Pay BillSCOPE | Provider Update
August 2024
Clinical Matters
Ensuring patient safety through accurate prescriptions
Prescriptions should reflect most current dose if dose or directions for use have changed.
Managing a treatment plan for a patient’s good health and well-being can lead to changes in the dosage of a prescription medication. A provider may instruct a patient to ‘try taking half a tablet instead of a whole tablet’ or ‘switch to one tablet per day instead of two.’
Please remember: If a patient’s dose or directions for use have changed, the prescription should be rewritten to reflect the most current dose. If the new dose is not sent to the pharmacy as a new prescription, serious problems may occur down the road such as:
- Patient errors and misunderstandings – more likely to occur if the change is communicated verbally.
- Health issues if the patient is hospitalized, and the pharmacy’s directions are used to direct future prescriptions.
- A patient appearing to be non-adherent when they are actually taking their medication as directed verbally.
Additionally, please have the pharmacy inactivate the old prescription to avoid dispensing errors.
Thank you for your continued care of our community.
Policy update for GLP-1s effective Sept. 1, 2024: Evidence-based, formalized weight management program requirements
Policy change aims to support your patients' efforts to lose weight and maintain their health
It’s well documented that individuals who lose weight at a gradual, steady pace—about 1 to 2 pounds a week—are more likely to keep the weight off compared to those who lose weight quickly. Factors such as sleep, medicines, medical conditions, and age can also affect weight management.
As the use of GLP-1s for weight loss grows, experts agree that safer, more cost-effective strategies to help individuals lose weight and maintain a healthy weight should be considered well before medication therapy.
Therefore, to support our members who are overweight and obese in their efforts to lose weight and improve the probability of success, Independent Health is enhancing our policy regarding the coverage of GLP-1s.
Policy update effective September 1, 2024
Glucagon-like peptide-1 (GLP-1) receptor agonists approved for the treatment of weight loss are covered on our commercial formularies and require prior authorization. These formulary weight loss medications are:
- Saxenda (liraglutide)
- Wegovy (semaglutide)
- Zepbound (tirzepatide)
The current policy has required providers to submit documentation that the patient has attempted to lose weight through a formalized weight loss program.
The updated policy clarifies that a commercial member must be enrolled and participating in an evidence-based, formalized weight management/ lifestyle modification program for at least six months prior to requesting coverage for a GLP-1.
The patient must continue to participate in the weight management/lifestyle program for at least an additional 6 months while receiving treatment with the GLP-1.
Prescribers must attest that the risks, benefits, alternatives, and possible complications of treatment with a GLP-1 receptor agonist medication for weight loss have been discussed with the patient and has documentation of the discussion in the patient’s medical record. These include, but are not limited to pancreatitis, gastroparesis, and bowel obstruction.
For additional details, please refer to our policy, Weight Loss Medications M20190904043 which will be posted to the portal on Aug. 1.
Recognized Programs
A formalized, evidence-based weight management program will support your patients’ journey to better health and better outcomes, and help promote a long-lasting lifestyle change.
We have evaluated a number of programs and have determined that the Weight Watchers Points program meets our criteria to support our members. A community-based, in-person, evidence-based formalized program may also be accepted. Our members who enroll in the Weight Watchers Points program may receive a discount.
Office Matters
New ICD-10-CM Diagnosis Code Billing Requirements Reimbursement Policy
New ICD-10-CM Diagnosis Code Billing Requirements policy was posted on May 1.
We would like to draw your attention to a new Reimbursement Policy which was posted to your Provider Portal on May 1, 2024. The ICD-10-CM Diagnosis Code Billing Requirements policy contains pertinent information on new claim edits which have been deployed in our claim processing system over the past two months and includes updates for new edits going into effect for August.
We strongly encourage your practice to review this policy and make necessary updates to your billing practices to ensure compliance. Providers receiving denials for these new claim edits will need to submit corrected claims in order for the claim to be eligible for reimbursement.
Timely filing deadlines extended again due to ongoing Change Healthcare incident
As health care providers continue to face challenges with claims submissions, Independent Health has extended timely filing deadlines through Aug. 31, 2024.
Independent Health continues to monitor the effect of the Change Healthcare cybersecurity event on some providers’ ability to submit claims to Independent Health.
Independent Health has been extending timely filing through the end of May, June and July. Due to ongoing issues, we will once again extend the timely filing relaxation period through August 31, 2024.
During this extension period, Independent Health will treat submissions for dates of service on and after the dates below as timely filed claims:
- Medicare and State Products = November 23, 2023
- Commercial Products = October 24, 2023
The approach remains the same: capture the earliest possible date of service for a still-timely claim as of February 21, 2024, which was the date the Change Healthcare cyber event occurred.
Independent Health may end the extension period earlier if billing is fully restored; additionally, we will consider continuing the timely filing extension period if the disruption continues beyond August 31, 2024.
Self-funded line of business:
Timely filing requirements for our self-funded line of business vary, and requests for reconsideration of untimely claims for self-funded clients will be reviewed on a group-specific basis.
If you have any questions or concerns, please contact Provider Relations Monday through Friday from 8 p.m. to 6 p.m. at 716-631-3292.
In addition, you may visit this page for additional information on claims and billing alternatives.
Policy change regarding skin substitutes effective Sept. 1.
Skin Substitutes policy includes coverage guidelines for burns & breast reconstruction, HCPCS/CPT codes and list of investigational/unproven products.
Effective September 1, 2024, the title of our current policy “Skin Substitutes for Venous Ulcers and Diabetic Foot Ulcers” will be changed to “Skin Substitutes.”
We have added coverage guidelines for Burns and Breast Reconstruction, added the HCPCS and/or CPT codes for each product, and a list of skin substitute products that are classified as investigational or unproven for any indication and will not be covered.
The policy is posted in the Policies section of the secure provider portal. To view it:
- Go to Policies & Guidelines at the top of the menu bar and click “Policies.”
- Enter Skin Substitutes in the search field.
Thank you for your attention to this matter and for your continued partnership in providing high-quality care to our members.
Upcoming member campaigns to encourage our members to take greater control of their health
Throughout the year, the Health Care Services and Population Health Management Departments deploy various tactics to encourage members to take a more active role in their health.
Metabolic Monitoring for Children and Adolescents on Antipsychotics
The Independent Health Behavioral Health and Pediatric Case Management departments will outreach to parents or guardians of members under the age of 13 who have been prescribed an antipsychotic medication but have not received metabolic monitoring (glucose and cholesterol testing). The Case Manager will provide the parent/guardian with education on the importance of metabolic screening for the child and encourage follow-up conversation with the provider regarding testing.
- Outreach method: Outbound telephone call campaign.
- Target members: Commercial and Medicaid managed care members under the age of 13 who are prescribed antipsychotics and have not received metabolic monitoring (glucose and cholesterol testing).
- Timeframe: August 2024
Gap in Care Reminder Calls
Independent Health’s Member Servicing team will perform telephonic outreach to provide education and encourage members with an open gap in care to reach out to their provider to schedule the appropriate appointments and/or get a prescription to complete the screening.
- Medicaid Managed Care members who have open gaps for: breast cancer, colorectal, and/or cervical cancer screenings.
- Medicaid Managed Care and Child Health Plus members (ages 9-12) who have started but not completed the series for HPV vaccinations.
- Medicare Advantage members who have open gaps for: breast cancer, colorectal, and/or eye exams for members with diabetes.
- Timeframe: Call campaign began in June and will run throughout 2024
Social Determinants of Health Screening
This telephonic outreach campaign will engage targeted Medicare Advantage members in a conversation around screening for social determinants of health to identify any needs the member has for food, housing, and/or transportation. If a need is identified, Independent Health will assist the member in making a connection to a community resource to address the need.
- Outreach method: Outbound telephone call campaign
- Target members: Medicare members identified with social risk factors including those with low-income subsidy or dual enrollment in Medicaid
- Timeframe: Call campaign began in June and will run throughout 2024
Pharmacy Updates
Formulary and Policy Changes
Stay up-to-date on Independent Health's pharmacy policies and formulary updates.
- Medicare Advantage formulary deletions for individual & group plan members, effective August 1, 2024.
- Pharmacy Benefit Dimensions 3-Tier formulary deletions, effective August 1, 2024.
- Pharmacy Benefit Dimensions 5-Tier formulary deletions, effective August 1, 2024.
View the most up to date versions of Independent Health’s policies when logged in to our provider portal.
Magellan Rx, administered by Magellan Rx Management, reviews select specialty drug prior authorization requests on Independent Health’s behalf. To view Magellan Rx policies for the drugs that they review, click here.
Independent Health's drug formularies
Access Independent Health's drug formularies here.
To obtain a hard copy, please contact Independent Health Provider Relations by calling (716) 631-3282 or 1-800-736-5771, Monday through Friday from 8 a.m. to 6 p.m.
In the News
New report illustrates efficiencies and long-term savings inherent in an aligned model of care - Alliance of Community Health Plans, July 25, 2024
A new report from the Alliance of Community Health Plans (ACHP) underscores how nonprofit, provider-aligned health plans are leading the industry in driving efficiencies resulting in improved outcomes for their communities.
Another Voice: ECMC, Independent Health work together to improve the quality and cost of care - Buffalo News, July 8, 2024.
A pilot program between the two organizations demonstrates that payer-provider partnerships and fresh approaches to longstanding challenges can pave the way to improved outcomes, better patient experiences, and lower costs.
Spotlight
Top Takeaways this Month
2024 Fraud, Waste, Abuse and Cultural Competency Awareness attestation now open. Get details on the process here.
Remember to check the Coding chart on a regular basis. The chart is under the Office Management tab; click on Coding.
Be sure to review our updated Provider Manual, posted in the secure portal under the Policies & Guidelines tab of your account home page.
We are now accepting gaps-in-care corrections for 2024; please read the June issue of Scope for complete details