the World Health Organization, diagnostic errors account for 16% of preventable patient harm and are common in all health care settings. These can include missed, incorrect, delayed, or miscommunicated diagnoses and can have significant consequences.

We encourage you to visit the WHO Patient Safety Day to find the latest research, resources, and suggested diagnostic interventions to help improve diagnostic safety.

Additional great resources on Patient Safety and diagnostic safety can also be found from the Agency for Healthcare Research and Quality:

Toolkit for Engaging Patients to Improve Diagnostic Safety and

Team Strategies and Tools to Enhance Performance & Patient Safety (TeamSTEPPS)

Thank you for helping ensure the health and safety of our communities.

Does the two-midnight benchmark apply to Medicare Advantage plans?

Yes. Medicare Advantage plans must provide coverage and pay for an inpatient admission when, based on consideration of complex medical factors (e.g., history and comorbidities, the severity of signs and symptoms, current medical needs, the risk of an adverse event occurring during hospitalization) documented in the medical record, the admitting physician expects the patient to require hospital care that crosses two midnights.¹  Medicare Advantage Plans may still use prior authorization or concurrent case management review to determine if the complex medical factors are sufficiently documented in the medical record to support medical necessity of the inpatient admission.² 

Does the two-midnight rule presumption apply to Medicare Advantage plans?

No. The presumption that all inpatient claims that cross two midnights are appropriate for payment and therefore should not be the focus of medical review does not apply to Medicare Advantage Plans. The two-midnight presumption directs medical reviewers to select Original Fee-for-Service Medicare Part A claims for review under a presumption that hospital stays that span two midnights after an inpatient admission are reasonable and necessary Part A payment.³

Does Wellcare by Allwell utilize medical necessity criteria?

Yes. Medicare Advantage plans such as Wellcare may apply internal coverage criteria when coverage criteria is not fully established in Medicare laws, national coverage determinations and/or local coverage determinations. As such, Medicare Advantage plans are permitted to create their own internal coverage criteria based upon widely-used treatment guidelines or clinical criteria, and may use coverage criteria products such as InterQual® or the like.⁴

Is the two-midnight benchmark enough to qualify an inpatient admission for coverage?

No. Wellcare by Allwell reviews inpatient admissions within the context of the patient’s medical record to evaluate whether the patient’s documented complex medical factors support hospital care that exceeds two midnights. As stated above, Wellcare by Allwell reviewers may consider other coverage criteria such as InterQual when conducting medical necessity reviews.

Can stays less than 24 hours qualify for inpatient admission payment?

In the majority of cases, hospital stays less than 24 hours do not meet criteria for payment as an inpatient stay. However, hospital services that do not exceed two midnights may be medically necessary in certain cases, such as an unexpected death, patient departure against medical advice, election of hospice in lieu of continued treatment in a hospital, and for a procedure on the CMS Inpatient Only List.

Does Wellcare by Allwell follow the case-by-case exception?

Yes. Generally, medical necessity will be met if an admitting physician does not expect a patient to require hospital care exceeding two midnights, but determines, based on complex medical factors documented in the medical record, that inpatient care is nonetheless necessary.5

^1. 88 Fed.Reg. 222120, 22191 (April 12, 2023)

^2. Id. at 22192

^3. Id

^4. Id. at 22194-22195

^5. Id. at 22191

Per Gainwell Technologies, the Medicaid Single Pharmacy Benefit Manager:

Effective 9/1/2024, the following medications will require prior authorization for Medicaid Managed Care Plan members if there is not already an active PA on file:

-          Bydureon Bcise (exenatide)

-          Mounjaro (tirzepatide)

-          Ozempic (semaglutide)

-          Rybelsus (semaglutide)

A letter has been sent out to members that may be affected by this policy. 

Prescribers can submit a prior authorization electronically, by faxing Gainwell Pharmacy Services at 833-679-5491, or by calling 833-491-0344 (TTY 833-655-2437). Submissions for these medications will be reviewed according to the Ohio Medicaid Unified Preferred Drug List (UPDL) clinical criteria.

For more details, visit SPBM    

1.       Select “Reference Material”

2.       Then “Unified Preferred Drug List”

3.       And view “UPDL criteria effective 07.01.2024”

As part of our all-MCO CPT II Workgroup initiative, we would like to announce an upcoming virtual training offering presented by ArchProCoding. This is an EMR agnostic beginning-level training, meant to identify best practices related to how clinical providers accurately document their care and diagnoses. We are also excited to announce that there will be an opportunity for CEUs provided with this training. This 90-minute training will be offered on two different dates:

• September 24 (10:00 a.m.)
• September 25 (2:00 p.m.)

If you have questions or would like to be added to the communication list for this training, please email MHOVBR@molinahealthcare.com. We hope to see you there!

PA Changes

Procedure Code	Procedure Code Description	New Standard	Line of Business
97110	THERAPEUTIC EXERCISES	Pre-authorization is required after 8 Physical or Occupational Therapy visits for All Providers	Medicaid
97010	HOT OR COLD PACKS THERAPY	Pre-authorization is required after 8 Physical or Occupational Therapy visits for All Providers	Medicaid
97140	MANUAL THERAPY 1/> REGIONS	Pre-authorization is required after 8 Physical or Occupational Therapy visits for All Providers	Medicaid
97113	AQUATIC THERAPY/EXERCISES	Pre-authorization is required after 8 Physical or Occupational Therapy visits for All Providers	Medicaid
97112	THERAP PROC 1/> AREAS EA 15 MIN; BALANCE/COORDIN	Pre-authorization is required after 8 Physical or Occupational Therapy visits for All Providers	Medicaid
97039	PHYSICAL THERAPY TREATMENT	Pre-authorization is required after 8 Physical or Occupational Therapy visits for All Providers	Medicaid
97530	THERAPEUTIC ACTIVITIES	Pre-authorization is required after 8 Physical or Occupational Therapy visits for All Providers	Medicaid
97533	SENSORY INTEGRATION	Pre-authorization is required after 8 Physical or Occupational Therapy visits for All Providers	Medicaid
G0151	SRVC PT HOM HLTH/HOSPICE EA 15 MIN	Pre-authorization is required for All Providers	Medicaid
G0152	SRVC OT HOM HLTH/HOSPICE EA 15 MIN	Pre-authorization is required for All Providers	Medicaid
G0153	SRVC SPCHANDLANG PATH HH/HOSPIC EA 15	Pre-authorization is required for All Providers	Medicaid
E1390	OXY CNCNTRTR/1 DLVRY PORT/CPBLE OF DLVRNG 85%OR>OXY CNCNTRTN	Pre-authorization is required after 30 days from start of service date for ALL Providers	Medicaid
E1391	OXY CNCNTRTR/DUAL DLVRY PRT/CPBL DLVRNG 85%OR>OXY CNCNTRTN	Pre-authorization is required after 30 days from start of service date for ALL Providers	Medicaid
E1392	PORTABLE OXYGEN CONCENTRATOR	Pre-authorization is required after 30 days from start of service date for ALL Providers	Medicaid
E0470	RSPRTRY DVCE/BI-LVL PRESS CPLTY/WOUT BCKP RATE FTRE/W NNINVSV INTRFC	Pre-authorization is required after 30 days from start of service date for ALL Providers	Medicaid
E0471	RSPRTRY DVCE/BI-LVL PRESS CPLTY/W BCKP RATE FTRE/W NNINVSV INTRFC	Pre-authorization is required after 30 days from start of service date for ALL Providers	Medicaid
E0601	CONTINUOUS AIRWAY PRESSURE (CPAP) DEVICE	Pre-authorization is required after 30 days from start of service date for ALL Providers	Medicaid

In preparation for expanded coverage for Doula Services under Ohio Medicaid, Buckeye is reaching out to our partner practices and medical groups,  and independent practitioners in the Doula Community with an interest in providing these  services for our members. ODM is hosting a series of training sessions for doulas starting in September and registration for that training series can be found on the ODM doula webpage.  Additional details are shown in the article below. 

Over the coming months, Buckeye will also be conducting training and rolling out resources and tools to onboard our new partners in care.  If you are interested in learning more, or would like to be included in upcoming trainings, please contact Mindy Ridgeway at melinda.ridgeway@centene.com.  Include in the subject line, "Doula Resources"

Upcoming Doula Trainings

The Ohio Department of Medicaid (ODM), along with our partners at the Ohio Board of Nursing (BON) and Medicaid Managed Care Organizations (MCO), will be hosting a training series for doulas. We hope that anyone interested in becoming a certified doula in the State of Ohio with the intent to serve Ohio Medicaid members, will register for this training series. Each virtual training session date and time, along with a quick snapshot of the agenda, can be found below. Registration for the training series can be found on the ODM doula webpage.

• Training session 1: Tuesday, September 10 from 1:30 p.m.-3:30 p.m.
  • Medicaid 101, National Provider Identifier (NPI) basics, BON certification process, ODM provider enrollment process
• Training session 2: Thursday, September 26 from 10 a.m.-12 p.m.
  • MCO 101 and contracting process
• Training session 3: Tuesday, October 29 from 1:30 p.m.-3:30 p.m.
  • MCO claims billing and prior authorization process
• Training session 4: Thursday, November 7 from 10 a.m.-12 p.m.
  • Fee-for-service billing and prior authorization process
• Training session 5: Thursday, November 21 from 12:30 p.m.-2 p.m.
  • Related maternal health topics overview

Register Here

We are pleased to announce that we recently added a new form on our website to allow providers to indicate on their profile that they offer Telehealth services. See our Telehealth section to learn where to find the form and tips from ODM on how to Announce Telehealth Availability.

Medicare Policy Changes Eff 11-11-24

Policy Number	Policy Title	Effective Date of Revision	Payment Edit	Revision Notes	Sent though CPC	CCO subsets updated with criteria change	Changes or No Changes to Policy?
MC.CP.MP.101	Donor Lymphocyte Infusion	4/30/2024	No	Annual review. Minor rewording in Description with no impact on criteria. Background updated with no impact on criteria. References reviewed and updated. Reviewed by external specialist.	Yes	Medicare Donor Lymphocyte Infusion	No Changes
MC.CP.MP.160	Implantable Wireless Pulmonary Artery Pressure Monitoring	4/30/2024	No	Annual review. Description updated with no impact to criteria. References reviewed and updated. Reviewed by external specialist.	Yes	Medicare Implantable Wireless Pulmonary Artery Pressure Monitoring	No Changes
MC.CP.MP.170	Peripheral Nerve Blocks	4/30/2024	No	Annual review. Added the following note under section I. “If administered as part of a surgery or other procedure, coding for peripheral/ganglion nerve blocks should follow proper coding practices and would not be subject to prior authorization or payment separately from the procedure.” Added “and neurolysis” to III.B. References reviewed and updated.	Yes	Medicare Peripheral Nerve Blocks	With Changes
MC.CP.MP.182	Short Inpatient Hospital Stay	4/30/2024	No	Annual review. Updated criteria I.A. by removing 2023 inpatient only link. Updated description and background with no clinical significance. References reviewed and updated.	Yes	Medicare Short Inpatient Hospital Stay	No Changes
MC.CP.MP.246	Pediatric Kidney Transplant	4/30/2024	No	Annual review. Updated contraindication I.B.2., adding a.-c. References reviewed and updated. Reviewed by external specialist.	Yes	Medicare Pediatric Kidney Transplant	With Changes
MC.CP.MP.57	Lung Transplantation	4/30/2024	No	Annual review. Updated I.C.2. from GFR < 40 mL/min/1.73m2 to GFR < 30 mL/min/1.73m2. Expanded I.C.9. with qualifying criteria for members who are HIV positive. Updated I.D.2.a.1. from FEV1<25% to FEV1<30%. Background updated with no impact to criteria. References reviewed and updated.	Yes	Lung Transplantation	With Changes
MC.CP.MP.69	Intesity-Modulated Radiotherapy	4/30/2024	No	Annual review. Description updated with no impact to criteria. Added criteria I.B.8. Hodgkin’s and non-Hodgkin’s lymphoma in close proximity to critical structures; I.B.9. Select rectal cancer cases where there is lymph node involvement or require treatment of the inguinal lymph nodes; I.B.10. Soft tissue sarcoma when organ at risk dose constraints cannot be met. References reviewed and updated. Reviewed by external specialist.	Yes	Medicare Intensity-Modulated Radiotherapy	With Changes
CP.CPC.03	Preventative Health and Clinical Practice Guideline Policy	4/30/2024	No	Updated and added guidelines to CPG grid	Yes	N/A	N/A
	CPG Grid	4/30/2024	No	Updated link and title for USPSTF Adult Preventive Service Recommendations under Preventive Care (Adults). Added USPSTF Adolescents and Pediatric Preventive Service Recommendations under Preventive Care (Pediatrics). Added Zero Suicide Consensus Guide for Emergency Departments under Suicidal Behavior.	Yes	N/A	With changes, added guidelines
V2.2024	CG Aortopathies Connective Tissue	4/30/2024	No	Semi-annual review. Updated title to reflect V2.2024 version. In Known Familial Variant Analysis for Aortopathies and Connective Tissue Disorders criteria, moved criteria to policy “Genetic Testing: General Approach to Genetic and Molecular Testing” to consolidate criteria for known familial variant tests. In FBN1 Sequencing and/or Deletion/Duplication Analysis criteria, made a minor expansion to criteria to better align with guidelines and allow for coverage of genetic testing for individuals with a clinical diagnosis of Marfan syndrome. In criteria for Loeys-Dietz Syndrome Multigene Panel, removed minimum gene list. In Classic Ehlers-Danlos syndrome (cEDS) Multigene panel criteria, made a minor expansion in gene list to align with current test offerings on the market and removed COL1A1 from the minimum gene list. In Familial Thoracic Aortic Aneurysm and Dissection (TAAD) Multigene Panel criteria, removed minimum gene list. In Other Covered Connective Tissue Disorders criteria, genes added to disease name in list for consistency and to provide further clarity. Minor rewording for clarity throughout. Coding, reference-table, background and references updated.	Yes	Concert Genetics Navigator in InterQual (not considered CCO)	With changes
V2.2024	CG Cardiac Disorders	4/30/2024	No	Semi-annual review. Updated title to reflect V2.2024 version. For Known Familial Variant Analysis for Cardiac Disorders, moved criteria to policy “Genetic Testing: General Approach to Genetic and Molecular Testing” to consolidate criteria for known familial variant tests. For Left Ventricular Non-Compaction Cardiomyopathy Panels, retired criteria set based on rarity of testing. For Familial Hypercholesterolemia, removed criteria point requiring a definitive genetic diagnosis prior to medication eligibility. Minor rewording for clarity throughout. Coding, reference-table, background and references updated.	Yes	Concert Genetics Navigator in InterQual (not considered CCO)	With changes
V2.2024	CG Dermatologic Conditions	4/30/2024	No	Semi-annual review. Updated title to reflect V2.2024 version. In Known Familial Variant Analysis for Dermatologic Conditions criteria, moved criteria to policy “Genetic Testing: General Approach to Genetic and Molecular Testing” to consolidate criteria for known familial variant tests. In Epidermolysis Bullosa Multigene Panels criteria, retired criteria set based on rarity of testing (low order volume and low claim volume). In Congenital Ichthyosis Multigene Panels criteria, removed minimum gene list; at present there is limited rationale for inclusion. Minor rewording for clarity throughout. Coding, reference-table, background and references updated.	Yes	Concert Genetics Navigator in InterQual (not considered CCO)	With changes
V2.2024	CG Epilepsy Neurodegenerative and Neuromuscular Disorders	4/30/2024	No	Semi-annual review. Updated title to reflect V2.2024 version. In Known Familial Variant Analysis for Epilepsy, Neurodegenerative, and Neuromuscular disorders criteria, moved criteria to policy “Genetic Testing: General Approach to Genetic and Molecular Testing” to consolidate criteria for known familial variant tests. In HTT Repeat Analysis criteria, added age restriction for testing (18 or older). In Amyotrophic Lateral Sclerosis (ALS) Multigene Panel criteria, removed age restriction for testing (18 or older) given there are childhood onset forms of ALS. In PMP22 Sequencing and/or Deletion/Duplication Analysis or Multigene Panel criteria, removed minimum gene list; at present there is limited rationale for inclusion. In PSEN1, PSEN2, and APP Sequencing and/or Deletion/Duplication Analysis criteria, Clarified age requirement for symptomatic individuals diagnosed at or over age 66 (previous criteria stated “any age”). Minor rewording for clarity throughout. Coding, reference-table, background and references updated.	Yes	Concert Genetics Navigator in InterQual (not considered CCO)	With changes
V2.2024	CG Exome Genome Sequencing	4/30/2024	No	Semi-annual review. Updated title to reflect V2.2024 version. In Reanalysis of Exome or Genome Sequencing Data criteria, expanded to allow a path to approval for patient to get reanalysis prior to 18 months if they have new qualifying findings (supported by PLUGS). In Standard Exome Sequencing criteria, minor expansion in coverage in response to client feedback to remove burdensome criteria and better align with guidelines (e.g., bilateral sensorineural hearing loss of unknown etiology plus one other eligible clinical finding is now covered under the policy). In Standard Exome Sequencing criteria, minor restriction - changed developmental delay definition to “global developmental delay” based on medical director feedback and to be consistent with guidelines. In Rapid Exome Sequencing criteria, minor expansion in coverage in response to client feedback to remove burdensome criteria and better align with guidelines (e.g., bilateral sensorineural hearing loss of unknown etiology plus one other eligible clinical finding is now covered under the policy). In Rapid Exome Sequencing criteria, removed “diagnosed at any age” from unexplained epilepsy criteria statement, since rapid exome sequencing is only appropriate for individuals 12 months of age or younger. Removed “intellectual disability” and “autism” from criteria set, since rapid exome sequencing is only appropriate for individuals 12 months of age or younger and these cannot be diagnosed until an older age Minor restriction - changed developmental delay definition to “global developmental delay” based on medical director feedback and to be consistent with guidelines. In Standard Genome Sequencing criteria, minor expansion in coverage in response to client feedback to remove burdensome criteria and better align with guidelines (e.g., bilateral sensorineural hearing loss of unknown etiology plus one other eligible clinical finding is now covered under the policy). In Standard Genome Sequencing, minor restriction - changed developmental delay definition to “global developmental delay” based on medical director feedback and to be consistent with guidelines. In Rapid Genome Sequencing criteria, minor expansion in coverage in response to client feedback to remove burdensome criteria and better align with guidelines (e.g., Epileptic encephalopathy is now an eligible clinical finding covered under the policy). In Reanalysis of Exome or Genome Sequencing Data criteria, criteria set name changed (formerly “Reanalysis of Whole Exome Sequencing Data”). Minor rewording for clarity throughout. Coding, reference-table, background and references updated.	Yes	Concert Genetics Navigator in InterQual (not considered CCO)	With changes
V2.2024	CG Eye Disorders	4/30/2024	No	Semi-annual review. Updated title to reflect V2.2024 version. In Known Familial Variant Analysis for Eye Disorders criteria, moved criteria to policy “Genetic Testing: General Approach to Genetic and Molecular Testing” to consolidate criteria for known familial variant tests. In Inherited Retinal Dystrophies Multigene Panel Analysis criteria, criteria set name changed (formerly “RPE65 Sequencing and/or Deletion/Duplication Analysis”). Clinical criteria updated to be more consistent with guidelines. In Glaucoma criteria, retired criteria set based on rarity of testing (low order volume and low claim volume). Minor rewording for clarity throughout. Coding, reference-table, background and references updated.	Yes	Concert Genetics Navigator in InterQual (not considered CCO)	With changes
V2.2024	CG General Approach to Genetic and Molecular Testing	4/30/2024	No	Semi-annual review. Updated title to reflect V2.2024 version. In General Criteria for Oncology Algorithmic Tests criteria, minor expansion of criteria to be consistent with guidelines (added “suspected neoplasm and/or malignancy” to the coverage criteria, previously only allowed for confirmed neoplasm). Criteria set name changed (former name: Oncology Algorithmic Tests). Updated coverage criteria assessing for clinical validity and utility. In General Criteria for Known Familial Variant Analysis for a Genetic Condition criteria, several Known Familial Variant criteria moved to policy “Genetic Testing: General Approach to Genetic and Molecular Testing” to consolidate criteria for known familial variant tests. Removed subjective criteria point: “The genetic condition is associated with a significant health problem or problems.” In Single Gene or Multigene Panel Analysis criteria, updated coverage criteria assessing for clinical validity and utility. Removed subjective criteria point: “Genetic testing for the suspected genetic condition has been scientifically validated to improve health outcomes (i.e., the test has been shown to have clinical utility).” In General Criteria for Targeted Carrier Screening criteria, moved criteria FROM policy “Genetic Testing: Prenatal and Preconception Carrier Screening” to align with other general coverage criteria tests. In General Criteria for Tumor Biomarker Analysis criteria, criteria set name changed (former name: General Tumor Biomarker Analysis). Updated coverage criteria assessing for clinical validity and utility. In General Criteria for Other Tests criteria, criteria set name changed (former name: Other Tests). Updated coverage criteria assessing for clinical validity and utility. Minor rewording for clarity throughout. Coding, reference-table, background and references updated.	Yes	Concert Genetics Navigator in InterQual (not considered CCO)	With changes
V2.2024	CG Hearing Loss	4/30/2024	No	Semi-annual review. Updated title to reflect V2.2024 version. In Known Familial Variant Analysis for Hereditary Hearing Loss criteria, moved criteria to policy “Genetic Testing: General Approach to Genetic and Molecular Testing” to consolidate criteria for known familial variant tests. Minor rewording for clarity throughout. Coding, reference-table, background and references updated.	Yes	Concert Genetics Navigator in InterQual (not considered CCO)	With changes
V2.2024	CG Hematologic Conditions Non-Cancerous	4/30/2024	No	Semi-annual review. Updated title to reflect V2.2024 version. In Known Familial Variant Analysis for Hematologic Conditions (non-cancerous) criteria, moved criteria to policy “Genetic Testing: General Approach to Genetic and Molecular Testing” to consolidate criteria for known familial variant tests. Minor rewording for clarity throughout. Coding, reference-table, background and references updated.	Yes	Concert Genetics Navigator in InterQual (not considered CCO)	With changes
V2.2024	CG Hereditary Cancer Susceptibility	4/30/2024	No	Semi-annual review. Updated title to reflect V2.2024 version. In CDKN2A Sequencing and/or Deletion/Duplication Analysis criteria, now COVERED to align with guidelines, which recommend genetic risk assessment for specific clinical indications. In Hereditary Breast Cancer Susceptibility Panels criteria, removed PALB2 testing criteria and PALB2 gene from the minimum gene list to reduce redundancy, given these criteria overlap with the BRCA1/BRCA2 testing criteria. In Hereditary Breast Cancer Susceptibility Panels criteria, removed criteria point (“The member is 18 years or older”) to reduce redundancy, given this criteria point overlaps with the BRCA1/BRCA2 testing criteria. In Hereditary Prostate Cancer Susceptibility Panels criteria, clarified criteria to better align with existing guidelines and allow for coverage of genetic testing for additional clinical indications. Further clarified and simplified criteria based on client feedback (wording clarification). In Hereditary Neuroendocrine Cancer Susceptibility Panels criteria, clarified and simplified criteria to better align with existing guidelines. Removed minimum gene list; at present there is limited rationale for inclusion. In BRCA1 and BRCA2 Sequencing and Deletion/Duplication Analysis criteria, minor expansion to criteria to be consistent with guidelines and allow for coverage of genetic testing for additional clinical indications (added ampullary adenocarcinoma as an indication). Clarified and simplified criterion based on client feedback (wording clarification). In PALB2 Sequencing and/or Deletion/Duplication Analysis criteria, minor expansion to criteria to be consistent with guidelines and allow for coverage of genetic testing for additional clinical indications (added ampullary adenocarcinoma as an indication). Clarified and simplified criteria based on client feedback (wording clarification). In MLH1, MSH2, MSH6, PMS2, or EPCAM Targeted Variant Analysis criteria, criteria set name changed (former name: MLH1, MSH2, MSH6, PMS2, or EPCAM Targeted Mutation Analysis). In MLH1, MSH2, MSH6, PMS2, or EPCAM Sequencing and/or Deletion/Duplication Analysis criteria, clarified criteria to better align with guidelines. In RB1 Sequencing and/or Deletion/Duplication Analysis criteria, clarified family history criterion to streamline format. In RET Sequencing and/or Deletion/Duplication Analysis criteria, removed “diagnosis of primary C cell hyperplasia” from criteria for testing to align with updated guidelines. In TP53 Sequencing and/or Deletion/Duplication Analysis criteria, Added “family history of pediatric hypodiploid ALL” as a criterion for testing to align with updated guidelines. Clarified criteria based on client feedback (wording clarification). In FLCN Sequencing and/or Deletion/Duplication Analysis criteria, clarified first degree relative criteria to be consistent with this category of testing. In SMAD4 and/or BMPR1A Sequencing and/or Deletion/Duplication Analysis criteria, removed criterion point D (pathogenic or likely pathogenic mutation detected on tumor profiling) as this criterion is covered in another section of this policy. Minor rewording for clarity throughout. Coding, reference-table, background and references updated.	Yes	Concert Genetics Navigator in InterQual (not considered CCO)	With changes
V2.2024	CG Immune, Autoimmune, and Rheumatoid Disorders	4/30/2024	No	Semi-annual review. Updated title to reflect V2.2024 version. In Known Familial Variant Analysis for Immune, Autoimmune, and Rheumatoid Disorders criteria, moved criteria to policy “Genetic Testing: General Approach to Genetic and Molecular Testing” to consolidate criteria for known familial variant tests. In HLA Typing for Axial Spondylarthritis criteria, updated criteria to clarify name of the condition. Minor rewording for clarity throughout. Coding, reference-table, background and references updated.	Yes	Concert Genetics Navigator in InterQual (not considered CCO)	With changes
V2.2024	CG Kidney Disorders	4/30/2024	No	Semi-annual review. Updated title to reflect V2.2024 version. In APOL-1 Targeted Variant Testing criteria, criteria set name changed (formerly “Targeted Variant Analysis”). Minor rewording for clarity throughout. Coding, reference-table, background and references updated.	Yes	Concert Genetics Navigator in InterQual (not considered CCO)	With changes
V2.2024	CG Lung Disorders	4/30/2024	No	Semi-annual review. Updated title to reflect V2.2024 version. In SERPINA1 Common Variant Analysis or Sequencing and/or Deletion/Duplication Analysis criteria, updated criteria to better align with current guidelines, allowing for an expansion to coverage. In SERPINA1 Known Familial Variant Analysis criteria, moved criteria to policy “Genetic Testing: General Approach to Genetic and Molecular Testing” to consolidate criteria for known familial variant tests. Minor rewording for clarity throughout. Coding, reference-table, background and references updated.	Yes	Concert Genetics Navigator in InterQual (not considered CCO)	With changes
V2.2024	CG Metabolic, Endocrine and Mitochondrial Disorders	4/30/2024	No	Semi-annual review. Updated title to reflect V2.2024 version. In Known Familial Variant Analysis for Metabolic, Endocrine, and Mitochondrial Disorders, moved criteria to policy “Genetic Testing: General Approach to Genetic and Molecular Testing” to consolidate criteria for known familial variant tests. In Monogenic Diabetes (Including Maturity-Onset Diabetes of the Young (MODY)) Panels, criteria set name changed (formerly “Maturity-Onset Diabetes of the Young (MODY)”). Minor rewording for clarity throughout. Coding, reference-table, background and references updated.	Yes	Concert Genetics Navigator in InterQual (not considered CCO)	With changes
V2.2024	CG Multisystem Inherited Disorders, ID and Developmental Delay	4/30/2024	No	Semi-annual review. Updated title to reflect V2.2024 version. In Known Familial Variant Analysis for the Multisystem Inherited Disorders, moved criteria to policy “Genetic Testing: General Approach to Genetic and Molecular Testing” to consolidate criteria for known familial variant tests. In NF1 Sequencing and/or Deletion/Duplication, additional criterion added to be consistent with guidelines. In Noonan Spectrum Disorders/RASopathies Multigene Panel, removed minimum gene list; at present there is limited rationale for inclusion. In Fanconi Anemia Multigene Panel, Removed minimum gene list; at present there is limited rationale for inclusion. minor rewording for clarity throughout. Coding, reference-table, background and references updated.	Yes	Concert Genetics Navigator in InterQual (not considered CCO)	With changes
V2.2024	CG Non-invasive Prenatal Screening	4/30/2024	No	Semi-annual review. Updated title to reflect V2.2024 version. Minor rewording for clarity throughout. Coding, reference-table, background and references updated.	Yes	Concert Genetics Navigator in InterQual (not considered CCO)	With changes
V2.2024	CG Oncology Algorithmic Testing	4/30/2024	No	Semi-annual review. Updated title to reflect V2.2024 version. In Evidence Based Cutaneous Melanoma Prognostic Algorithmic Tests, now COVERED for specific cutaneous melanoma prognostic algorithmic tests, based on Concert Evidence Review demonstrating clinical validity and utility. In Evidence Based Lung Cancer Diagnostic Algorithmic Tests, now COVERED for specific lung cancer diagnostic algorithmic tests, based on Concert Evidence Review demonstrating clinical validity and utility. In Cutaneous Melanoma Risk Assessment Algorithmic Tests, now COVERED for specific cutaneous melanoma risk assessment algorithmic tests, based on review of guidelines and current literature, which demonstrated clinical validity and utility. In Evidence Based Prostate Cancer Risk Assessment and Diagnostic Algorithmic Tests, now COVERED for specific prostate cancer risk assessment and diagnostic algorithmic tests based on guidelines. In Prostate Cancer Diagnostic Algorithmic Tests, consolidated criteria into the Evidence Based Prostate Cancer Risk Assessment and Diagnostics Algorithmic Tests coverage criteria. In Emerging Evidence Prostate Cancer Diagnostic and Algorithmic Tests, NEW - Created separate criteria to distinguish between tests with varying levels of evidence for validity and guideline support. In Emerging Evidence Cutaneous Melanoma Prognostic Algorithmic Tests, NEW - Created separate criteria sets to distinguish between tests with varying levels of evidence for validity and guideline support. In Emerging Evidence Lung Cancer Diagnostic Algorithmic Tests, NEW - Created separate criteria sets to distinguish between tests with varying levels of evidence for validity and guideline support. In Oncology Test Specific Not Covered Algorithmic Tests, moved criteria to policy “Genetic Testing: General Approach to Genetic and Molecular Testing” to consolidate general coverage criteria for new algorithmic tests. Minor rewording for clarity throughout. Coding, reference-table, background and references updated.	Yes	Concert Genetics Navigator in InterQual (not considered CCO)	With changes
V2.2024	CG Oncology Cancer Screening	4/30/2024	No	Semi-annual review. Updated title to reflect V2.2024 version. Minor rewording for clarity throughout. Coding, reference-table, background and references updated.	Yes	Concert Genetics Navigator in InterQual (not considered CCO)	With changes
V2.2024	CG Oncology Circ Tumor DNA Tumor Cells Liquid Biopsy	4/30/2024	No	Semi-annual review. Updated title to reflect V2.2024 version. In Broad Molecular Profiling Panel Tests via Circulating Tumor DNA (ctDNA), minor expansion of criteria to be consistent with guidelines (added several tumor types for coverage). In Colorectal Cancer Focused Panel Tests via Circulating Tumor DNA (ctDNA), clinical criteria removed due to lack of currently available tests for this indication. In Lung Cancer Focused Panel Tests via Circulating Tumor DNA (ctDNA), minor clarification of criteria to update staging of cancer types to better align with guidelines, and removed additional tissue criteria to better align with guidelines. In Melanoma Focused Panel Tests via Circulating Tumor DNA (ctDNA), clinical criteria removed due to lack of currently available tests for this indication. In EGFR Variant Analysis via ctDNA, updated criteria to align with current guidelines. Minor expansion via removal of requirement that tissue testing be unavailable, to align with updated guidelines. In BRAF Variant Analysis via ctDNA, updated criteria to align with current guidelines. Minor expansion via removal of requirement that tissue testing be unavailable, to align with updated guidelines In KRAS Variant Analysis via ctDNA, updated criteria to align with current guidelines. Minor expansion via removal of requirement that tissue testing be unavailable, to align with updated guidelines. Minor rewording for clarity throughout. Coding, reference-table, background and references updated.	Yes	Concert Genetics Navigator in InterQual (not considered CCO)	With changes
V2.2024	CG Oncology Cytogenetic Testing	4/30/2024	No	Semi-annual review. Updated title to reflect V2.2024 version. In Tumor Specific ALK Gene Rearrangement (Qualitative FISH and PCR) Tests, minor expansion of criteria to be consistent with guidelines (added several tumor types for coverage). Tumor Specific BCR/ABL Gene Rearrangement (Qualitative FISH and PCR) Tests, moved criteria and combined with BCR/ABL1 criteria in the Solid Tumor and Hematological Malignancies policy to align with the clinical use of these tests. In Tumor Specific ERBB2 (HER2) Deletion/Duplication (FISH and CISH), minor expansion of criteria to be consistent with guidelines (added several tumor types for coverage). In NTRK Fusion Analysis Panel, Minor expansion of criteria to be consistent with guidelines (added several tumor types for coverage). In Tumor Specific FOLR1 Protein Analysis, Clarified ovarian cancer pathology. In Tumor Specific RET Gene Rearrangement Tests (FISH0), minor expansion of criteria to be consistent with guidelines (added several tumor types). In Tumor Specific ROS1 Gene Rearrangement, minor expansion of criteria to be consistent with guidelines (added several tumor types for coverage). Minor rewording for clarity throughout. Coding, reference-table, background and references updated.	Yes	Concert Genetics Navigator in InterQual (not considered CCO)	With changes
V2.2024	CG Oncology Molecular Analysis of Solid Tumor and Hem Malignancies	4/30/2024	No	Semi-annual review. Updated title to reflect V2.2024 version. In Broad RNA Fusion Panels, now COVERED, for acute lymphoblastic leukemia. In Tumor-Type Agnostic Solid Tumor Molecular Profiling Panels, minor expansion of criteria to be consistent with guidelines (added several tumor types for coverage). In Tumor Specific BCR/ABL1 FISH, Qualitative, and Quantitative Tests, criteria set name changed (formerly “Tumor Specific BCR/ABL1 Quantitation and Breakpoint Analysis”). Criteria updated to include indication for diagnostic testing. In Tumor Mutational Burden (TMB), minor expansion of criteria to be consistent with guidelines (added several tumor types for coverage). In Colorectal Cancer Focused Molecular Profiling Panels, clinical criteria updated to be consistent with guidelines. In Tumor Specific BRAF Variant Analysis, minor expansion of criteria to be consistent with guidelines (added several tumor types for coverage). In Tumor Specific BRCA1/2 Variant Analysis, clarification requirements for pancreatic cancer diagnosis to better align with guidelines. In Tumor Specific CALR Variant Analysis, clarification of criteria wording to be more clear/streamlined. In Tumor Specific FLT3 Variant Analysis, minor expansion of criteria to be consistent with guidelines (added tumor type for coverage). In Tumor Specific KRAS Variant Analysis, minor expansion of criteria to be consistent with guidelines (added several tumor types for coverage). In Tumor Specific Microsatellite Instability (MSI) Analysis, minor expansion of criteria to be consistent with guidelines (added tumor type for coverage). Clarified qualifying stages of other cancers to be consistent with guidelines. In Overview and Clinical Considerations, policy overview updated to include information from the Clinical Considerations section, which has been consolidated into the Overview section. Minor rewording for clarity throughout. Coding, reference-table, background and references updated.	Yes	Concert Genetics Navigator in InterQual (not considered CCO)	With changes
V2.2024	CG Pharmacogenetics	4/30/2024	No	Semi-annual review. Updated title to reflect V2.2024 version. In Warfarin Sensitivity Analysis Panels, clinical criteria section added to allow coverage of small targeted panels for this indication. Minor rewording for clarity throughout. Coding, reference-table, background and references updated.	Yes	Concert Genetics Navigator in InterQual (not considered CCO)	With changes
V2.2024	CG Preimplantation Genetic Testing	4/30/2024	No	Semi-annual review. Updated title to reflect V2.2024 version. In Overview and Clinical Considerations, Policy overview updated to include information from the Clinical Considerations section, which has been consolidated into the Overview section. Minor rewording for clarity throughout. Coding, reference-table, background and references updated.	Yes	Concert Genetics Navigator in InterQual (not considered CCO)	With changes
V2.2024	CG Prenatal and Preconception Carrier Screening	4/30/2024	No	Semi-annual review. Updated title to reflect V2.2024 version. In HBA1, HBA2, or HBB Sequencing and/or Deletion/Duplication Analysis, updated criteria to align with current ACOG recommendations for universal hemoglobinopathy screening. In General Criteria for Targeted Carrier Screening, moved criteria to policy “Genetic Testing: General Approach to Genetic and Molecular Testing” to align with other general coverage criteria tests. In HBA1, HBA2, or HBB Targeted Variant Analysis, several clinical criteria were removed to better align with Guidelines. In CFTR Targeted Variant Analysis, criteria set name changed (formerly “CFTR Known Familial Variant Analysis”). In Ashkenazi Jewish Carrier Panel Testing, genes added to disease names in list for consistency and to provide further clarity. Professional society corrected from ACMG to ACOG. In Expanded Carrier Screening Panels, added note with clarifying language to indicate that if 81243 is billed with 81443, the patient should still meet Fragile X criteria. In  FMR1 Repeat Analysis, added note with clarifying language to indicate that if 81243 is billed with 81443, the patient should still meet Fragile X criteria. In HBA1, HBA2, or HBB Sequencing and/or Deletion/Duplication Analysis,  Added clarifying information in the “investigational” statement that this testing does not include fetal hemoglobin testing via circulation fetal DNA. Minor rewording for clarity throughout. Coding, reference-table, background and references updated.	Yes	Concert Genetics Navigator in InterQual (not considered CCO)	With changes
V2.2024	CG Prenatal Dx of Amnio CVS or PUBS and Pregnancy Loss	4/30/2024	No	Semi-annual review. Updated title to reflect V2.2024 version. In Prenatal Diagnosis for Noonan Spectrum Disorders/, minor expansion in coverage: changed nuchal translucency requirement to 3.0 mm to better align with ACOG guidelines and published literature. In Prenatal Diagnosis for Noonan Spectrum Disorders/RASopathies, removed minimum gene list; at present there is limited rationale for inclusion. In Definitions, clarified that the definition of “major malformations” includes fetal growth restriction/IUGR, as primary literature suggests that fetuses with IUGR have a relatively high diagnostic yield via exome sequencing. In Chromosomal Microarray Analysis (CMA) for Pregnancy Loss, updated requirements for counseling to be consistent with coverage criteria throughout this policy. In Prenatal Diagnosis via Exome Sequencing, removed one criterion from this section regarding exome or genome sequencing for pregnancy loss on products of conception, based on lack of volume in claims. Minor rewording for clarity throughout. Coding, reference-table, background and references updated.	Yes	Concert Genetics Navigator in InterQual (not considered CCO)	With changes
V2.2024	CG Skeletal Dysplasia and Rare Bone Disorders	4/30/2024	No	Semi-annual review. Updated title to reflect V2.2024 version. In Overview and Clinical Considerations, policy overview updated to include information from the Clinical Considerations section, which has been consolidated into the Overview section. Minor rewording for clarity throughout. Coding, reference-table, background and references updated.	Yes	Concert Genetics Navigator in InterQual (not considered CCO)	With changes
V2.2024	CG Gastroenterologic Disorders Non-Cancerous	4/30/2024	No	Semi-annual review. Updated title to reflect V2.2024 version. Non-Invasive Liver Fibrosis Serum Tests criteria is new, created criteria to align coverage with guidelines. In Known Familial Variant Analysis for Gastroenterologic Conditions criteria, moved criteria to policy “Genetic Testing: General Approach to Genetic and Molecular Testing” to consolidate criteria for known familial variant tests. In HLA-DQ Genotyping Analysis criteria, updated criteria to align coverage with new guidelines. In Hereditary Inflammatory Bowel Disease / Crohn’s Disease Panel Tests criteria, changed age at diagnosis for Crohn’s disease to align with updated guidelines criteria (see Redline document). In MCM6 Targeted Variant Analysis criteria, retired criteria set based on rarity of testing (low order volume and low claim volume). In Other Not Covered Gastroenterologic Disorders Tests criteria, FibroSure tests moved to the new Non-invasive Liver Fibrosis Serum Tests coverage criteria. Remaining tests moved to the General Genetic and Molecular Testing policy for consolidation. Minor rewording for clarity throughout. Coding, reference-table, background and references updated.	Yes	Concert Genetics Navigator in InterQual (not considered CCO)	With changes
MC.CP.MP.250	Lantidra (donislecel) Allogeneic Pancreatic Islet Cellular Therapy	2/29/2024	No	New Policy	Yes	NA	New
MC.CP.MP.185	Skin and Soft Tissue Substitutes for Chronic Wounds	3/31/2024	No	New Policy	Yes	NA	New
InterQual 2024 Criteria

Our annual provider satisfaction survey will launch later this summer and we hope you’ll take a moment to share your feedback. This survey serves as the foundation for key improvement initiatives that we undertake each year and your feedback is critical to making sure we address the issues that are important to you. Last year, a few of the initiatives we accomplished based on your feedback are: 

• Webpage dedicated to finding your Provider Engagement Administrator.  That way you can always find your advocate.
• Enhanced ability to track authorization status online.
  
• Initiated the Care Guide program to assist engaging with your patients and closing care caps.
• Increased number of high quality network specialists to enhance your referral options.

We look forward to learning about how we can continue to improve your experience doing business with us. Please keep an eye out for our survey in the coming weeks.

The Centers for Medicare & Medicaid Services (CMS) requires health plans to provide annual education and training on our Special Need’s Plans (SNP) Model of Care to providers who treat our SNP members. This applies to our Dual Eligible Special Needs Plan (D-SNP) members, who are eligible for both Medicare and Medicaid, and our Chronic Condition Special Needs Plan (C-SNP) members.

As stated in the Provider Manual, all providers who treat our SNP members regardless of network participation status must complete Model of Care (MOC) training annually by December 31st of each year.

The training is designed to help you better understand our approach to the delivery of care for SNP members.

See our Required Training Section of the website and click on MOC.

Our annual provider satisfaction survey will launch later this summer and we hope you’ll take a moment to share your feedback. This survey serves as the foundation for key improvement initiatives that we undertake each year and your feedback is critical to making sure we address the issues that are important to you. Last year, a few of the initiatives we accomplished based on your feedback are: 

• Webpage dedicated to finding your Provider Engagement Administrator.  That way you can always find your advocate.
• Enhanced ability to track authorization status online.
  
• Initiated the Care Guide program to assist engaging with your patients and closing care caps.
• Increased number of high quality network specialists to enhance your referral options.

We look forward to learning about how we can continue to improve your experience doing business with us. Please keep an eye out for our survey in the coming weeks.

Payment Policies Effective 8-1-24

Policy Name	Policy Revision Date	More or Less Restrictive	Configuration Updates and Reason	Applicable Lines of Business
GI Pathogen Nucleic Acid Detection Panel Testing (CP.MP.209)	3/23	More and Less	Applied POS and diagnosis code edits to 87506; added new payable POS for 87506 and 87507; added coding combinations for diagnosis code matching as payable with 87506 and 87507, all consistent with the CMS Local Coverage Determination the policy is based on.	AM Medicaid and AM Marketplace
Wheelchair Seating (CP.MP.99)	1/24	More and Less	Edits made to align with recent changes made to the CMS local coverage article the policy is based upon, including new-for-2024 ICD-10 codes.	AM Medicaid and AM Marketplace
ADHD (CP.BH.124)	2/23	More	Changes made per literature review, payer comparison and specialist consultation. Internal BH Psy.Ds. reviewed and approved the following changes, as did an external specialist:   Neuropsychological testing codes removed from edit (now made payable with only an ADHD diagnosis on the claim): 96132 and 96133.   The following codes were added as not medically necessary/not payable when billed only with a diagnosis of ADHD on the claim: • 70496- CT angiography, head, with contrast • 70554-Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration • 70555-Magnetic resonance imaging, brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing • 78610-Brain imaging, vascular flow only • 84436-Thyroxine; total • 84437-Thyroxine; requiring elution (eg, neonatal) • 84439-Thyroxine; free • 84442-Thyroxine binding globulin (TBG) • 84443-Thyroid stimulating hormone (TSH) • 84445-Thyroid stimulating immune globulins (TSI) • 84478-Triglycerides • 84479-Thyroid hormone (T3 or T4) uptake or thyroid hormone binding ratio (THBR) • 84481-Triiodothyronine T3; free • 92568-Acoustic reflex testing, threshold • 92569-Acoustic reflex testing; decay • 92570-Acoustic immittance testing, includes tympanometry (impedance testing), acoustic reflex threshold testing, and acoustic reflex decay testing • 95954-Pharmacological or physical activation requiring physician or other qualified health care professional attendance during EEG recording of activation phase (eg, thiopental activation test) • 96020-Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping, with test administered entirely by a physician or other qualified health care professional (ie, psychologist), with review of test results and report • 96902-Microscopic examination of hairs plucked or clipped by the examiner (excluding hair collected by the patient) to determine telogen and anagen counts, or structural hair shaft abnormality • 97010-Application of a modality to 1 or more areas; hot or cold packs • 97012-Application of a modality to 1 or more areas; traction, mechanical • 97014-Application of a modality to 1 or more areas; electrical stimulation (unattended) • 97016-Application of a modality to 1 or more areas; vasopneumatic devices • 97018-Application of a modality to 1 or more areas; paraffin bath • 97022-Application of a modality to 1 or more areas; whirlpool • 97024-Application of a modality to 1 or more areas; diathermy (eg, microwave) • 97026-Application of a modality to 1 or more areas; infrared • 97028-Application of a modality to 1 or more areas; ultraviolet • 97032-Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes • 97033-Application of a modality to 1 or more areas; iontophoresis, each 15 minutes • 97034-Application of a modality to 1 or more areas; contrast baths, each 15 minutes • 97035-Application of a modality to 1 or more areas; ultrasound, each 15 minutes • 97036-Application of a modality to 1 or more areas; Hubbard tank, each 15 minutes	AM Medicaid and AM Marketplace and AM Medicare
Laser Therapy for Skin Conditions  (CP.MP.123)	3/23	Less	Added medically necessary diagnosis codes as payable to match newly added indications (per NCCN guidelines) for cutaneous T-cell lymphoma	AM Medicaid and AM Marketplace
Testing for Select Genitourinary Conditions (CP.MP.97)	9/23	Less	Edits made after payer comparison, literature review and consultation with internal OB, Dr. Steiner: Changed age at which any payment edit restrictions apply to 16 years and older, as this represents the upper limit of menarche, after which the diagnosis restrictions in the policy would be appropriate (previously the edits applied to ages 13 and over; the revision is more lenient). 81513, 81514, 0352U and 87511  as payable when billed with vaginitis codes in Table 2; added UTI in pregnancy dx codes to Table 2 (med nec codes). Added additional dx codes for asymptomatic screening to not med nec dx code table. 0353U removed from all payment edits; not in scope for policy. Removed vaginitis-related diagnosis codes from Table 7, to allow payment for candida amplified probe testing with vaginitis symptoms.	AM Medicaid and AM Marketplace
Urodynamic Testing (CP.MP.98)	3/23	Less	Changed N40.3 Nodular prostate with lower urinary tract symptoms from med nec only when billed with 51798 to med nec when billed with any procedure code in policy, per the CMS Local Coverage Determination on urodynamic testing.	AM Medicaid and AM Marketplace and AM Medicare
Measurement of Serum 1,25-dihydroxyvitamin D (CP.MP.152)	9/23	Less	Add the following ICD-10 codes as payable when billed with CPT code 82652, in addition to those already payable: E89.2- Postprocedural hypoparathyroidism added per literature review (The Journal of Clinical Endocrinology & Metabolism. Serum 1,25-Dihydroxyvitamin D as a Biomarker of the Absence of Hypercalciuria in Postsurgical Hypoparathyroidism)  and external specialist recommendation.   M83.8 and M83.9- Adult osteomalacia codes added to align with indication for oncogenic osteomalacia (previously only cancer codes were included for this indication)	AM Medicaid and AM Marketplace
Holter Monitors (CP.MP.113)	9/23	Less	Added new for 2023 and new for 2024 ICD-10 codes as payable with holter monitors:   The following were added as medically necessary to align with the indication for assessment of suspected variant angina in the policy: I25.112        Atherosclerosic heart disease of native coronary artery with refractory angina pectoris I25.702        Atherosclerosis of coronary artery bypass graft(s), unspecified, with refractory angina pectoris I25.712        Atherosclerosis of autologous vein coronary artery bypass graft(s) with refractory angina pectoris I25.722        Atherosclerosis of autologous artery coronary artery bypass graft(s) with refractory angina pectoris I25.732        Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with refractory angina pectoris I25.752        Atherosclerosis of native coronary artery of transplanted heart with refractory angina pectoris I25.762        Atherosclerosis of bypass graft of coronary artery of transplanted heart with refractory angina pectoris I25.792        Atherosclerosis of other coronary artery bypass graft(s) with refractory angina pectoris   The following codes were added as payable within existing medically necessary code ranges in the policy: Angina pectoris code range: I20.2 I20.81 I20.89 Nonrheumatic mitral valve disorders code range: I34.81 I34.89   Paroxysmal tachycardia code range: I47.10 I47.11 I47.19 I47.20 I47.21 I47.29	AM Medicaid and AM Marketplace
Digital EEG Spike Analysis (CP.MP.105)	1/24	Less	New 2024 ICD-10 codes for intractable epilepsy  added consistent with existing policy stance: G40.C11        Lafora progressive myoclonus epilepsy, intractable, with status epilepticus G40.C19        Lafora progressive myoclonus epilepsy, intractable, without status epilepticus	AM Medicaid and AM Marketplace
EEG for headache (CP.MP.155)	12/23	More	Updated not medically necessary migraine code range to reflect new for 2024 ICD-10 codes- changed from G43.001-G43.919 to G43.001-G43.E19.	AM Medicaid and AM Marketplace
Pulmonary Function Testing (CP.MP.242)	12/23	Less	Added new for 2024 ICD-10 codes as payable for all PFTs in the scope of the policy except bronchoprovocation testing: J15.61        Pneumonia due to Acinetobacter baumannii J15.69        Pneumonia due to other gram-negative bacteria J44.81        Bronchiolitis obliterans and bronchiolitis obliterans syndrome J44.89        Other specified chronic obstructive pulmonary disease J4A.0        Restrictive allograft syndrome J4A.8        Other chronic lung allograft dysfunction J4A.9        Chronic lung allograft dysfunction, unspecified   Note: per UpToDate, bronchoprovocation testing is mainly intended for diagnosing asthma, for cough and testing for reaction to environmental exposures. None of the above new codes fall in these categories.	AM Medicaid and AM Marketplace
Scanning Computerized Ophthalmic Diagnostic Imaging (CP.VP.14)	11/23	Less	Updated medically indicated diagnoses for posterior segment, retina 92134 – SCODI to include new ICD-10 codes for sickle-cell retinopathy.	AM Medicaid and AM Marketplace and AM Medicare and XL Medicare
Extended Ophthalmoscopy (CP.VP.26)	11/23	Less	Updated medically indicated diagnoses to include new ICD-10 codes for sickle-cell retinopathy.	AM Medicaid and AM Marketplace and AM Medicare and XL Medicare
Fluorescein Angiography (CP.VP.28)	11/23	Less	Updated medically indicated diagnoses to include new ICD-10 codes for sickle-cell retinopathy.	AM Medicaid and AM Marketplace and AM Medicare and XL Medicare
Fundus Photography (CP.VP.29)	11/23	Less	Updated medically indicated diagnoses to include new ICD-10 codes for sickle-cell retinopathy.	AM Medicaid and AM Marketplace
Gonioscopy (CP.VP.31)	11/23	Less	Updated medically indicated diagnoses to include new ICD-10 codes for sickle-cell retinopathy.	AM Medicaid and AM Marketplace
Visual Field Testing (CP.VP.63)	11/23	Less	Updated medically indicated diagnoses to include new ICD-10 codes for sickle cell retinopathy and chronic migraine with aura.	AM Medicaid and AM Marketplace and AM Medicare and XL Medicare

CPT Category II Codes are intended to facilitate the collection of information about the quality of care delivered by coding several services or test results that support performance measures. 

By submitting CPT Category II and HCPCS codes you are able to report services and/or values based on nationally recognized, evidence-based performance guidelines for improving quality of care for patients/members, benefits including: 

• Decrease the need for chart abstractions
• Better reporting of open and closed care needs for your assigned members
• Increase in Payment for Quality (P4Q) due to submission of additional codes
• Gap closure is reported timelier with code submission versus medical records
• Can improve member outcomes and the health of patients 

WellCare by Allwell has taken steps to ensure submissions pass through clearing house without issue for select CPT II and HCPCS codes to the Medicare fee schedule at a price of $0.01. This will result in fewer dropped codes by billing companies due to non-payable codes. Review the flyer to learn more details about codes included in this program

Our Medicare Advantage* and Prescription Drug Plans offer a robust, dependable pharmacy network with over 60,000 pharmacies in network — many offering preferred cost-sharing! See the 2024 Benefit Updates.

CenTeam’s very own Chief Health Officer, Dr. Alice Chen, has been named to Modern Healthcare’s 50 Most Influential Clinical Executives list for the second year in a row. Dr. Chen’s commitment to advancing Centene’s health equity and drivers of health efforts, including spearheading the REAL (race, ethnicity and language) SOGI (sexual orientation, gender identity) DOH (drivers of health) Data Project, was a cornerstone to her nomination. Dr. Chen’s focus on health equity and drivers of health has been a top priority for her throughout her career. Learn more about her passion for this critically important work and CenTeam’s commitment to advancing health equity.

Provider Advisory Committee – Interested?

Are you interested in being part of the change you would like to see in healthcare? Buckeye Health Plan is looking for practitioners to participate in our Provider Advisory Committee (PAC) as an advocate for providing the best service to our patients and community.

As a member of the PAC, you are the voice of the members and the provider partners of every specialty.

You can share firsthand what our members need, what is important to them and how we as a health plan can best provide that service.

Our PAC meets four times a year for one hour to share your knowledge and expertise in the delivery of care to improve our members’ well-being through healthy behavior, disease prevention, and self- management of chronic conditions. Other PAC participants include Buckeye Health Plan Medical Directors, network development staff, medical affairs, Ohio Department of Medicaid Representatives, and guest speakers. Topics of discussion include new initiatives, programs, counsel-directed issues, and community resources.

Below are a few examples of topics discussed in past PAC meetings:

• Provider Advisory Roles/Goals, Medicaid in Ohio, Population Health Strategy
• Pharmacy and Prior Authorizations - What is the purpose and how can we make it make it easier for high quality providers?
• Annual Provider Satisfaction Survey Results - How do health plans use the surveys and improve provider satisfaction?
• New Sleep Treatment Pilot - Buckeye partnered with providers to offer a solution for Sleep Apnea.
• BHP Diamond Designation Program - The council asked about ways that health plans recognize and reward high quality providers.
• BHP Alternative Payment Model (APM) Strategy 2023 – 2027- Continued conversation from Senior Leaders about rewarding high quality providers.
• Buckeye Health Plan SDoH Care Coordination Mode l - The council wanted to learn how a health plan could help their patients if they identified non-clinical barriers to care at the site of health care.

If you interested in joining the Provider Advisory Committee, please notify us via email at:  buckeyerequests@centene.com.  We look forward to hearing from you.

 

Buckeye Health Plan is streamlining the process for Medicaid provider faxed requests for urine drug screen testing. Beginning in June, please fax all requests for urine drug screen testing, both Behavioral Health related testing requests and Physical Health related testing requests to 866-535-4083. Providers should use the Medicaid Outpatient Prior Authorization Form (PDF) For your convenience, the above fax number is located on the form for ease of use.

Buckeye Health Plan is committed to providing an individual approach when reviewing requests for home health services, including Private Duty Nursing services (PDN). We do not apply hard limits on the number of days in a Medicaid certification period when members with special, complex needs are identified, and those needs are not expected to change over an extended period of time. Providers may request a longer certification period for these authorizations with supporting clinical documentation. 

See our MyCare Ohio Program Website Page

In 2023, Governor DeWine and ODM Director Maureen Corcoran introduced enhancements to reimbursement rates for providers participating in Ohio’s Medicaid programs. These enhancements were signed into law under HB 33 by both the House and Senate and approved by the Centers of Medicare & Medicaid Services (CMS) effective January 1, 2024.

These increases total approximately $579M, or 5%, across most codes. We are pleased to highlight that the Postpartum Care (CPT 59430) and Transportation Services saw significant increases. You will find the complete list of changes to the Billing Fee Schedule and Rates on the ODM website.  

In October, we notified you of changes to the Short Stay policy in response to CMS 2024 rules updates. Medicare Advantage plans are now required to adhere to the CMS 2 Midnight Rule when determining hospital inpatient admission level of care.

In response to the CMS 2024 rules updates Buckeye Health Plan has revised the Short Stay Policy with the following exclusions:

1. It is the policy of Medicare health plans affiliated with Centene Corporation^® that inpatient hospital stays (vs. observation) spanning less than two midnights are medically necessary when meeting any of the following criteria:
   • Admission is for a procedure on the current calendar year CMS Inpatient Only List (2023 addendum E, 2024 addendum E);
   • The admitting physician expects the patient to require hospital care that crosses two-midnights based on consideration of complex medical factors documented in the medical record. Such requests will be reviewed on a case-by-case basis by a medical director, considering factors such as member/enrollee history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event occurring during the time period for which hospitalization is considered;
   • The admitting physician does not expect the patient to require care that crosses two midnights, but determines, based on complex medical factors documented in the medical record that inpatient care is nonetheless necessary. Such requests will be reviewed on a case-by-case basis by a medical director, considering factors such as member/enrollee history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event occurring during the time period for which hospitalization is considered;1
   • Admission to an intermediate or intensive care unit level of care is considered medically necessary per a nationally-recognized clinical decision support tool;
   • Admission to acute hospital care at home;
   • Unexpected death during the admission;
   • Departure against medical advice from a medically necessary (per a nationally-recognized clinical decision support tool) inpatient stay;
   • Transferred from another facility, with a medically necessary (per a nationally-recognized clinical decision support tool) total length of stay greater than two days;
   • Election of hospice care in lieu of continued treatment in hospital.
2. It is the policy of Medicare health plans affiliated with Centene Corporation that inpatient hospital stays on day three and beyond are medically necessary when supported by nationally-recognized clinical decision support tools.

The final rule can be found at the American Hospital Association website.

IMPORTANT UPDATE: Terminations to resume effective January 23, 2024, for failure to complete Medicaid Agreement Revalidations in the Provider Network Management module

If you are currently due for a revalidation in the Provider Network Management (PNM) module, it is imperative that you take immediate action to complete and submit your revalidation application to renew your Ohio Medicaid Provider Agreement. Ohio Department of Medicaid (ODM) will begin terminating providers who fail to complete their revalidation prior to their specified deadline, starting January 23, 2024.

ODM resumed provider revalidation notices in June 2023 as part of the federally required unwinding process from the COVID public health emergency. ODM issues a series of notices with the first one delivered 120 days prior to your Medicaid agreement end date. Subsequent reminders are issued at 90 days, 60 days, and a final notice at 30 days. If you receive a revalidation notice, it is imperative that you take action to complete your revalidation on time. All providers are subject to either three- or five-year time-limited provider agreements.

How do you know if you are due for revalidation?

1. Check your mail and email.

Revalidation reminder notices are mailed and emailed to providers who are due for revalidation prior to the end of their Medicaid agreement. The email will be sent from OHPNM@maximus.com to advise you of a revalidation notice in the PNM Correspondence folder. Please check your spam folder for this email.

2. View the Correspondence folder in the PNM module.

Revalidation notices are posted in the PNM module and can be accessed in the Correspondence folder. Please be sure to select the type of correspondence from the drop down (in this case <Enrollment Notices>), and search for the “Revalidation Notices.” Review the Accessing Communications within PNM Quick Reference Guide for step-by-step instructions.

NOTE: If you think you are due for revalidation but have not received notices, please login to the PNM module and verify that the primary contact information is accurate in accordance with your Ohio Medicaid Provider Agreement. All mailers and email notices are directed to the primary contact individual or address identified in the system.

If I am due for revalidation, what action do I need to take?

A “Begin Revalidation” option appears in the PNM Enrollment Action Selections 120 days prior to the Medicaid Agreement end date. This can be found under the “Manage Application”, “Enrollment Actions” option within the provider file. Review the Revalidation/Reenrollment Quick Reference Guide for step-by-step instructions.

For more information

For technical support or assistance, contact Ohio Medicaid’s Integrated Helpdesk (IHD) at 800-686-1516 and follow the prompts for Provider Enrollment (option two, option two) or email IHD@medicaid.ohio.gov. Representatives are available Monday-Friday, 8:00 a.m.-4:30 p.m. Eastern time.

To learn more about the PNM module and Centralized Credentialing, visit the PNM and Centralized Credentialing page on the Next Generation website.

To assist Providers with the prioritization of ePRAF submissions, the Ohio Managed Care Plans (MCPs) have created sustainable interventions through the Technical Assistance Package and Quality Enhancer Incentive Program. The Quality Enhancer Incentive Program provides increased payments to eligible Providers who submit the ePRAF.

Please visit our Pregnancy and Prenatal Information page for more information on these interventions, along with the PRAF 2.0 submission and payment guidelines.

We are excited to share a change for our Provider Update Newsletter for 2024. To better reflect the importance of the content delivered in our monthly communication, the title will now be: Buckeye Provider Bulletin. 

 

Beginning October, 2023, providers not enrolled for Medicaid and Marketplace Electronic Funds Transfer (EFT) payments started receiving payment via the Virtual Credit Card (VCC) program.

This program will begin for Medicare payments in 2024.

Going forward all payments will be issued either via electronic funds transfer (EFT) such as PaySpan or the Virtual Credit Card (VCC) program from Change Healthcare. 

Change Healthcare is a widely used payment option in healthcare that we are making available to our provider network.

VCC PAYMENTS

VCC payments work like any other credit card payment. You will follow the same process as taking a credit card payment from a patient. Here’s how it works:

• You receive a printed Explanation of Payment that includes a 16-digit card number.
• You enter the number and the full amount of the payment into your credit/debit point-of-sale terminal before the expiration date.
• You receive funds in the same timeframe as your other credit card payments.
• There is no need to enroll to receive VCC payments as they are processed under the merchant agreement with your banking partner.
• Note that your merchant/banking partner charges fees for the payment transaction.  These fees are in lieu of the check clearing fees you currently pay.

Providers that had not previously signed up for EFT, were automatically signed up for the VCC when using VCC for other health plans.

You may opt out of VCC at any time by calling 888-678-5862 or via the Echo Payments Simplified website.

If you prefer to enroll in EFT rather than VCC, please go to  Providersupport@payspanhealth.com to access the enrollment form and instruction or call 877-331-7154.

We value your ongoing partnership and are excited to offer this new payment option to you.

As required by State and Federal governing entities, Buckeye Health Plan is committed to continuously evaluating and improving overall Payment Integrity solutions.  We have partnered with Optum who is supporting us in performing prepayment claim reviews. The purpose of this review is to verify the extent and nature of services rendered for the patient’s condition and claims are coded correctly for services billed. 

Optum’s edits will be implemented in phases and are not applied as a blanket “rule” for all claims.  This will be implemented for all lines of business – Medicaid, Medicare and Marketplace products.

Only a small number of claims that meet the criteria will be chosen for review.  Providers may experience a slight increase in written requests for medical record submission prior to payment.  These requests will come from Optum and will contain instructions for providing the documentation.  Should the requested documents not be returned, the claim(s) may be denied.  Providers will have the ability to dispute findings through Optum directly in the event of a disagreement.

Thank you for your continued participation and cooperation in our ongoing efforts to render quality health care to our members. We look forward to partnering with you to provide the highest quality care for your patients/our members.

Buckeye, in support of Ohio Recovery Housing, is helping to spread the word about new state registration requirements for recovery housing. Providers that operate recovery housing should complete the form through OhioMHAS’ website. 

Recovery Housing Registry (PDF)

Notable pharmacy changes for Medicare plans coming in 2024

• PBM will be moving from CVS to Express Scripts in 2024 for all Medicare plans. Members have been sent new ID cards with new pharmacy billing information.
• Prior Authorizations will be required for GLP-1 agonists in 2024
• The following table shows the most frequently prescribed drugs that will be non-formulary and their preferred alternatives in 2024:

Medicare Changes in 2024

Top Drug Removals With Alternatives (Medicare Plans Only)
DRUG(S) REMOVED	FORMULARY ALTERNATIVES
All MAPD Plans
Lantus vial; Lantus SoloStar insulin pen	Basaglar KwikPen insulin pen; Toujeo SoloStar insulin pen; Toujeo Max SoloStar insulin pen;  Tresiba vial; Tresiba FlexTouch insulin pen
Levemir vial; Levemir FlexPen insulin pen	Basaglar KwikPen insulin pen; Toujeo SoloStar insulin pen; Toujeo Max SoloStar insulin pen;  Tresiba vial; Tresiba FlexTouch insulin pen
Victoza pen injector	Bydureon Bcise auto-injector;  Mounjaro pen injector; Ozempic pen injector; Rybelsus tablet; Trulicity pen injector
Byetta pen injector	Bydureon Bcise auto-injector; Mounjaro pen injector; Ozempic pen injector; Rybelsus tablet; Trulicity pen injector
Flovent Diskus inhalation device;  Flovent HFA inhaler (Discontinued by manufacturer)	Arnuity Ellipta inhalation device; Pulmicort Flexhaler aerosol powder
Betoptic-S suspension eye drops	Alphagan P 0.1% eye drops; Brimonidine Tartrate eye drops; Combigan eye drops
Kevzara pen injector;  Kevzara syringe	Enbrel injection;  Humira injection; Rinvoq tablet; Xeljanz tablet; Xeljanz XR tablet (diagnosis dependent)
Ingrezza capsule	Austedo tablet; Tetrabenazine tablet
Mavyret tablet;  Mavyret pellets in packet	No impact for current utilizers; Epclusa tablets; Epclusa pellets in packet; Harvoni tablets; Harvoni pellets in packet
D-SNP and MMP Only
Simbrinza suspension eye drops	Alphagan P 0.1% eye drops; Brimonidine Tartrate eye drops; Combigan eye drops
Vyzulta eye drops	Alphagan P 0.1% eye drops; Brimonidine Tartrate eye drops; Combigan eye drops

Step Therapy programs are developed by Wellcare's P&T Committee. They encourage the use of therapeutically equivalent, lower-cost medication alternatives (first-line therapy) before “stepping up” to alternatives that are usually less cost-effective.

Step Therapy programs are intended to be a safe and effective method of reducing the cost of treatment by ensuring that an adequate trial of a proven safe and cost-effective therapy is attempted before progressing to a more costly option. First-line drugs are recognized as safe, effective, and economically sound treatments.

The first-line drugs on Wellcare’s formulary have been evaluated through the use of clinical literature and are approved by Wellcare’s P&T Committee. Step therapy is failure of at least one different or less expensive drug prior to coverage of a drug on this list.

Drugs requiring step therapy effective January 01, 2024 are listed below. The prescriber, patient, or authorized representative may ask for an exception. Step therapy applies if the drug has not been used in the past 365 days.

Drug Name

• Abatacept (Orencia®)
• Ado-trastuzumab emtansine (Kadcyla®)
• Aflibercept (Eylea®)
• Atezolizumab (Tecentriq®)
• Axicabtagene ciloleucel (Yescarta®)
• Bevacizumab (Avastin®, Alymsys®, Mvasi®, Vegzelma™, Zirabev™)
• Brentuximab vedotin (Adcetris®)
• Brexucabtagene autoleucel (Tecartus™)
• Brolucizumab-dbll (Beovu®)
• Cemiplimab-rwlc (Libtayo®)
• Certolizumab (Cimzia®)
• Ciltacabtagene autoleucel (Carvykti™)
• Corticosteroid intravitreal implants: dexamethasone (Ozurdex®), fluocinolone acetonide (Iluvien®, Retisert®, Yutiq™)
• Corticotropin (H.P. Acthar®, Purified Cortrophin™ Gel)
• Daratumumab (Darzalex®), daratumumab/hyaluronidase-fihj (Darzalex Faspro™)
• Darbepoetin alfa (Aranesp®)
• Denosumab (Xgeva®)
• Durvalumab (Imfinzi®)
• Eflapegrastim-xnst (Rolvedon™)
• Elotuzumab (Empliciti®)
• Emapalumab-lzsg (Gamifant™)
• Epoetin alfa (Epogen®, Procrit®)
• Faricimab-svoa (Vabysmo™)
• Ferric carboxymaltose (Injectafer®)
• Ferric derisomaltose (Monoferric®)
• Ferric pyrophosphate (Triferic®, Triferic Avnu®)
• Ferumoxytol (Feraheme®)
• Filgrastim (Neupogen®, Zarxio®, Nivestym™, Granix®, Releuko®)
• Golimumab (Simponi®, Simponi Aria®)
• Hyaluronate derivatives: sodium hyaluronate (Euflexxa®, Gelsyn-3™, GenVisc®850, Hyalgan®, Supartz FX™, Synojoynt™, Triluron™, TriVisc™, VISCO-3™), hyaluronic acid (Durolane®), cross-linked hyaluronate (Gel-One®), hyaluronan (Hymovis®, Orthovisc®, Monovisc®), hylan polymers A and B (Synvisc®, Synvisc One®)
• Idecabtagene vicleucel (Abecma™)
• Immune globulins (Asceniv™, Bivigam®, Cutaquig®, Cuvitru™, Flebogamma® DIF, GamaSTAN®, GamaSTAN® S/D, Gammagard® liquid, Gammagard® S/D, Gammaked™, Gammaplex®, Gamunex®-C, Hizentra®, HyQvia®, Octagam®, Panzyga®, Privigen®, Xembify®)
• IncobotulinumtoxinA (Xeomin®)
• Lisocabtagene maraleucel (Breyanzi®)
• Lurbinectedin (Zepzelca™)
• Luspatercept-aamt (Reblozyl®)
• Lutetium Lu 177 dotatate (Lutathera®)
• Nadofaragene firadenovec-vncg (Adstiladrin®)
• Natalizumab (Tysabri®)
• Nivolumab (Opdivo®)
• Pegfilgrastim (Neulasta®, Fulphila™, Fylnetra®, Nyvepria™, Stimufend®, Udenyca™, Ziextenzo™)
• Pembrolizumab (Keytruda®)
• Polatuzumab vedotin-piiq (Polivy™)
• Ramucirumab (Cyramza®)
• Ranibizumab (Lucentis®, Byooviz®, Cimerli™, Susvimo™)
• RimabotulinumtoxinB (Myobloc®)
• Rituximab (Rituxan®, Riabni™, Ruxience™, Truxima®), rituximab/hyaluronidase (Rituxan Hycela™)
• Romiplostim (Nplate®)
• Romosuzumab-aqqg (Evenity™)
• Sargramostim (Leukine®)
• Sipuleucel-T (Provenge®)
• Teclistamab-cqyv (Tecvayli®)
• Teprotumumab-trbw (Tepezza™)
• Tisagenlecleucel (Kymriah®)
• Tocilizumab (Actemra®)
• Trastuzumab (Herceptin®, Ontruzant®, Herzuma®, Ogivri™, Trazimera™, Kanjinti™), trastuzumab/hyaluronidase (Herceptin Hylecta™)
• Triamcinolone ER injection (Zilretta®)
• Triamcinolone acetonide suprachoroidal injection (Xipere™)
• Vedolizumab (Entyvio®)
• Verteporfin (Visudyne®)

We are pleased to announce that, effective January 1, 2024, Express Scripts® will begin processing pharmacy claims for our plan members.

Express Scripts is a pharmacy benefit management (PBM) company serving more than 100 million Americans. Express Scripts Pharmacy delivers specialized care that puts patients first through a smarter approach to pharmacy services.

Members have been notified in advance and will receive a new ID card with updated pharmacy information, so that they are prepared to begin having their prescriptions filled at participating network pharmacies when this change occurs.

Providers can direct members to call the Member Services phone number listed on their ID card should they have questions about this change.

Please contact your Provider Engagement Administrator with any additional questions.

Thank you for the care you provide to our members.

FAQ (PDF)

Buckeye Health Plan is pleased to share that we will be transitioning from Optum to 6 Degrees Health for our clean claim reviews. The Go-Live launch is tentatively set for January 2, 2024.

This transition will be seamless for our provider community and reflects our ongoing efforts to make it easier to do business with Buckeye. 6 Degrees offers providers the ability to submit records via mail, fax or email.

You may begin seeing record request correspondence from 6 Degrees Heath.

ODM has asked us to remind you that Provider Network Management (PNM) is continuing our provider awareness and training efforts. Registration for the November 6-16 PNM module refresher training is now open. The training schedule is available on the PNM and Centralized Credentialing page. Below you will find how to register and a list of training topics.

New Sandata Mobile Connect (SMC) application for EVV Providers

A new Sandata Mobile Connect (SMC) application was released in application (app) stores in July 2023. This is an enhanced app with a focus on the end user experience. In addition to an updated look and feel that simplifies navigation, the update includes a simplified login process and efficient reset password process. For providers using their own devices, the old app will be available until June 30, 2024. Between now and then, no updates will be available for the old app, so be sure to download the new one.

The new SMC app can now be downloaded in either Android or Apple stores:

Apple

Android  

Information on the new SMC app is available online at Sandata on Demand. 

Reminder: Nursing Facility Claims Billing Value Code 31

For Nursing facility claims, Value code 31 should only be used to indicate a Lump Sum amount, and not the individual’s monthly patient liability amount as indicated in OAC 5160-3-39.1. Buckeye Health Plan will separately apply any amount billed under value code 31, on nursing claims as a separate Lump sum payment.  The Lump Sum amount will be applied in addition to the member’s monthly liability indicated to Buckeye by ODM.

Value code 31 should not be used to indicate the member’s monthly liability.  For additional guidance on billing the appropriate member liability codes, please see Ohio Medicaid companion Guides

Effective January 1, 2024, Buckeye Health Plan is expanding our prior authorization program to include non-emergent MSK procedures. The expansion includes inpatient and outpatient hip, knee, shoulder, lumbar and cervical spine surgeries for Buckeye Health Plan members.

We are pleased to announce a partnership with National Imaging Associates, Inc (NIA)* for utilization management services for non-emergent, Medical Specialty Solutions. In consideration of the aforementioned agreement, Buckeye Health Plan will terminate its current MSK program and utilization management efforts with TurningPoint as of December 31, 2023.

Under the terms of the agreement between Buckeye Health Plan and NIA, Buckeye Health Plan will oversee the MSK program and continue to be responsible for claims adjudication and medical policies. NIA will manage non-emergent outpatient interventional spine pain management services, and inpatient and outpatient MSK surgeries through the existing contractual relationships with Buckeye Health Plan.

Planned for a January 1, 2024, implementation, this announcement serves as notice under your participating Buckeye Health Plan Provider Agreement of changes to the program.

Providers may begin contacting NIA on January 1, 2024, to seek prior authorization for procedures scheduled on or after January 1, 2024.

The following outlines the specific procedures requiring prior authorization.

MSK Surgeries

Prior authorization will be required for the following non-emergent inpatient and outpatient hip, knee, shoulder, lumbar and cervical surgeries:

Hip

• Revision/Conversion Hip Arthroplasty
• Total Hip Arthroplasty/Resurfacing
• Femoroacetabular Impingement (FAI) Hip Surgery (includes CAM/pincer & labral repair)
• Hip Surgery – Other (includes synovectomy, loose body removal, debridement, diagnostic hip arthroscopy, and extra-articular arthroscopy knee)

Knee

• Revision Knee Arthroplasty
• Total Knee Arthroplasty (TKA)
• Partial-Unicompartmental Knee Arthroplasty (UKA)
• Knee Manipulation under Anesthesia (MUA)
• Knee Ligament Reconstruction/Repair
• Knee Meniscectomy/Meniscal Repair/Meniscal Transplant
• Knee Surgery – Other (includes synovectomy, loose body removal, diagnostic knee arthroscopy, debridement with or without chondroplasty, lateral release/patellar realignment, articular cartilage restoration)

Shoulder

• Revision Shoulder Arthroplasty
• Total/Reverse Shoulder Arthroplasty or Resurfacing
• Partial Shoulder Arthroplasty/Hemiarthroplasty
• Shoulder Rotator Cuff Repair
• Shoulder Labral Repair
• Frozen Shoulder Repair/Adhesive Capsulitis
• Shoulder Surgery – Other (includes debridement, manipulation, decompression, tenotomy, tenodesis, synovectomy, claviculectomy, diagnostic shoulder arthroscopy)

Lumbar

• Lumbar Microdiscectomy
• Lumbar Decompression (Laminotomy, Laminectomy, Facetectomy & Foraminotomy)
• Lumbar Spine Fusion (Arthrodesis) With or Without Decompression – Single & Multiple Levels
• Lumbar Artificial Disc Replacement
• Sacroiliac Joint Fusion

Cervical

• Cervical Anterior Decompression with Fusion –Single & Multiple Levels
• Cervical Posterior Decompression with Fusion –Single & Multiple Levels
• Cervical Posterior Decompression (without fusion)
• Cervical Artificial Disc Replacement
• Cervical Anterior Decompression (without fusion)

KEY PROVISIONS:

• It is the responsibility of the ordering physician to obtain prior authorization for all interventional spine pain management procedures and MSK surgeries outlined above.
• NIA does not manage prior authorization for emergency MSK surgery cases that are admitted through the emergency room or for MSK surgery procedures outside of those procedures listed above.
• Any Buckeye Health Plan prior authorization requirements for the facility or hospital admission must be obtained separately and only initiated after the surgery/procedure has met NIA’s medical necessity criteria.

Services other than MSK surgeries outlined above will continue to follow Buckeye Health Plan prior-authorization requirements for hospital admissions and elective surgeries.

We appreciate your support and look forward to your assistance in assuring that Buckeye Health Plan members receive MSK services delivered in a quality, clinically appropriate fashion.

We will provide additional information as we get closer to the implementation date.  Should you have questions at this time, please contact Buckeye Health Plan Provider Services Department at 1-866-246-4359.

 

* Effective 1/20/2023, National Imaging Associates, Inc. is now a subsidiary of Evolent Health.  Evolent Health and its affiliates and subsidiaries collectively referred to as “Evolent.”

New Policies for Medicare

•      MC.CP.MP.170 Peripheral Nerve Blocks

•      MC.CP.MP.22 Stereotactic Body Radiation Therapy

•      MC.CP.MP.69 Intensity-Modulated Radiotherapy

•      MC.CP.MP.246 Pediatric Kidney Transplantation

•      MC.CP.MP.57 Lung Transplantation

•      MC.CP.MP.101 Donor Lymphocyte Infusion

•      MC.CP.MP.108 Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-thalassemia

•      MC.CP.MP.182 Short Inpatient Stay

•      MC.CP.MP.106 Endometrial Ablation

•      MC.CP.MP.160 Wireless Pulmonary Artery Monitoring

•      CP.PP.206 Skilled Nursing Facility Leveling

•      V2.2023 Concert Genetics Genetic Testing Aortopathies and Connective Tissue Disorders

•      V2.2023 Concert Genetics Genetic Testing Cardiac Disorders

•      V2.2023 Concert Genetics Genetic Testing Dermatologic Conditions

•      V2.2023 Concert Genetics Genetic Testing Epilepsy, Neurodegenerative, and Neuromuscular Conditions

•      V2.2023 Concert Genetics Genetic Testing Exome and Genome Sequencing for the Diagnosis of Genetic Disorders

•      V2.2023 Concert Genetics Genetic Testing Eye Disorders

•      V2.2023 Concert Genetics Genetic Testing Gastroenterologic Disorders (non-cancerous)

•      V2.2023 Concert Genetics Genetic Testing General Approach to Genetic Testing

•      V2.2023 Concert Genetics Genetic Testing Hearing Loss

•      V2.2023 Concert Genetics Genetic Testing Hematologic Condition (non-cancerous)

•      V2.2023 Concert Genetics Genetic Testing Hereditary Cancer Susceptibility

•      V2.2023 Concert Genetics Genetic Testing Immune, Autoimmune, and Rheumatoid Disorders

•      V2.2023 Concert Genetics Genetic Testing Kidney Disorders

•      V2.2023 Concert Genetics Genetic Testing Lung Disorders

•      V2.2023 Concert Genetics Genetic Testing Metabolic, Endocrine, and Mitochondrial Disorders

•      V2.2023 Concert Genetics Genetic Testing Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay

•      V2.2023 Concert Genetics Genetic Testing Non-Invasive Prenatal Screening (NIPS)

•      V2.2023 Concert Genetics Genetic Testing Pharmacogenetics

•      V2.2023 Concert Genetics Genetic Testing Preimplantation Genetic Testing

•      V2.2023 Concert Genetics Genetic Testing Prenatal and Preconception Carrier Screening

•      V2.2023 Concert Genetics Genetic Testing Prenatal Diagnosis via Amniocentesis, CVS or PUBS and Pregnancy Loss

•      V2.2023 Concert Genetics Genetic Testing Skeletal Dysplasia and Rare Bone Disorders

•      V2.2023 Concert Genetics Oncology Algorithmic Testing

•      V2.2023 Concert Genetics Oncology Cancer Screening

•      V2.2023 Concert Genetics Oncology Circulating Tumor DNA and Circulating Tumor Cells Liquid Biopsy

•      V2.2023 Concert Genetics Oncology Cytogenetic Testing

•      V2.2023 Concert Genetics Oncology Molecular Analysis of Solid Tumors and Hematologic Malignancies

Policies with updates

•      CP.CPC.05 Medical Necessity Criteria Hierarchy

•      Clinical Practice Guidelines

Policies Retired for Medicare

•      CP.MP.100 Allergy Testing and Therapy

•      CP.MP.101 Donor Lymphocyte Infusion

•      CP.MP.102 Pancreas Transplant

•      CP.MP.105 Digital EEG Analysis

•      CP.MP.106 Endometrial Ablation

•      CP.MP.107 Durable Medical Equipment and Orthotics and Prosthetics Guidelines

•      CP.MP.108 Allogeneic Hematopoietic Cell Transplants For Sickle Cell Anemia and Beta-thalassemia

•      CP.MP.109 Panniculectomy

•      CP.MP.110 Bronchial Thermoplasty

•      CP.MP.113 Holter Monitors

•      CP.MP.114 Disc Decompression Procedures

•      CP.MP.115 Discography

•      CP.MP.116 Lysis of Epidural Lesions

•      CP.MP.117 Spinal Cord Stimulation

•      CP.MP.12 Vagus Nerve Stimulation

•      CP.MP.120 Pediatric Liver Transplant

•      CP.MP.121 Homocysteine Testing

•      CP.MP.123 Laser Therapy for Skin Conditions

•      CP.MP.126 Sacroiliac Joint Infusion

•      CP.MP.127 Total Artificial Heart

•      CP.MP.128 Optic Nerve Decompression Surgery

•      CP.MP.129 Fetal Surgery in Utero for Prenatally Diagnosed Malfunctions

•      CP.MP.130 Fertility Preservation

•      CP.MP.132 Heart-Lung Transplant

•      CP.MP.133 Posterior Tibial Nerve Stimulation for Voiding Dysfunction

•      CP.MP.134 Evoked Potential Testing

•      CP.MP.136 Home Births

•      CP.MP.137 Fecal Incontinence Treatments

•      CP.MP.138 Pediatric Heart Transplant

•      CP.MP.139 Low-frequency Ultrasound and Noncontact Wound Therapy

•      CP.MP.14 Cochlear Implant Replacements

•      CP.MP.141 Non-myeloablative Allogeneic Stem Cell Transplants

•      CP.MP.142 Urinary Incontinence Devices and Treatments

•      CP.MP.143 Wireless Motility Capsule

•      CP.MP.144 Mechanical Stretching Devices for Joint Stiffness and Contracture

•      CP.MP.145 Electric Tumor Treating Fields (Optune)

•      CP.MP.146 Sclerotherapy for Chemical Endovenous Ablation for Varicose Veins

•      CP.MP.147 Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention

•      CP.MP.148 Radial Head Implant

•      CP.MP.150 Phototherapy for Neonatal Hyperbilirubinemia

•      CP.MP.151 Transcatheter Closure of Patent Foramen Ovale

•      CP.MP.152 Measurement of Serum 1,25-dihydroxyvitamin D

•      CP.MP.153 Helicobacter Pylori (H Pylori) Serology Testing

•      CP.MP.154 Thyroid Hormones and Insulin in Pediatrics

•      CP.MP.155 EEG Headache

•      CP.MP.156 Cardiac Biomarker Testing

•      CP.MP.157 25-hydroxyvitamin D Testing in Children and Adolescents

•      CP.MP.158 Ambulatory Surgery Center Optimization

•      CP.MP.160 Implantable Wireless Pulmonary Artery Pressure Monitoring

•      CP.MP.162 Tandem Transplant

•      CP.MP.163 Total Parenteral Nutrition and Intradialytic Parenteral Nutrition

•      CP.MP.164 Caudal or Interlaminar Epidural Steroid Injections

•      CP.MP.165 Selective Nerve Root Blocks and Transforaminal Epidural Injections

•      CP.MP.166 Sacroiliac Joint Interventions for Pain Management

•      CP.MP.167 Intradiscal Steroid Injections for Pain Management

•      CP.MP.168 Biofeedback

•      CP.MP.169 Trigger Point Injections for Pain Management

•      CP.MP.170 Nerve Blocks for Pain

•      CP.MP.171 Facet Joint Interventions

•      CP.MP.173 Implantable Intrathecal or Pain Pump

•      CP.MP.174 Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy

•      CP.MP.175 Air Ambulance

•      CP.MP.176 Outpatient Cardiac Rehabilitation

•      CP.MP.180 Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea

•      CP.MP.181 Polymerase Chain Reaction Respiratory Viral Panel Testing

•      CP.MP.182 Short Inpatient Hospital Stay

•      CP.MP.184 Home Ventilators

•      CP.MP.185 Skin and Soft Tissue Substitutes for Chronic Wounds

•      CP.MP.186 Burn Surgery

•      CP.MP.188 Pediatric Oral Function Therapy

•      CP.MP.190 Outpatient Oxygen Use

•      CP.MP.194 Osteogenic Stimulation

•      CP.MP.202 Orthognathic Surgery

•      CP.MP.203 Diaphragmatic Phrenic Nerve Stimulation

•      CP.MP.206 Skilled Nursing Facility Leveling

•      CP.MP.209 Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing

•      CP.MP.210 Repair of Nasal Valve Compromise

•      CP.MP.22 Stereotactic Body Radiation Therapy

•      CP.MP.24 Multiple Sleep Latency Testing

•      CP.MP.242 Pulmonary Function Testing

•      CP.MP.243 Implantable Loop Recorder

•      CP.MP.244 Liposuction for Lipedema

•      CP.MP.246 Pediatric Kidney Transplant

•      CP.MP.247 Transplant Service Documentation Requirements

•      CP.MP.248 Facility Based Sleep Studies for OSA

•      CP.MP.26 Articular Cartilage Defect Repair

•      CP.MP.31 Cosmetic and Reconstructive Surgery

•      CP.MP.36 Experimental Technologies

•      CP.MP.37 Bariatric Surgery

•      CP.MP.38 Ultrasound in Pregnancy

•      CP.MP.40 Gastric Electrical Stimulation

•      CP.MP.43 Functional MRI

•      CP.MP.46 Ventricular Assist Devices

•      CP.MP.48 Neuromuscular and Peroneal Nerve Electric Stimulation

•      CP.MP.49 Physical Occupational and Speech Therapy Services

•      CP.MP.50 Drugs of Abuse Definitive Testing

•      CP.MP.51 Reduction Mammoplasty and Gynecomastia Surgery

•      CP.MP.53 Ferriscan R2-MRI

•      CP.MP.54 Hospice

•      CP.MP.55 Assisted Reproductive Technology

•      CP.MP.57 Lung Transplantation

•      CP.MP.58 Intestinal and Multivisceral Transplant

•      CP.MP.61 IV Moderate Sedation IVE Deep Sedation and General Anesthesia for Dental Procedures

•      CP.MP.62 Hyperhidrosis Treatments

•      CP.MP.69 Intensity Modulated Radiotherapy

•      CP.MP.70 Proton and Neutron Beam Therapies

•      CP.MP.71 Long Term Care Placement Criteria

•      CP.MP.81 NICU Discharge Guidelines

•      CP.MP.82 NICU Apnea Bradycardia

•      CP.MP.85 Neonatal Sepsis Management

•      CP.MP.86 Neonatal Abstinence Syndrome Guidelines

•      CP.MP.87 Therapeutic Utilization of Inhaled Nitric Oxide

•      CP.MP.91 Obstetrical Home Care Programs

•      CP.MP.92 Acupuncture

•      CP.MP.93 Bone-Anchored Hearing Aid

•      CP.MP.94 Clinical Trials

•      CP.MP.95 Gender-Affirming Procedures

•      CP.MP.98 Urodynamic Testing

•      CP.MP.99 Wheelchair Seating

•      CP.BH.100 Substance Use Disorders and Treatment Services

•      CP.BH.104 Applied Behavioral Analysis

•      CP.BH.124 ADHD

•      CP.BH.200 TMS for Treatment Resistant Major Depression

•      CP.BH.201 Deep Transcranial Magnetic Stimulation for Treatment of Obsessive-Compulsive Disorder

•      CP.BH.300 Biofeedback for BH Disorders

We are writing to address a critical issue affecting some of our accounts within the provider portal and to provide guidance on how to resolve it promptly.

Buckeye Password Policy

As part of our commitment to maintaining the highest level of security for our government partners, the provider portal enforces a 'One Year Password Policy.' This policy mandates that passwords be changed before 365 days. Failure to update passwords within the specified timeframe results in the user’s account locking. 

Buckeye is proactively working to identify ‘locked’ accounts and unlock them. If you have NOT reset your password within the designated timeframe, you may now be locked out.

Resolution and Next Steps

Step 1: Please go to the Buckeye Provider Portal and attempt to login:

• If you are NOT locked out, you need to take immediate action to reset your password.
• If you ARE locked out, you need to follow these steps.

Step 2: If you are NOT locked out:

To prevent any lock out, please do the following on the Portal Login page: 

• Click on 'Trouble Logging In' on the portal login page. 
• Follow the "Forgot Password" process to reset your password. 

Step 2: If you ARE locked out:

If your account is locked, you will see the Account Recovery screen.

In addition, you will receive an error message and an email that notifies you that your password change was NOT successful. Please take the following steps: 

1. Reach out to the call center at 866.296.8731: The call center will raise an incident ticket which will help us unlock your account.  
2. Reset Password: To regain access to the account, users must reset their password. Here's how to reset: 
   1. On the Portal Login page, click on 'Trouble Logging In'. 
   2. Follow the "Forgot Password" process to reset password. 
   3. Important: After resetting your password, your account will be reactivated.

If you have any problems, please contact Provider Services at: 866.296.8731.

 

Buckeye is in receipt of the below notice from ODM.  We understand many of you have already seen and your Clinical Engineering departments have acted on this notice, but Buckeye wants to ensure you are aware:

ODM would like to make the MCEs aware of the below critical recall from the FDA.   

The full announcement is available on the FDA's website. 

Hamilton Medical Inc. Recalls HAMILTON-C1, T1, MR-1 Ventilators for Capacitator Leaks and Short Circuits

Hamilton Medical, Inc. is recalling the HAMILTON-C1, T1, MR-1 ventilators because the capacitators may leak electrolyte fluid onto the ventilator’s control board. If the control board contacts the electrolyte fluid, the control board or installed spare parts could short circuit. As a result of the short circuit, the ventilator may switch to “Ambient State.”

The FDA has identified this as a Class I recall, the most serious type of recall. Use of these devices may cause serious injuries or death.

Questions?

If you have questions about this recall, contact Hamilton Medical Inc. at 1-800-426-6331 or email reno.techsupport@hamiltonmedical.com.

When providers follow appointment access standards, emergency room visits decrease, health outcomes improve and patient trust in their primary care provider (PCP) increases. 

• What are appointment access standards?
  These standards ensure members have timely access to care, so they get the right care, at the right time, in the right location.
  
  
• Why do appointment access standards matter?
  Providers are required to follow the guidelines that are outlined by government agencies and in their participating provider agreement. This helps to reduce unnecessary emergency room visits and increases patient engagement with their PCP.

• How can Health Plans help providers meet the appointment access standards?
  Health Plan staff should have a full understanding of the standards and encourage providers to follow these access standards. Providers should adhere to these required timeframes when they schedule appointments.
  
  

Refer to your Provider Manual for additional information pertaining to appointment access standards.

Centene CEO Sarah London was selected for Fortune's 2023 "Most Powerful Women," coming in at No. 40 on the list.

Sarah joins 100 women leaders, including 67 women CEOs, from organizations such as CVS, General Motors and UPS. The ranking includes the following criteria — the size and importance of the leader's business in the global economy, the health and direction of the business, the arc of the woman's career, her social and cultural influence, and how she shapes her company and the world.

Since becoming Centene's CEO in 2022, Sarah has been instrumental in guiding the organization to realize its vision to transform the health of the communities we serve. She has focused the organization on its three core lines of business and invested in programs and technology that support our ability to improve health and access to high-quality care for the members and communities we serve. 

This year, Sarah was also named one of Modern Healthcare's Top Women Leaders in Healthcare 2023. The program honors female executives who are leading change, developing policy and guiding healthcare delivery improvement. The distinction recognizes leaders from all sectors of the industry for their professional accomplishments and contributions to their organizations.

The youngest female CEO on the Fortune 500, Sarah also took part in a Fortune interview and videos where she discussed leadership, teamwork and culture.

The Comprehensive Maternal Care (CMC) re-attest links in PNM are currently not working correctly

ODM's vendor for the Provider Network Management (PNM) module is already working on this known issue. This system bug is impacting the Medicaid provider file for those that are currently participating in CMC for the 2023 program year. If a participating Medicaid ID received an invitation for next year, we recommend ensuring that users have the proper access needed and are able to see the CMC re-attest link, but to refrain from clicking on the link until the system has been fixed. 

At this time, we do not have an ETA for resolution. Additional communication will be sent once more information is known.

This is not impacting any Medicaid ID that would be enrolling in CMC for the first time. Those enrollment actions are available and working as expected. We highly recommend completing those enrollments while awaiting the system fix for continuing practices.

Login to PNM Here

Ohio Department of Medicaid (ODM) is aware trading partners are submitting Electronic Data Interchange (EDI) transactions with more than 5,000 CLM segments. Submissions of over 5,000 CLM segments are causing downstream issues and affecting the delivery of corresponding 277CAs back to trading partners.

Trading partners should remember to limit their transaction size to less than 5,000 CLM segments as required by ODM Companion Guides. This best practice is outlined in the Technical Reports Type 3 (TR3) which recommends “that trading partners limit the size of the transaction (ST-SE envelope) to a maximum of 5,000 CLM segments.” This limitation also applies to the submission of batch 270 eligibility inquiries and 276 claim status inquiries.

Trading partners who have submitted more than 5,000 CLM segments in an EDI file and have not received a rejection via 999 or 824 AND have not received a corresponding 277CA and 835, should resubmit those claims.

Effective October 20, Next Generation Medicaid managed care organizations (MCO), the OhioRISE plan, and MyCare Ohio plans must use provider data from Ohio Medicaid’s Provider Network Management (PNM) module as it is the official system of record. To ensure the provider data sent from the PNM to the managed care entities (MCE) is accurate, it is imperative that your records are updated within the PNM module. If your data in the PNM module does not match your data on the submitted claim, your claims will be denied for payment. 

Actions needed by you as a provider or a trading partner

1. Check that all data submitted on a claim and within the PNM module (e.g., addresses, affiliations, specialties, locations) is accurate and up to date.  
2. Access Provider Education & Training Resources within the PNM ‘Learning’ tab for step-by-step instructions. 
3. Continue to update data as changes occur. MCEs will use this information as the system of record moving forward.

The MCEs download a complete extract of the Provider Master File (PMF) that includes all provider data daily.

For more information  

For technical support or assistance, contact Ohio Medicaid’s Integrated Helpdesk (IHD) at 800-686-1516 and follow the prompts for Provider Enrollment (option 2, option 2) or email IHD@medicaid.ohio.gov. Representatives are available Monday-Friday, 8 a.m.-4:30 p.m. Eastern time.

To learn more about the PNM module and Centralized Credentialing, visit the PNM and Centralized Credentialing page on the Next Generation website. 

This year, Ohio Department of Medicaid (ODM) will be hosting a virtual CPC Fall Learning Collaborative in place of the Annual Summer Learning Session. 

Will be held on Friday, October 20, from 9:30 a.m.-12:30 p.m. via GoToWebinar. If you are interested in attending, register here for webinar.

Some of the topics to be covered include:

• Risk stratification
• Quality and efficiency metrics
• CPC and managed care organization (MCO) collaboration
• IPRO activity monitoring reviews

There will also be break out group discussions on CPC operationalization with your peers, from similar facility sizes and types.

ODJFS Rolls Out E-Signature Feature for Ohio Benefits Recipients

The Ohio Department of Job and Family Services (ODJFS) Director Matt Damschroder announced on September 13, 2023, a new electronic signature process that will save Ohioans time when applying for certain benefits by phone. 

“Beginning today, residents in all 88 counties will be able to apply, renew, or recertify for Medicaid, SNAP, cash assistance, and publicly funded childcare right from their smart phone,” said Damschroder. “The e-signature program is not mandatory, but it will be a time-saver for those who participate.”

The new e-signature process allows customers to receive a link on their smart phone, review their Rights and Responsibilities and sign in real time, which is instantly transferred to Ohio Benefits, the system used to manage food, cash, medical, and childcare assistance. It is an alternative to the existing telephonic signature process and could save up to 20 minutes for the applicant on the phone.

Summit, Ross, Vinton, and Hocking counties have been piloting e-signatures since early July. Cuyahoga and Franklin counties started in early August and Columbiana, Coshocton, Fairfield, Guernsey, Licking, Monroe, Muskingum, Noble, Perry, and Wayne counties rolled out the program August 31st.

“We’ve had a great deal of positive feedback from both counties and customers during the pilot period,” said Damschroder. “We are pleased to make this available as part of our ongoing efforts to improve the customer service for those Ohioans we serve.”

Customers can still mail, drop off, or fax applications to their county office to apply, renew, or recertify their benefits, or they can complete the same applications through the online Self-Service Portal (SSP).

Modifier SA is used when the Nurse Practitioner (NP) is assisting with any other procedure that does not include surgery in accordance with MTL No. 3336-18-01. This is currently a requirement for Medical claims, and in order to better align OH Medical with Behavioral health services, Buckeye will now require the SA modifier for non-84/95 provider types on the Behavioral health services beginning 11/01/2023.  Provider claims where the Nurse Practitioner is assisting with any other procedure that does not include surgery that are not billed with the SA modifier will be denied beginning 11/01/2023.

All Ohio Department of Medicaid (ODM) providers are required to revalidate or renew your ODM provider agreement every three years or five years. Credentialed provider types are subject to three-year provider agreements and are both revalidated and recredentialed at that interval. All other providers are subject to five-year provider agreements and must revalidate before the end date of that agreement to continue participation in Ohio Medicaid as an active enrolled provider.   

ODM mails and emails a reminder notice to the contact listed on the Primary Contact page in the Provider Network Management (PNM) module 120 days before the Ohio Medicaid provider agreement expires. To ensure you receive these notices, you must maintain a current mailing and email address.

Review the “2023 Upcoming Revalidations” file 

To provide additional support and information about provider revalidation schedules, ODM has published a 2023 Upcoming Revalidations file on the Ohio Medicaid website and can be found here. This report provides a complete list of all revalidations due in 2023. The revalidation list contains the provider’s name and National Provider Number (NPI) or Medicaid ID.

Once the revalidation workflow in PNM is initiated within the 120-day provider agreement revalidation timeframe, providers cannot initiate any other workflows to perform PNM updates (i.e., affiliations, demographic updates, requesting a new specialty, etc.) until the revalidation is complete and approved. However, updates or changes may still be made within the revalidation workflow as part of the revalidation verification process.

Note: ODM will publish a revalidation list for 2024 in early October 2023.

For More Information

For technical support or assistance, contact ODM’s Integrated Helpdesk (IHD) at 800-686-1516 and follow the prompts for Provider Enrollment (option 2, option 2) or email IHD@medicaid.ohio.gov. Representatives are available 8 a.m.-4:30 p.m. Eastern time Monday-Friday.

To learn more about the PNM module and Centralized Credentialing, visit the PNM and Centralized Credentialing page on the Next Generation website.

Buckeye Grievances & Appeals is looking to continue the trend of making Buckeye easier to do business with. Following Prior Authorization policies will minimize the chances of needing an Appeal. Please review the key steps on our Prior Authorization website page.

Help Your Medicaid/MyCare Patients get their Incontinence Supplies Faster

When ordering incontinence supplies, remember to indicate both a primary diagnosis and the type of incontinence on the prescription. This is an ODM requirement. Without both items, the order cannot be completed and your patients will not receive their supplies.

 

Effective October 1^st, 2023, there are changes to prior authorization requirements. Please see the PDF document below. 

For complete CPT/HCPCS code listing, please see Online Prior Authorization Tool.  

CNC Medicare PA List Changes 10.01.23

Babylon Health’s telehealth services are no longer available as of August 7, 2023. Due to this change, you may receive new requests for both virtual and in-person services from Ambetter Virtual Access members as you are currently in our network.

As always, please verify each member's eligibility, benefits, and referral requirements before rendering care. You can find an example of an Ambetter Virtual Access member ID card on our website. 

Please contact Provider Services at 877-687-1189 with any questions.

In an effort to eliminate administrative burden for facility-based Hospice services, Buckeye Health Plan is removing prior authorization requirements for the following service codes, effective September 30, 2023.

NON-PAR PROVIDERS REQUIRE AUTHORIZATION FOR ALL HOSPICE SERVICES EXCEPT WHERE INDICATED

Prior Authorization Changes

Service Code	Service/Procedure Description	Line of Business
T2044	Hospice inpatient respite care	Medicaid, MMP Duals
T2045	Hospice general inpatient care	Medicaid
T2046	Hospice long term care, room and board only	Medicaid, MMP- Duals

Important information on clinical diagnostic claims

Ohio Department of Medicaid (ODM) is aware that some claims for clinical diagnostic laboratory services are currently not being paid because system edit 103 has determined that the procedure reported on a detail line is "not an approved service for provider". 

This problem is occurring because the Fiscal Intermediary (FI) is attempting to verify the Clinical Laboratory Improvement Amendments (CLIA) certification only of the rendering provider (e.g., individual practitioner) and not of the billing provider (e.g., professional medical group).

Claims with detail lines for clinical diagnostic laboratory services that are affected by edit 103 were in 'pending' status but have been released for processing, at which point payment for the pended details will be paid or denied.

ODM is working with our vendor on a solution to this issue. We will provide updates as they become available.

Please direct any questions about this matter to NONINSTITUTIONAL_POLICY@medicaid.ohio.gov.

Medicare

Risk Adjustment Coding Webinar: Vascular Conditions

• August 9 @ 10am (EST) 
• August 11 @ 9am (EST) 
• August 15 @ 12noon (EST)  
• August 15 @ 6pm (EST)  
• August 17 @ 9am (EST)  

Tips for Pediatric Risk Coding

• August 22 @ 10am (EST)  
• August 24 @ 3pm (EST) 
• August 30 @ 12noon (EST) 
• August 30 @ 6pm (EST) 
• September 1 @ 9am (EST)

MarketPlace

HHS Risk Adjustment – What do you need to know

• August 23 @ 10am (EST) 
• August 25 @ 9am (EST)  
• August 29 @ 12noon (EST)  
• August 29 @ 6pm (EST)  
• August 31 @ 3pm (EST)  

Risk Adjustment 101 Medicare - Best Practices

• September 19 @ 10am (EST)  
• September 21 @ 3pm (EST)  
• September 26 @ 12noon (EST)  
• September 28 @ 6pm (EST)  
• September 29 @ 9am (EST)  

 

Assertive Community Treatment (ACT) is an evidence-based model of delivering comprehensive community based behavioral health services to adults with certain serious and persistent mental illnesses who have not benefited from traditional outpatient treatment. ACT is a benefit available to Medicaid and MyCare Buckeye members who meet the criteria outlined in this revised clinical policy. The first 12 months of ACT services do not require prior authorization. This policy will be available on our Policy website page on September 24, 2023.

For claims received on or after September 1, 2023, providers may experience a slight increase in written requests for medical records to determine if documentation supports services billed for ER surgical services where the follow up was not performed in the ER setting, and the correct modifier (54) was not included with the claim. These requests will come from Optum and will contain instructions for providing requested documentation. Should the requested documents not be returned, the claim(s) will be denied. Providers will have the ability to dispute findings through Optum directly in the event of a disagreement. Impacted lines of business are Medicare and Marketplace products. 

Thank you for partnering with us to provide quality health care to our members, your patients.

Columbus Public Health is offering recommended childhood vaccines at no cost to ensure all children have a healthy and safe school year. City of Columbus and Worthington residents under the age of 18 who receive a school-required vaccine from Columbus Public Health at a specific vax cash clinic will receive a $100 visa gift card onsite when they are vaccinated, while supplies last. Various locations. You must make an appointment in advance. 

Defects impacting delivery of 835 files

Ohio Department of Medicaid (ODM) is aware of issues affecting the provider community’s ability to consistently receive fee-for-service (FFS) 835 files since the Fiscal Intermediary (FI) launch on February 1. ODM understands the importance of timely and accurate data exchange and is committed to ensuring a smooth and reliable user experience. Over the last few months, ODM and its vendors have been identifying and correcting 835-related errors. As a result of the fixes, the majority of missing 835 details have been generated. A large batch was released on May 24, followed by a second batch released on June 26, and we expect another batch to be released today, July 7.

There is one remaining known issue that is currently being addressed. ODM has identified that this issue is primarily affecting hospitals claims. These files cannot be delivered since they failed SNIP edits at the Electronic Data Interchange (EDI). ODM vendors are working on implementing a fix in the coming 2-3 weeks.

If you have any questions or concerns about this issue, please contact Ohio Medicaid’s Integrated Helpdesk (IHD) at 800-686-1516 or email IHD@medicaid.ohio.gov. Representatives are available 8 a.m.-4:30 p.m. Eastern time Monday-Friday. We appreciate your understanding and your continued partnership.

Provider Network Management Disenrollment Quick Reference Guide is available

The Provider Network Management (PNM) Disenrollment Quick Reference Guide (QRG) offers step-by-step instructions on disenrolling a provider from Ohio Medicaid within the PNM module. These steps should only be completed if you wish to request the withdrawal of a provider’s enrollment with Ohio Medicaid. Once completed, the Medicaid ID assigned to that provider will no longer be active. The Disenrolling a Provider from Ohio Medicaid and other PNM QRGs are available on the PNM Learning tab.  

Note: Disenrolling a provider is not the action you should take to remove or manage a provider’s affiliation with an organization or group.

For additional questions or technical support, please contact Ohio Medicaid’s Integrated Helpdesk (IHD) at 800-686-1516 or email IHD@medicaid.ohio.gov. Representatives are available 8 a.m.-4:30 p.m. Eastern time Monday-Friday. 

To learn more about the PNM module and Centralized Credentialing, visit the PNM and Centralized Credentialing page on the Next Generation website. 

Requests to Providers for MyCare Contact Information

As part of Buckeye Health Plan’s normal business practice, we may reach out to our providers to gather the latest contact information on our MyCare members. Coordination of care between providers is part of our provider agreement, which allows us to work collaboratively to support our members.

Using submitted claims information, we touch base with various types of service providers to obtain or verify updated phone numbers, addresses and other information for our members. As the member’s health plan, we want to assure you that responding to us with this requested information is not a HIPAA violation. If you receive a request from us, we ask that you please provide this information at your earliest convenience. Thank you for all you do for our members, your patients.

If you have questions, please contact Provider Services at: 866.296.8731.

Update to CMS’ Three-Day Rule effective August 1, 2023

Centers for Medicare & Medicaid Services’ three-day rule, also known as the 72-hour rule guidelines require that hospitals bundle the technical component of all outpatient diagnostic and non-diagnostic services with the claim for an inpatient stay when services are furnished in the 3 days preceding an inpatient admission.   

CMS requires that the 72 hours prior to an inpatient stay is bundled into the inpatient stay/claim and cannot be reimbursed separately.

1. CMS requires that the 72 hours prior to an inpatient stay is bundled into the inpatient stay/claim and cannot be reimbursed separately
2. Claims are matching based on provider TIN
3. Professional claims are excluded
4. Critical Access Hospital are excluded
5. Any customization that was previously in place remains in place

Pilot Program Announcement

Buckeye Health is pleased to announce a pilot program in partnership with Ohio Sleep Treatment which specializes in treating Obstructive Sleep Apnea (OSA) with Oral Appliance Therapy (OAT).  Buckeye is evaluating OAT as an "in lieu of" therapy for Sleep Apnea patients. 

OAT is the main CPAP alternative and is recommended for mild and moderate OSA by the American Academy of Sleep Medicine (AASM).  Ohio Sleep Treatment has offices in Westerville, Circleville, and Lancaster.

Providers who wish to learn more about Ohio Sleep Treatment may contact Rob Kibler directly at:

Email robk@sleeptreatmentoh.com

Direct - (614) 316-2062 

Action required: PNM eLicense terminations

The Provider Network Management (PNM) module processed a monthly eLicense update on May 28 that matched the current license numbers entered in the PNM module as of that date. As a result, the system automatically terminated Ohio Medicaid providers with an expired license listed in the PNM module. On June 1, the PNM performed an automated script to reactivate affected providers in the system to allow time for providers to update this information before the next eLicense job.

What action do providers need to take?

Access the PNM module and confirm the license information is current before the next eLicense process runs on June 24. If the license information is not current, providers risk being terminated as an Ohio Medicaid provider. To prevent this from occurring in the future, all licensed Medicaid practitioners must keep their license date spans current in the PNM module.

For more information

For questions regarding this notice, please call the Ohio Department of Medicaid Integrated Helpdesk (IHD) at 800-686-1516 and select option 2; option 2 for provider enrollment. Representatives are available 8 a.m.-4:30 p.m. Eastern Time Monday-Friday.

Termination of Somatus Care Management Program for Patients with CKD/ESRD

Effective July 1, 2023, we will no longer partner with Somatus Inc., which provides care management services for members with chronic kidney disease (CKD) and end-stage renal disease (ESRD). Some of your patients may be affected by this change.

Consequently, some of your patients may be enrolled in our internal care management program, the Centene CKD Center of Excellence. This program will continue supporting care management needs for members with CKD and ESRD.

If you have any questions, please do not hesitate to contact your Provider Engagement Administrator.

Reminder: Non-agency (independent) waiver services providers must complete 12-hours of continuing education annually

Federal and state regulations require all non-agency waiver services providers to complete at least 12 hours of continuing education annually on or before your Ohio Department of Medicaid (ODM) contract anniversary date. If unknown, your ODM contract anniversary date can be found on the ‘Specialties’ page in the Provider Network Management (PNM) module. Your fulfillment of this rule requirement is reviewed when you participate in structural compliance reviews conducted by ODM’s Provider Oversight Contractor, Public Consulting Group (PCG).

What actions do I need to take?

• Complete 12 hours of continuing education each year prior to participating in the structural compliance review with PCG. PCG offers free continuing education courses on their website: PCG Training Materials. In addition, providers can take any qualified course or training that enhances the skills and competencies relevant to their job responsibilities and support person-centered service delivery.
• PCG will send an email one month prior to your ODM contract anniversary date, requesting a structural compliance review. Please reply promptly or call to schedule the date and time for the review.

For questions regarding this notice, please contact PCG via email at ohiohcbs@pcgus.com or via phone at 877-908-1746.

Ohio Department of Medicaid in-person site visits to resume July 1, 2023

The public health emergency has ended, and Ohio Department of Medicaid (ODM) is resuming site visits for initial provider enrollments and revalidations effective July 1, 2023. Site visits had been paused without impacting provider enrollment status. Site visits are part of ODM’s provider enrollment screening process and are required by state and federal regulations for certain provider types.

What action do I need to take?

Public Consulting Group (PCG), will be contacting you to schedule a site visit, which may be conducted either virtually or onsite. Please be responsive to PCG when they contact you.

For more information

For questions regarding this notice, please email OH_Provider_Screening@pcgus.com. For more information about provider enrollment and resources check out the Provider Enrollment page on the Medicaid website.

Announcing: Buckeye Health Plan Receives Health Equity Accreditation from the National Committee for Quality Assurance 

Buckeye Health Plan is delighted to share that we have received Health Equity Accreditation from the National Committee for Quality Assurance (NCQA). We are honored to be Ohio’s first managed care plan to receive Health Equity Accreditation from the NCQA. This accreditation recognizes Buckeye for providing culturally and linguistically sensitive services in more than 100 areas to eliminate healthcare disparities and support better health outcomes for our members. 

During the accreditation process, Buckeye met and exceeded standards in key focus areas including community and member engagement, disparity reduction, provider training on cultural competency and health equity and diversity, equity, and inclusion. The NCQA accreditation process included a rigorous evaluation by a health plan expert.

Buckeye is thinking in new ways about the many systems that influence health, from education and housing to transportation and public safety. Health equity is central to our work across all lines of business, including our processes, practices, programs, and products. This accreditation gives us a solid framework to build upon to ensure we make meaningful differences in the lives of those we are honored to serve. Buckeye delivers high-quality care and service to help everyone live their healthiest life.

As you know, we continually review and update our payment and utilization policies to ensure that they are designed to comply with industry standards while delivering the best patient experience to our members. This is to inform you of the revision to existing Medicare and Marketplace effective 7-1-23. 

Policy Updates

Policy Number	Policy Name	Policy Description	Line of Business
CP.MP.100	Allergy Testing and Therapy	Change codes 86160, 86161 and 86162 from not payable to NOT payable only when billed with the following diagnosis codes:, B44.81, H10.01* through H10.45, J30.1 through J30.9, J30.0, J31.0, J45.2* through J45.998 , L20.84  , L20.89, L20.9, L23.0 through L23.9*, L25.1 through L25.9, L27.0 through L27.9 , L50.0, L50.1, L50.6, L50.8, L50.9, L56.1, L56.2, L56.3, R06.2, T36.0X5A through T50.995S , T63.001* - T63.94*, T78.00X* through T78.1XXS, T78.49XA through T78.49XS , T80.52XA through T80.52XS, T88.6XXA through T88.6XXS , Z88.0 through Z88.9, Z91.010 through Z91.018, Add the following diagnosis codes as payable with 86003, 86005, 86008, 95004, 95017, 95018, 95024, 95027 and 95028. L20.0, L20.81-L20.83, L24.9, L30.2. Add CPT 86001 as NOT payable.	Medicare & Marketplace
CP.MP.97	Testing for Select Genitourinary Conditions	Added 0330U and 0352U as not med nec for members over age 13 (new code for July '22 with no utilization/cost data). Changed matching requirements for ICD-10 B37.3 to apply to B37.31 and B37.32 which together now replace B37.3. There will be no savings change from this edit. Changed CPT 87481 from not medically necessary in any circumstance to not med nec when paired with the following dx codes, and only applied to members 13 years and over. Required the same dx code matching for new code 0353U (with no utilization/cost data): B37.31, B37.32, L29.2, L29.3, N39.0,N72, N76.0, N76.1, N76.2, N76.3, N76.81, N76.89, N77.1, N89.8, N89.9, N90.89, N90.9, N91.0 –N91.5, N92.0, N93.0, N93.8, N93.9, N94.3, N94.4 – N94.6, N94.89, N94.9, O09.00-O09.03, O09.10-O09.13, O09.A0-O09.A3, O09.211-O09. 219,O09. 291-O09. 299,O09.30-O09.33,O09. 40-O09.43, O09.511-O09.519, O09.521- O09. 529, O09.611-O09.619, O09.621-O09.629, O09.70-O09.73, O09.811-O09.819,  O09.821-O09.829, O09.891-O09.899, O09.90-O09.93, O23.511– O23.93, 00.00,Z00.8,Z01.419,Z11.3,Z11.51,Z22.330,Z23,Z30.011 – Z30.019,Z30.02, Z30.09,Z30.40 – Z30.9,Z32.00, Z33.1, Z34.00 – Z34.03, Z34.80 – Z34.83, Z34.90 – Z34.93, Z36.0-Z36.5, Z36.81-Z36.9, Z38.00 – Z38.01, Z38.30 – Z38.31, Z38.61 – Z38.69, Z39.0 – Z39.2, Z3A.00 – Z3A.49, Z72.51 – Z72.53, Z86.19, Z97.5	Medicare & Marketplace

Effective July 1, 2023 Buckeye Health Plan will follow ODM guidance requiring use of the 33 modifier for the full reimbursement for filing the ePRAF.  Buckeye will no longer reimburse providers the full payment unless the provider files the claim for the ePRAF with the 33 modifier as stipulated by ODM.   Buckeye offered a grace period since ODM initially provided this guidance.  Please refer to the chart below. 

Payment for Completing the ePRAF

After completing the PRAF, submit a claim based on the guidelines below:

Reimbursement of ePRAF

Code + modifier	Description	Fee Schedule Amount*
H1000 + 33	Electronic PRAF Submission	$90.00
H1000	Paper/Faxed version	$12.10

* Provider’s contracted rate will be applied to the fee schedule rate to determine final amount.   

See more information on the PRAF and proper billing on our website. 

 

Buckeye Health Plan's Payment Integrity department is implementing changes to the suite of unbundling edits with enhanced business rules to improve customer experience. Providers may see a reduction in unbundling edits starting in July of 2023, as Internal editing will reduce denials to only bundled modifier 59 code pair services which are clinically related. 

We want to provide you with a heads up on upcoming enhancements to the Provider Portal Landing Page and a Pop-Up Survey you may encounter on the portal toward the end of June.

One of the most propelling reasons for the changes, is to make the page more accessible for our users. The portal is now 508 Compliant to come in line with the governments directive to ensure that disabled members of the public have comparable access. By doing this, we also ensure that everyone’s experience on the site is elevated. While none of the functionality will be changing, how the users interact with the information is changing. Below is an overview of the capabilities/modules you can expect: 

1. Notifications: Updated design to incorporate color coding, limit the characters allowed, and enabled the ability to set expiration dates.
2. Personalized welcome with quick messages about the improved functionality.
3. Admin Settings: Quick and easy access to core functionality of an Admin User.
4. Quick Actions: Quick and easy access to Member Eligibility, New Claim, Recurring Claim, and Authorizations.
5. Claims Overview: Dashboard of claims, segmented by Denied, Rejected, and Pending.
6. Authorizations Overview: Quick access to inpatient and outpatient authorizations
7. Useful links that are relevant to the user’s permissions and role.

In addition, you may encounter a Site Intercept Satisfaction Pop-Up Survey and/or a Feedback Tab Survey. To ensure you are experiencing the best possible use of the portal, we are placing short, automated pop-up intercepters to collect direct feedback from you about the portal experience.  

More details and a Quick Start Guide will be coming soon. 

Ohio Department of Medicaid will be hosting an opportunity to offer input and feedback on proposed updates to the CPC program administrative code rules (OAC 5160-19-01 and -02). ODM will be reviewing proposed changes, which will include updates to risk stratification, quality and efficiency metrics, and activities.

This meeting will take place on Thursday June 1, 2023 from 2:00 p.m. – 3:00 p.m. via GoToWebinar. If interested, please register here.

Medicare Member Plan Benefits Resume for Applicable COVID-19 Testing, Screening, and Treatment Services on May 12, 2023

Earlier this year, the Biden Administration announced that the federal Public Health Emergency (PHE) related to the COVID-19 pandemic will end on May 11, 2023.

During the PHE, we followed guidance from the Centers for Medicaid & Medicare Services (CMS) and instituted temporary waivers for select services. This action ensured that critical care could be quickly delivered to our members during a time of heightened need. Beginning May 12, 2023, these temporary waivers will expire, and our members’ Medicare plan benefits will be reinstated for the following services:

Sunsetting

Service	Member Liability	Prior Auth Needed?
COVID-19 Testing and Screening (Administered by Provider)	Per member plan benefits	No
COVID-19 Vaccinations	$0 member cost-share for vaccine administration*	No
COVID-19 Monoclonal Antibody Treatments	$0 member cost-share for treatment administration*	Prior authorization only required for CPT code Q0221

*Vaccine ingredient cost is still covered directly by Medicare FFS.

Alongside these waivers, the Coronavirus Aid, Relief, and Economic Security (CARES) Act provided for a 20% increase to the inpatient prospective payment system (IPPS) Diagnosis Related Group (DRG) rate for COVID-19 patients for the duration of the public health emergency. This increase applied to claims that included the applicable COVID-19 ICD-10-CM diagnosis code and met the date of service requirement. When the PHE ends on May 11, 2023, these add-on payments will no longer be included for discharge dates of service as of May 12, 2023 and thereafter.

Wellcare by Allwell is committed to providing a smooth transition for both our members and providers as we resume business as usual. While we will continue to communicate any updates to our business practices directly to our provider partners, we always highly recommend that providers verify member eligibility, benefits, and prior authorization requirements before rendering services.

End Date of Public Health Emergency (PHE) and PASRR Impact

In March 2020, the Ohio Department of Medicaid (ODM) made a number of operational changes to its Medicaid program in response to the COVID-19 public health emergency (PHE). These changes included taking advantage of the flexibilities offered to states including but not limited to allowing nursing facilities to delay the completion of the Preadmission Screening and Resident Review (PASRR) for 30-days.

On February 9, 2023, the Department of Health & Human Services announced that the PHE will end on May 11, 2023. While there were various flexibilities granted, the 30-day delay of PASRR Level I screenings and Level II evaluations will terminate on May 11, 2023.

As such, the Center for Medicare and Medicaid Services expect states to resume full PASRR activities in accordance with state PASRR rules (OAC 5160-3-15, OAC 5160-3-15.1 and OAC 5160-3-15.2) as of May 12, 2023. Therefore, providers must also return to the pre-PHE timeframes for completing PASRR requirements and related level of care requests. As a reminder, level of care determinations must not precede the date the PASRR requirements were met.

For additional questions, please submit them to PASRR@medicaid.ohio.gov

See OhioRISE

See Next Gen Contract Website Page

See EVV Website Page

Medicaid Providers Note:

We identified an issue where 835 files from Buckeye were not being received by OMES; therefore 835 files sent between February 1 to March 20, 2023, may be reprocessed which could cause duplication. Please make staff aware of this possibility to ensure the file is not posted a second time. If you have any questions, please reach out to Provider Services at 866-296-8731.

We apologize for any inconvenience this may cause and thank you in advance for your understanding.

Claims Auditing – Custom Fitted or Custom Fabricated Prosthetics or Orthotics

On March 27, 2023, we notified our providers that we will begin performing additional prepayment claim reviews on July 1, 2023, using Optum’s Comprehensive Payment Integrity (CPI) tool. For Phase 1, claims received on or after July 1, 2023, providers may experience a slight increase in written requests for medical record submission prior to payment for Custom Fitted or Custom Fabricated Prosthetics or Orthotics. We will be requesting medical records to verify documentation that supports high-dollar custom DME codes billed by the provider. These requests will come from Optum and will contain instructions for providing the documentation.

Notification for Buckeye Health Plan, Wellcare By Allwell and Ambetter Providers:

We are committed to continuously improving our overall payment integrity solutions to prevent overpayments due to waste or abuse. This is a notification that we will begin performing additional prepayment claim reviews on July 1, 2023, using Optum’s Comprehensive Payment Integrity (CPI) tool. As a result of these prepayment claim reviews, providers may be asked for medical records and billing documents that support the charges billed.

We utilize widely acknowledged national guidelines for billing practices and support the concept of uniform billing for all payers. The prepayment claim reviews will look for overutilization of services or other practices that directly or indirectly result in unnecessary costs. A provider’s order must be present in the medical record to support all charges, along with clinical documentation to support the diagnosis and services or supplies billed.

If Optum’s review results in a finding, the provider will receive detailed instructions about how to submit requested documentation. Providers who do not submit the requested documentation may receive a technical denial, which will result in the claim being denied until the information required to adjudicate the claim is received.

If it is determined that a coding and/or payment adjustment is applicable, the provider will receive the appropriate claim adjudication. Providers retain their right to dispute results of reviews. 

Please contact the applicable Provider Services listed on our home page or your Provider Engagement Administrator if you have any questions.

ODM Pause on Provider Agreement Revalidation/Recredentialing

The Ohio Department of Medicaid (ODM) paused provider agreement revalidations/recredentialing by pushing out all pending provider revalidation due dates in the Provider Network Management (PNM) module by 180 days. Dates were pushed out in the system during the week of February 6, 2023.  

The updated due dates applied to all providers who had not begun the revalidation process prior to the week of February 6, including those that already displayed the “Begin Revalidation” button.  This button indicated the provider had entered the 120-day period before revalidation is due.  A provider’s revalidation date is indicated by the Medicaid Agreement End Date field in PNM.   ODM issues a revalidation notice to the provider 120 days in advance of that date, including display of the “Begin Revalidation” button within their PNM account.  

As a provider, what action do I need to take?

• If you do not see the “Begin Revalidation” button in the provider record, you do not need to do anything. The update will move the dates out another 180 days. 
• If you do have the “Begin Revalidation” button, this means you are within the current 120-day window for revalidation.

EXCEPTION:  If you started a revalidation prior to the week of February 6, 2023, it must be completed and submitted, as this change cannot be applied to providers that were already in the revalidation process.

Providers are strongly encouraged to avoid potential enrollment delays by submitting revalidation applications early in the process.

For more information:  For technical support or assistance, contact Ohio Medicaid’s Integrated Helpdesk (IHD) at 800-686-1516 and follow the prompts for Provider Enrollment (option 2) or email IHD@medicaid.ohio.gov.

To learn more about the PNM module and Centralized Credentialing, visit the PNM and Centralized Credentialing page on the Next Generation website.  ODM will provide additional guidance but the 5/11/23 date is the likely date that PHE is lifted which sets in motion various timelines to unwind from provider flexibilities.   ODM will realign all revalidation dates accordingly and the MCE will access that information from the daily PMF. 

See Next Gen Contract Website Page

See Behavioral Health Website page

PA Changes Eff April 1, 2023

Service Code	Service/Procedure Description	Comments
A4239 (Formerly Code K0553, now retired)	Supplies, Continuous Glucose Monitoring	Allow 1 unit per month billed- PA required for over benefit limit only
E2103 (Formerly Code K0554, now retired)	Receiver/Monitor, Continuous Glucose Monitor	Allow 1 monitor every 3 years- PA required for over benefit limit only
A9277	External Transmitter	Allow up to 2 per benefit year- PA required for over benefit limit only
A9278	External Receiver/Monitor	Allow 1 per benefit year- PA required for over benefit limit only

See Next Gen Contract website page

Effective April 1, 2023

Policy Number	Policy Name	Policy Description
CP.MP.96	Ambulatory EEG	Policy is being retired across all lines of business
CP.MP.149	Testing for Rupture of Fetal Membranes	Policy is being retired across all lines of business due to changes in standards of care.
CP.MP.113	Holter Monitors	Retiring for Medicare only as the LCDs are more lenient
CP.MP.139	Low-frequency ultrasound wound therapy	Retiring for Medicare only as the LCDs are more lenient
CP.MP.152	Measurement of Serum 1,25-dihydroxyvitamin D	Retiring for Medicare only as the LCDs are more lenient
CP.MP.38	Ultrasound in Pregnancy	Added new-for-2022 diagnosis codes as medical necessity/payable with 76811
CP.MP.134	Evoked Potential Testing	Changed configuration so the edits don't apply to outpatient surgeries by matching revenue codes Retire for Medicare
OC.UM.CP.0026	Extended Ophthalmoscopy	Add the following ICD-10 codes to the list of diagnoses that are payable when billed with 92201/92202: , E09.37X1, E09.37X2, E09.37X3, E10.37X1, E10.37X2, E10.37X3, E11.37X1, E11.37X2, E11.37X3, H20.011, H20.012, H20.013, H20.021, H20.022, H20.023, H20.031, H20.032, H20.033, H20.041, H20.042, H20.043, H20.11, H20.12, H20.13, H20.21, H20.22, H20.23, H20.811, H20.812, H20.813, H20.01, H20.02, H20.03, H21.301, H21.302, H21.303, H21.311, H21.312, H21.313, H21.321, H21.322, H21.323, H21.341, H21.342, H21.343, H21.351, H21.352, H21.353, H21.531, H21.532, H21.533, H21.541, H21.542, H21.543, H21.551, H21.552, H21.553, H35.051, H35.052, H35.053, H35.21, H35.22, H35.23, H47.231, H47.232, H47.233, P07.01, P07.02, P07.03, P07.14, P07.15, P07.16, P07.17, P07.18, P07.21, P07.22, P07.23, P07.24, P07.25, P07.26, P07.31, P07.32, P07.33, P07.34, P07.35, P07.36, P07.37, P07.38, P07.39, Q85.01, Q85.02, Q85.03, S05.41XA, S05.41XD, S05.41XS, S05.42XA, S05.42XD, S05.42XS, T74.4XXA, T74.4XXD, T74.4XXS.  Remove the following ICD-10 codes to the list of diagnoses that are payable when billed with 92201/92202:, H31.101, H31.102, H31.103, S05.71XA, S05.71XD, S05.71XS, S05.72XA, S05.72XD, S05.72XS Retire all edits for Medicare LOB as the LCDs are more lenient
OC.UM.CP.0028	Fluorescein Angiography	Add the following ICD-10 codes to the list of diagnoses that are payable when billed with 92235: B20, B39.5, H33.111, H33.112, H33.113, H35.21, H35.22, H35.23, H35.361, H35.362, H35.363, H43.11, H43.12, H43.13, H43.821, H43.822, H43.823, Q14.8 Retire all edits for Medicare LOB as the LCDs are more lenient.
OC.UM.CP.0029	Fundus Photography	Add the following ICD-10 codes to the list of diagnoses that are payable when billed with 92250: Add the following ICD-10 codes to the list of diagnoses that are payable when billed with 92250: A51.43, A52.15, B25.8, G93.2, H33.121, H33.122, H33.123, Q14.8, S05.41XA, S05.41XD, S05.41XS, S05.42XA, S05.42XD, S05.42XS, S05.61XA, S05.61XD, S05.61XS, S05.62XA, S05.62XD, S05.62XS, Z85.840.  Remove the following ICD-10 codes from the list of diagnoses that are payable when billed with 92250:, C69.01, C69.02, C69.11, C69.12, C69.51, C69.52, D49.89, Q87.1 Retire all edits for Medicare LOB as the LCDs are more lenient.
OC.UM.CP.0043	External Ocular Photography	Add the following ICD-10 codes to the list of diagnoses that are payable when billed with 92285: , A18.51, A18.54, A50.31, B00.53, B30.0, B30.1, B30.2, B30.3, C44.1922, C44.1991, C44.1992, C69.51, C69.52, C69.61, C69.62, C69.81, C69.82, D09.21, D09.22, D31.51, D31.52, H00.011, H00.012, H00.014, H00.015, H00.021, H00.022, H00.024, H00.025, H00.031, H00.032, H00.034, H00.035, H00.11, H00.12, H00.14, H00.15, H02.881, H02.882, H02.884, H02.885, H02.88A, H02.88B, H04.011, H04.012, H04.013, H04.021, H04.022, H04.023, H04.031, H04.032, H04.033, H04.111, H04.112, H04.113, H04.131, H04.132, H04.133, H04.161, H04.162, H04.163, H04.311, H04.312, H04.313, H04.321, H04.322, H04.323, H04.331, H04.332, H04.333, H04.411, H04.412, H04.413, H04.421, H04.422, H04.423, H04.431, H04.432, H04.433, H04.511, H04.512, H04.513, H04.521, H04.522, H04.523, H04.531, H04.532, H04.533, H05.011, H05.012, H05.013, H05.021, H05.022, H05.023, H05.031, H05.032, H05.033, H05.041, H05.042, H05.043, H05.111, H05.112, H05.113, H05.121, H05.122, H05.123, H05.211, H05.212, H05.213, H05.221, H05.222, H05.223, H05.231, H05.232, H05.233, H05.241, H05.242, H05.243, H05.251, H05.252, H05.253, H05.261, H05.262, H05.263, H05.311, H05.312, H05.313, H05.321, H05.322, H05.323, H05.331, H05.332, H05.333, H05.341, H05.342, H05.343, H05.351, H05.352, H05.353, H05.411, H05.412, H05.413, H05.421, H05.422, H05.423, H05.51, H05.52, H05.53, H05.811, H05.812, H05.813, H05.821, H05.822, H05.823, H16.241, H16.242, H16.243, H20.11, H20.12, H20.13, H20.21, H20.22, H20.23, H20.811, H20.812, H20.813, H20.821, H20.822, H20.823, H21.331, H21.332, H21.333, H21.561, H21.562, H21.563, H21.81, H27.111, H27.112, H27.113, H27.121, H27.122, H27.123, H27.131, H27.132, H27.133, H44.011, H44.012, H44.013, H44.111, H44.112, H44.113, H44.121, H44.122, H44.123, H44.131, H44.132, H44.133, S00.211A, S00.212A, S00.221A, S00.222A, S00.241A, S00.242A, S00.251A, S00.252A, S00.261A, S00.262A, S05.01XA, S05.01XD, S05.01XS, S05.02XA, S05.02XD, S05.02XS.  Remove the following ICD-10 codes from the list of diagnoses that are payable when billed with 92285:, C44.131, H18.501, H18.502, H18.503 Retire all edits for Medicare LOB as the LCDs are more lenient.
OC.UM.CP.0063	Visual Field Testing	Add the following ICD-10 codes to the list of diagnoses that are payable when billed with 92081-3: , B58.01, C75.3, C79.31, D35.4, D43.3, E05.20, E05.21, E05.30, E05.31, E05.40, E05.41, G45.1, G45.2, G46.0, G46.1, G46.2, H02.211, H02.212, H02.214, H02.215, H02.21A, H02.21B, H02.21C, H02.221, H02.222, H02.224, H02.225, H02.22A, H02.22B, H02.22C, H02.231, H02.232, H02.234, H02.235, H02.23A, H02.23B, H02.23C, H02.841, H02.842, H02.844, H02.845, H02.851, H02.852, H02.854, H02.855, H05.121, H05.122, H05.123, H17.01, H17.02, H17.03, H17.11, H17.12, H17.13, H17.811, H17.812, H17.813, H17.821, H17.822, H17.823, H21.331, H21.332, H21.333, H31.011, H31.012, H31.013, H31.021, H31.022, H31.023, H33.121, H33.122, H33.123, H43.01, H43.02, H43.03, H43.11, H43.12, H43.13, H43.21, H43.22, H43.23, H43.311, H43.312, H43.313, H43.821, H43.822, H43.823, H44.21, H44.22, H44.23, H44.311, H44.312, H44.313, H44.411, H44.412, H44.413, H44.421, H44.422, H44.423, H44.431, H44.432, H44.433, H44.441, H44.442, H44.443, H44.511, H44.512, H44.513, H44.521, H44.522, H44.523, H44.531, H44.532, H44.533, H44.611, H44.612, H44.613, H44.621, H44.622, H44.623, H44.631, H44.632, H44.633, H44.641, H44.642, H44.643, H44.651, H44.652, H44.653, H44.691, H44.692, H44.693, H44.711, H44.712, H44.713, H44.721, H44.722, H44.723, H44.731, H44.732, H44.733, H44.741, H44.742, H44.743, H44.751, H44.752, H44.753, H44.791, H44.792, H44.793, H44.811, H44.812, H44.813, H44.821, H44.822, H44.823, H53.451, H53.452, H53.453, H57.02, H57.03, H57.04, H57.051, H57.052, H57.053, I60.2, I63.013, I63.033, I63.113, I63.133, I63.313, I63.323, I63.333, I63.343, I63.413, I63.423, I63.433, I63.443, I67.850, M31.6, S05.11XA, S05.11XD, S05.11XS, S05.12XA, S05.12XD, S05.12XS, S06.0X0A, S06.0X0D, S06.0X0S, S06.0X1A, S06.0X1D, S06.0X1S, S06.0X9A, S06.0X9D, S06.0X9S, S06.1X0A, S06.1X1A, S06.1X2A, S06.1X3A, S06.1X4A, S06.1X5A, S06.1X6A, S06.1X9A, S06.2X0A, S06.2X1A, S06.2X2A, S06.2X3A, S06.2X4A, S06.2X5A, S06.2X6A, S06.2X9A, S06.300A, S06.301A, S06.302A, S06.303A, S06.304A, S06.305A, S06.306A, S06.309A, S06.310A, S06.311A, S06.312A, S06.313A, S06.314A, S06.315A, S06.316A, S06.319A, S06.320A, S06.321A, S06.322A, S06.323A, S06.324A, S06.325A, S06.326A, S06.329A, S06.340A, S06.341A, S06.342A, S06.343A, S06.344A, S06.345A, S06.346A, S06.349A, S06.350A, S06.351A, S06.352A, S06.353A, S06.354A, S06.355A, S06.356A, S06.359A, S06.370A, S06.371A, S06.372A, S06.373A, S06.374A, S06.375A, S06.376A, S06.379A, S06.380A, S06.381A, S06.382A, S06.383A, S06.384A, S06.385A, S06.386A, S06.389A, S06.4X0A, S06.4X1A, S06.4X2A, S06.4X3A, S06.4X4A, S06.4X5A, S06.4X6A, S06.4X9A, S06.5X0A, S06.5X1A, S06.5X2A, S06.5X3A, S06.5X4A, S06.5X5A, S06.5X6A, S06.5X9A, S06.6X0A, S06.6X1A, S06.6X2A, S06.6X3A, S06.6X4A, S06.6X5A, S06.6X6A, S06.6X9A, S06.810A, S06.811A, S06.812A, S06.813A, S06.814A, S06.815A, S06.816A, S06.819A, S06.820A, S06.821A, S06.822A, S06.823A, S06.824A, S06.825A, S06.826A, S06.829A Retire all edits for Medicare LOB as the LCDs are more lenient.

In response to your feedback, we have removed 16 services from our prior authorization list effective April 1, 2023:

PA Removals Eff April 1, 2023

Service Code	Service/Procedure Description	Comments
81220	Cystic Fibrosis Carrier Screen
97110	PT Services
81420	Fetal Chromosomal Screen
81206	Familial dysautonomia
20550	Injections ganglion cysts/plantar fascia
20605	Arthrocentesis, aspiration and/or injection, intermediate joint or bursa
86832	Antibody testing human leukocyte antigens (HLA)
64885	Nerve Graft Required PA for Non Par only.  This will now be NO AUTH REQUIRED FOR ALL PROVIDERS
97530	Therapeutic Activities
77002	Fluoroscopic guidance for needle placement	No PA for All Providers
81546	Testing (genetic) with Thyroid Biopsies
92507	Speech Treatments
41899	Facility charges around dental procedures done in hospital OR or Outpatient Surgery locations	No PA for All Providers
00170	Anesthesia charges for dental procedures done in hospital surgery,  Outpatient Surgery locations

Buckeye Health Plan is aligning with Ohio Department of Medicaid PA requirements for Continuous Glucose Monitoring supplies.  PA requirements for network providers will be required if monthly/yearly amounts are more than the ODM recommended amounts below: 

PA Changes Effective April 1, 2023

SERVICE CODE	SERVICE/PROCEDURE DESCRIPTION	COMMENTS
K0553	Supplies, Continuous Glucose Monitoring	Allow 1 unit per month billed- PA required for over benefit limit only
A9277	External Transmitter	Allow up to 2 per benefit year- PA required for over benefit limit only

See Next Gen Contract Website Page

See Next Gen Contract Website Page

See Next Gen Contract Website Page

• Anyone accessing the PNM or the SPBM secure web portal will need an OH|ID to log in and complete key administrative tasks and processes. The following resources are available to providers assist in setting up an account.
  • Create an OH|ID account. 
  • Get help logging in. 
  • View an in-depth OH|ID account creation user guide. 
• Providers needing technical assistance should contact the Ohio Department of Medicaid Integrated Help Desk (IHD) at 1-800-686-1516. Hours of operation are Monday-Friday, 8 a.m. - 4:30 p.m. ET.

(ODM apologizes for the error found in a communication sent out earlier this month. They stated that all demographic updates, including the CPC contact information, needed to be done in the MITS system by Aug 20 or the change will have to be held until Oct 1. The correct date is Aug 31st. Please see the corrected communication below.)

CPC Enrollment for the 2023 Program Year

The enrollment period for the CPC program is again slated for October. ODM anticipates sending out invitations to those who are eligible in early September 2022. Invitations will be sent via email to the CPC contact found in the MITS Secure Provider Portal. 

Beginning Aug. 31, all provider demographic and agent maintenance update functionality will be closed for conversion of data in MITS. ENROLLED PROVIDERS SHOULD UPDATE THEIR DEMOGRAPHIC INFORMATION IN MITS BY AUGUST 31 or plan to hold updates until Oct. 1. It is therefore vital to make sure updates are completed by Aug. 31 to ensure all CPC invitations are received.

For assistance with how to update your demographic information, refer to the training video found on the ODM website. If additional assistance is needed, contact the Provider Hotline 800-686-1516.