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In this bulletin, we’ll update you on recent website content that may be helpful for you and your patients, along with highlighting our 2023 annual report and sharing updates on prior approval requirements, medical benefit management and pharmacy.
In the news: Here’s what we’re talking about with Members
Last quarter we shared some details about the availability of nutritional therapy for your patients and we’ve begun to encourage Members to consider asking you about that option as well for help with certain health conditions.
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Our recent blog, Eat, drink and get healthy, focuses on getting help from a registered dietitian to get personalized plans to help make lifestyle changes to prevent, manage or even reverse some health conditions.
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We also focused on what’s included in preventive care in a recent blog titled, Need a check-up? Here’s what’s including in a preventive visit—and what’s not. This idea came from you. As patients ourselves, we’ve seen some of the flyers you have in your offices to try to help with some of the confusion patients have around billing when they come for wellness checks.
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Finally, we know MaineCare has asked providers to help spread the word to patients about renewing coverage as the state finishes the review of Medicare eligibility following the end of the Covid 19 emergency. We’re trying to help as well, through a blog and social media. You can find No longer qualify for MaineCare? You have options on our website with all of our blog content.
Please let us know if you see a need for a topic we should address. Email suggestions to our editor, Theresa Miller, at tmiller@healthoptions.org
ICYMI: Community Health Options 2023 Annual Report—Accessibility Drives Possibility
Our 2023 Annual Report highlights how Community Health Options is expanding access to healthcare services, whether by adding providers to our behavioral health network, introducing virtual primary care on all plans, offering a new wellness platform or finding ways to trim out-of-pocket costs.
From our founding more than a decade ago until now, we’ve never wavered in our commitment to provide the people of Maine with new healthcare coverage solutions and access to wellness tools.
Read or download the full report here.
Updates on Prior Approvals
All mastectomies require Prior Approval
Effective Oct. 1, 2024, all mastectomies require Prior Approval regardless of place of service. Previously, mastectomies did not require Prior Approval if done in an office setting or emergency room setting.
Currently this change impacts about 150 codes, including the codes for removing breast lesions or placement of breast localization devices and this sampling of commonly billed codes:
• 19125, Excision of breast lesion identified by preoperative placement of radiological marker, open, single lesion
• 19126, Excision of breast lesion identified by preoperative placement of radiological marker, open; each additional lesion separately identified by a preoperative radiological marker (List separately in addition to code for primary procedure)
• 19281, Placement of breast localization device(s) (e.g., clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including mammographic guidance
• 19282, Placement of breast localization device(s) (e.g., clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; each additional lesion, including mammographic guidance (List separately in addition to code for primary procedure)
• 19283, Placement of breast localization device(s) (e.g., clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including stereotactic guidance
• 19284, Placement of breast localization device(s) (e.g., clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; each additional lesion, including stereotactic guidance (List separately in addition to code for primary procedure)
• 19285, Placement of breast localization device(s) (e.g., clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including ultrasound guidance
• 19286, Placement of breast localization device(s) (e.g., clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; each additional lesion, including ultrasound guidance (List separately in addition to code for primary procedure)
• 19287, Placement of breast localization device(s) (e.g. clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including magnetic resonance guidance
• 19288, Placement of breast localization device(s) (e.g. clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; each additional lesion, including magnetic resonance guidance (List separately in addition to code for primary procedure)
Imaging services require Prior Approval
Effective October 1, 2024, the following codes require a Prior Approval:
• 76376, 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation
• 76377, 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation
Community Health Options can save with Humira biosimilar partnership
Community Health Options’ pharmacy benefit manager, Express Scripts, has partnered with Quallent Pharmaceuticals to provide an interchangeable Humira biosimilar at 85% less cost as seen with comparable products. In addition, patients who qualify for Quallent’s copay assistance program will pay $0 out of pocket cost for this biosimilar, saving the patient an estimated average of $3,500 per year.
Medical Benefit Management Updates
Newly Added Medications Requiring Prior Approval, Effective July 1, 2024
Medications that are subject to voluntary Infusion Site of Care transition are denoted with an asterisk (*).
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