Ring in 2020 With CCA’s Provider e-Newsletter
Start the new year, and new decade, off right with our Winter 2020 provider e-newsletter! You’ll find important updates to CCA’s member plans, claims and billing guidelines, and tips for your practice.
Our work to enhance CCA’s model of care is well underway. We are diligently working to provide all our members with a reliable and predictable care management and care delivery system that meets their complex medical, social, and behavioral needs. Along with you, our provider partners, we are focused on integrating quality into our care model and are actively deploying strategies to close quality gaps.
Model of Care updates impacting our providers include:
- A new Contact Center prompt menu for providers:
The prompt menu for providers has changed to help support you with a much faster response to clinical calls that require the attention of a live attendant and Care Partner. This change has been piloted for the past several weeks and we have received reports of much quicker turnaround times and responsiveness.
- Centralized Provider and Member units:
These units are designed to streamline activities for improved member and provider experience and will include a fulfillment unit to supply DMEs to members in a timely and accurate fashion.
As we deploy these updates to our provider partners, CCA is also realigning care teams and members by geography and primary care location (PCL). The final go-live date for all provider and member Model of Care enhancements will be March 30. You will receive additional communications as we hit key milestones with our provider partners. Please stay tuned!
Commonwealth Care Alliance has updated member benefits for 2020. These go into effect on January 1st. The updates include new benefit descriptions, services requiring a Prior Authorization for 2020, and changes to CCA’s Senior Care Options (SCO) eyewear and Healthy $avings coverage. Please see the list of changes below.
New Benefit Descriptions:
- Supervised Exercise Therapy (SET) is a new benefit description in member materials and does require prior authorization.
- Opioid Treatment Program Services through Medicare Part B is a new benefit description in member materials and does not require prior authorization.
Updated Prior Authorization Requirements:
- Acupuncture and Chiropractic Services are covered up to 36 sessions per calendar year. Additional sessions will require prior authorization in the member’s care plan.
Senior Care Options Eyewear and Healthy $avings Coverage Updates:
- The Senior Care Options (SCO) annual maximum benefit for eyewear is now $200. This means CCA’s SCO plan pays up to $200 per calendar year for eyewear, including frames and/or lenses, under the Medicare supplemental plan benefit for SCO members. After the Medicare supplemental benefit of $200 is exhausted, the Medicaid benefit can be used by the member with a written and dated prescription from a CCA contracted provider. CCA will cover any lenses a prescriber indicates.
- The SCO Healthy $avings quarterly benefit is now $110. Members receive a card with an allowance of $110 every quarter (every three months) to purchase Medicare-approved items such as first aid supplies, dental care, cold symptoms supplies, and others, without a prescription.
Please review the updated 2020 CCA Provider Manual for a full list and description of covered services, as well as for more details on CCA’s 2020 Prior Authorizations requirements. This includes instructions on faxing the Prior Authorization Request Forms to 855-341-0720.
We know that easy access to provider resources and information makes doing business with us easier. That’s why we have updated and posted our 2020 Provider Manual. Highlights include:
- Key Contacts in section 1
- Covered Services and Prior Authorizations Requirements information in section 4
- Claims and Billing information in section 6
Please review the provider manual for our policies and procedures, prior authorization and claim information, and other useful reference materials. You can access it anytime here on our website.
When a claim is denied because it is identified as a possible readmission, please send both sets of medical records: those tied to the initial admission and the readmission. If only one set of medical records are submitted the claim will be denied, and the provider will have the right to appeal.
Provider Explanation of Payments (EOPs) have been updated to include this helpful information about readmissions, see below.
The recently implemented Payment Policy is located here.
To provide quality care that meets the unique needs of each member, CCA works to provide programs and services that are as accessible to members with disabilities as they are to members without disabilities. In line with these efforts, CCA asks you to please complete this Accessibility Survey. When you complete the survey, icons that denote your accommodations will appear in CCA’s provider directory. This allows members to easily identify the accessibility of provider sites.
Please complete the survey by Monday, March 2, 2020 so that we can help individuals with disabilities and other complex needs get the right care in the right setting.
CMS selected Commonwealth Care Alliance’s Senior Care Options plan for a Risk Adjustment Data Validation (RADV) Audit. The RADV audit confirms that a member’s medical record contains supportive documentation for diagnosis codes that were submitted to Medicare. This ensures that CMS has paid CCA appropriately.
If Medicare selects a CCA member who is your patient or a patient of your facility, a representative of CCA’s RADV Audit Team may reach out to obtain copies of member medical records. The audit requires that CCA submit CMS-selected medical records for dates of service between January 1, 2014 and December 31, 2014. CMS will review the records to validate the diagnostic information previously submitted via claims.
CMS’s audit of CCA opens January 10, 2020, and closes July 10, 2020. We appreciate your compliance with this CMS required audit. If you have any questions, please contact Tricia Dougherty, Program Manager, Risk Adjustment at [email protected] or 857-426-1351.
When billing for transitional care management (TCM) codes 99495 and 99496, please follow the AMA current procedural terminology (CPT) coding guidelines. If guidelines are not properly followed and billing requirements for these services are not met, recoupment of payment may result. Please see the Evaluation & Management Payment Policy for further guidance.
Providers are required to confirm a patient’s CCA eligibility prior to rendering services. It’s important to remember that a prior authorization is contingent upon a member’s active eligibility on the dates of service.
Here’s how to quickly confirm a patient’s CCA eligibility:
Keeping your information up-to-date in our Provider Directory helps your practice by making it easier for our members to find your practice locations. Updating your information in our health plan provider directories also helps our members:
- Get easy access to your services.
- Receive important information about your practice
- Find accurate information about where to find your practice.
Quarterly Updates Now Easier with LexisNexis
CMS requires us to list accurate provider information in our health plan provider directories. To simplify the process for you, we’ve partnered with LexisNexis. Each quarter, you will be contacted by LexisNexis and asked to provide updated information about your locations and services.
Your Assistance is Greatly Appreciated!
We ask that you provide a complete and prompt response to LexisNexis every quarter. If you wish to provide your updated information to CCA directly, please email us at [email protected] and a CCA representative will contact you.
Learn more about the CMS Provider Directory regulations on our website here.