In 2019, Spectrum Health Lakeland (SHL) was under their own pharmacy benefit plan with Express Scripts.
In 2020, pharmacy benefiit coverage will still be processed through Express Scripts - but under Priority Health's plan.
See the attached FAQ for more pharmacy benefit information. Be advised that the formulary has changed from 2019 to 2020.
Attached you will find the monthly handouts relating to the following topics:
Please visit the Meridian website for more detailed information.
On Jan. 1, 2020, The Centers for Medicare and Medicaid Services (CMS) is changing its payment system for home health agencies for original Medicare.
The U.S. Department of Transportation’s Federal Motor Carrier Safety Administration’s Clearinghouse rules are effective January 6, 2020. The FMCSA Clearinghouse is an electronic database that will contain information about commercial motor vehicle drivers’ drug and alcohol program violations. 49 CFR Part 382, Subpart G
For those of you who asked, here is the electronic version of Mary Ellen Duffy's November 20th presentation on How to Aggressively Manage your Revenue Cycle.
(click on the news article title to see the attachment)
Effective Feb. 1, 2020, all commercial group and individual plans will cover counseling services as a preventive service, for pregnant and postpartum women identified as at-risk for depression.
When preventive, counseling services will be covered at 100% ahead of deductible.
Why are we making this change?
Thank you to all who spent the day with us back in October at the Lakeland Care Annual Payor Conferece. We hope it was a valuable day for you and your office. As promised, attached are the presentations for your reference.
(click on the news article title to see the attachments)
MeridianComplete (Medicare-Medicaid Plan) is pleased to announce the launch of a new and innovative Surgical Quality and Safety Management Program, effective January 1, 2020. This program is designed to work collaboratively with providers in promoting patient safety through the practice of high-quality and cost-effective care for MeridianComplete members undergoing musculoskeletal surgical procedures.
Effective January 5, 2020, Optum UnitedHealthcare will be the administrator for the Veterans Affairs Community Care Network (VA CCN). Attached you will find an invitation to educational sessions available to you and your Staff during the month of December. Registration is required as space is limited.
We heard you, and we're making an exciting change to our online provider portal to help you work with us faster and easier. As part of our commitment to reducing your hold time when you call us and giving you more of the information you need at your fingertips, front-end rejected claims and reasons are now available on our provider portal.
Where to find your front-end rejected claims
Effective Jan. 1, 2020, substance use disorder intensive outpatient services will no longer require authorization or clinical review for commercial members.
Why we’re making this change
We’re removing the authorization requirement to improve members’ access to substance abuse intensive outpatient services to ensure they’re able to get the right care at the right time.
How services will be monitored
Priority Health is making changes to their 340B program based on your feedback. PH will now review 340B claims post-payment, which means that they will review paid claims quarterly.
What can facilities expect?
The first post-payment review will begin in December 2019 for providers enrolled in the 340B program. We may contact facilities for a list of drugs purchased through the 340B program or for specific exclusion criteria.
Does the 340B program apply to Medicaid claims?
MeridianComplete (Medicare-Medicaid Plan) is pleased to announce the launch of a new and innovative Surgical Quality and Safety Management Program, effective January 1, 2020. This program is designed to work collaboratively with providers in promoting patient safety through the practice of high-quality and cost-effective care for MeridianComplete members undergoing musculoskeletal surgical procedures.
Please see the attachment for details.
Meridian is providing monthly handout on these following topics:
Why we’re making this change
We’re removing the authorization requirement to improve members' access to the mental health services they need to ensure they’re able to get the right care at the right time.
LMOA is an independent, non-profit organization dedicated to providing quality education to southwestern Michigan's healthcare community.
The Lakeland Medical Office Association invites you to attend our November luncheon and seminar.
Program: Revenue Cycle – Tips & Tricks to Aggressively Monitor your Financial Performance
Priority Health offers monthly educational Virtual Office Advisory (VOA) webinars to our providers and their staff. Priority encourages participation in regularly viewing these presentations.
Recently, Meridian has been receiving a significant number of claims where a prior authorization was not obtained.
Attached are the informational handouts from Meridian for October:
All patient reviews will be posted to the Cigna for Health Care Professionals website (CignaforHCP.com). They can only be accessed by the providers for whom they were submitted or their delegated office staff. To view, read, and respond to reviews, providers and their delegated office staff must be registered users of CignaforHCP.com.
Below is Humana's link to Availity. It is optional for providers, but encouraged for easier processes. Availity is efficient to use rather than traditional calling/faxing when working on the following:
As previously discussed, the following improvements have been made to the tool:
- Additional Blanket Statements added
- Both excel and PDF versions posted to our website
- Accessibility on the website was updated to provide easy access to the tool. Providers now can access directly from the home page through the provider tool “Prior Auth Form and Requirements”.
eviCore healthcare and Meridian are expanding their partnership to include the following programs: physical therapy (PT), occupational therapy (OT), genetic testing, pain management, and sleep studies. eviCore will be leading orientation sessions designed to assist you and your staff with the new programs. You will be able to attend the web orientation session that works best for you and your schedule.
This year’s Payor Conference will feature the major payors in our market – including those who have Commercial, Medicare, Medicaid and Dual-eligible products. Lakeland Care will also provide an update on our network's current projects and future initiatives.
Attached are the informational handouts from Meridian for September:
HealthSCOPE Benefits (HSB) is the Benefits Administrator for Whirlpool Corporation medical plan participants. We wanted to make sure you and your billing teams were aware that effective October 1, 2019, the PPO provider network for the Whirlpool Corporate members will change to the United Healthcare Choice Plus Network. In addition, Whirlpool plan members will continue to have in-network access to all of the Lakeland Care Network providers as they have had in the past.
US Health & Life is the only remaining LCN contracted payor who is a part of our Cofinity contract that remains to switch for claims address changes. Their change date is set for 10/1/19.
Important: Some Payer EDI #’s were updated since the last version, please look for the Payers with an asterisk next to their name as those EDI#’s will need updated for accurate routing!
UHC-CP has issued some new member ID cards. Please see the attachment for sample cards for the following product lines:
If you pick up any health care trade publication, you cannot avoid reading a headline regarding efforts to improve “health care value.” However, the what, how and when behind this detailed work varies depending on who you ask; the health plan, the provider, or the patient.
eviCore Healthcare and Meridian are expanding their partnership to include the following programs: physical therapy (PT), occupational therapy (OT), genetic testing, pain management, and sleep studies. eviCore will be leading orientation sessions designed to assist you and your staff with the new programs. You will be able to attend the web orientation session that works best for you and your schedule
Meridian Health is asking providers to complete their Annual Model of Care (MOC) training for ALL providers who care for their plan members.
You can find this training module at their website: www.mymeridiancare.com for additional instructions; also, please see attachment for full instructions and details on this training from Meridian Health.
Note: One person in the office can take this training, and then train the rest of the office.
Please call Meridian Health for any questions at 1-877-902-6784.
BCBSM/BCN is offering a FREE learning opportunity for your physician offices in September at a movie theater near you. They are hoping that you’ll join them and encourage your physicians and their office managers, patient experience leaders, billers and coders to attend.
TRUTHS, TIPS AND TACTICS
About patient experiences that will help your patient:
Attached are the informational handouts from Meridian for August:
At times, a PCP office has a UHC - CP member who requests to change their primary care provider (PCP) .
This attached form will expedite the change request for the member. Instructions are listed on this form.
Lakeland Care has several payors who are a part of our Cofinity contract. These payors are listed below:
A friendly reminder from UHC:
Attached is a brief summary of UHC's electronic data education which includes information and resources for electronic transactions.
Here is this month's educational handouts from Meridian:
Aetna Better Health has recently provided the following informaiton:
Please review the information below regarding EVICORE authorizations and appeal guidelines.
Medical Prior Authorizations:
Note: If a claim denies not authorized, providers must request an authorization before submitting a provider appeal. If the retro authorization request is denied, a provider appeal can be submitted to the health plan.
High Tech Radiology Authorizations
