Pay BillSCOPE | Provider Update
January 2025
Clinical Matters
Screenings, HPV vaccine help to improve cervical cancer prevention
Most cases of cervical cancer occur due to inadequate screening.
The number of deaths from cervical cancer in the United States have decreased substantially since the implementation of widespread cervical cancer screening and continue to decline.
Most cases of cervical cancer occur among women who have not been adequately screened. Strategies that aim to ensure that all women are appropriately screened and receive adequate follow-up are most likely to succeed in further reducing cervical cancer incidence and mortality.
The USPSTF recommends screening for cervical cancer every 3 years with cervical cytology alone in women aged 21 to 29 years.
For women aged 30 to 65 years, the USPSTF recommends screening every 3 years with cervical cytology alone, every 5 years with high-risk human papillomavirus (hrHPV) testing alone, or every 5 years with hrHPV testing in combination with cytology (cotesting).
HPV vaccine is another important tool in cervical cancer prevention. Per the Centers for Disease Control, HPV vaccination prevents new HPV infections but does not treat existing HPV infections or diseases. HPV vaccine works best when given before any exposure to HPV.
Vaccine Recommendations:
- HPV vaccine is recommended for routine vaccination at age 11 or 12 years. Vaccination can be started as early as age 9.
- ACIP also recommends vaccination for everyone through age 26 years if not adequately vaccinated when younger. HPV vaccination is given as a series of either two or three doses, depending on age at initial vaccination.
- Vaccination is not recommended for everyone older than age 26 years. Some adults ages 27 through 45 years might decide to get the HPV vaccine based on discussion with their clinician, if they did not get adequately vaccinated when they were younger. HPV vaccination of people in this age range provides less benefit, for several reasons, including that more people in this age range have already been exposed to HPV.
- For adults ages 27 through 45 years, clinicians can consider discussing HPV vaccination with people who are most likely to benefit.
For more information, please visit:
HPV Vaccination Recommendations | CDC
Cardiac and Pulmonary rehabilitation supports patient recovery
Patients recovering from a cardiac or pulmonary event can benefit from rehabilitation services that include exercise and education.
Aside from treating acute heart or pulmonary events, consider referring patients to the appropriate cardiac and pulmonary rehabilitation service.
Cardiac rehabilitation provides:
- Exercise counseling and training
- Education for heart-healthy living
- Counseling to reduce stress
Pulmonary rehabilitation provides:
- Education and exercise to increase awareness about the lungs and disease.
- Patients learn how to achieve appropriate exercise levels with lessened shortness of breath.
If your patient is recovering from a cardiac or pulmonary event/surgery, consider a referral to a local rehabilitation program. (Benefits and coverage vary by plan).
For additional education and resources, please visit:
What is Cardiac Rehabilitation?
Cardiac Rehabilitation Tools and Resources
Our Case Management team is also here to help with care coordination needs. You may contact Case Management at 716-635-7822.
Office Matters
CVS Pharmacy no longer participates with Independent Health as of 1/1/2025
Members must use a different participating pharmacy after that date.
As a reminder, CVS Pharmacy will no longer be a participating pharmacy as of January 1, 2025. This network change is for all lines of business.
We have notified our members who have been customers of CVS Pharmacy and advised them to change to a participating pharmacy before January 1. However, please keep this in mind as your Independent Health patients need prescriptions. Members may still need assistance in transferring their prescriptions from CVS over to a new participating pharmacy. We appreciate your efforts to accommodate these transfers for your patients and apologize for any inconvenience this change may cause.
Reminder: Billing & anti-discrimination rules for dual-eligible patients
Federal law prohibits Medicare providers from collecting cost share for Qualified Medicare Beneficiaries and must not refuse to serve enrollees who get help with Medicare cost-sharing from a State Medicaid program.
CMS continues to identify issues which cause concern regarding discrimination and billing practices for QMB (fully dual) Medicare and Medicaid eligible members. CMS sets clear expectations for plans to re-educate and communicate to providers the importance of adhering to these regulations based on the vulnerability of these members.
Based on CMS guidance, Independent Health annually notifies participating providers about billing rules applicable to dual eligible members.
As required under 42 C.F.R. §422.504(g)(1)(iii). Federal law prohibits Medicare providers from collecting Medicare Part A and Medicare Part B deductibles, coinsurance, or copayments from those enrolled in the Qualified Medicare Beneficiaries (QMB) program, a dual eligible program which exempts individuals from Medicare cost-sharing liability.
Independent Health understands that provider offices may have trouble identifying QMB members. To help providers identify Independent Health’s QMB members and provide clear expectations regarding the prohibition on collecting copayments from these members, Independent Health includes Remittance Advice Remark Codes (RARCs) on provider Evidences of Payment. The RARCs informs providers that the member has QMB status and to not collect a cost share.
- The code is N783: Patient is a Medicaid/Qualified Medicare Beneficiary. Review your records for any wrongfully collected copayment. This amount may be billed to a subsequent payer.
Members are also informed of their appropriate cost share on Explanations of Benefits.
Balance billing prohibitions may also apply to other dual eligible members in Medicare Advantage plans if the State Medicaid Program holds these individuals harmless for Part A and Part B cost sharing. Note that the prohibition on collecting Medicare cost-sharing is limited to services covered under Parts A and B. Low Income Subsidy copayments still apply for Part D benefits.
Also, it is important to note that providers may not refuse to serve enrollees solely because they receive assistance with Medicare cost-sharing from a State Medicaid program.
In addition, all Medicare-enrolled providers (and their authorized third-party eligibility and billing vendors) can also discern a beneficiary’s QMB status through HETS.
More information about HETS is accessible on the CMS website.
EFT payment schedule changing as of Jan. 24
Please note for planning purposes
Due to schedule changes with our internal operations, weekly provider payments will be effective on Fridays in provider bank accounts that receive EFT payments. Therefore, EFTs previously deposited on Wednesdays will now be deposited on Fridays starting with Friday, January 24.
This date realignment will help with our quality assurance and accuracy reviews.
Please note: this change does not affect Self-funded payment schedules.
View and download the 2025 monthly payment cycle
Pharmacy Updates
Formulary and Policy Changes
Remember to view our up-to-date policies online.
Independent Health's drug formularies and policies
- Access all drug formularies
- Search for and view the most current versions of all drug policies when logged in to our provider portal.
Prime Therapeutics (formerly Magellan Rx) reviews select specialty drug prior authorization requests on Independent Health’s behalf. View Prime Therapeutics policies for the drugs that they review
In the News
Independent Health in the News
New report examines problems, solutions across health care industry - Healthy Vision blog, Dec. 2, 2024
A new report issued by Independent Health provides a deep dive into the many issues and statistics currently rattling healthcare, and charts a way forward with practical and applicable initiatives aimed at making a real difference.
Spotlight
Top Takeaways this Month
January 2025 Policy Updates: View them here (Posted as Monthly Policy Updates under the News tab in the secure portal). It is very important to review the monthly updates.