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In this bulletin, we’ll share information about Prior Authorizations for outside laboratories, our new credentialing partnership with Verisys, along with reminders on claims payments, the continued expansion of our EMS network, and formulary updates, along with general Community Health Options updates.
Filing Prior Authorizations for Outside Lab Work Helps to Lower Costs
Providers or hospitals using outside laboratories should check whether a Prior Authorization is required for certain tests, before sending a patient or specimen for testing. Without authorization, claims could be denied, not only for the provider asking the testing to be done, but also for the lab doing the test—a problem that drives up costs for providers and Members.
Importantly, clinical pathology labs don’t see patients face-to-face or have any clinical information related to the patient. As a result, they’re unable to obtain the authorization they need when a service requires one. Without it, they won’t be paid if the requesting doctor doesn’t get one. To avoid non-payment and to keep costs low, please check requirements and submit a Prior Authorization request before the service is performed or within 10 business days after the date of service.
You can find code-specific requirements on our online authorization platform in the provider portal. A sampling of categories generally requiring authorization include: (not an all inclusive list)
- Allergen Specific IGE/IGG
- Urine Drug Testing (see Urine Drug Testing for details)
- Genetic Testing
- Molecular Pathology Procedure
- Unlisted Lab Codes
Community Health Options Partners with Verisys for Credentialing
Community Health Options has begun working with Verisys®, the largest outsourced credentialing provider in the market, for primary source credentialing verifications. Verisys has a 99.9% verification accuracy rate when it comes to verifying professional licenses, status, issue and expiration dates and any current or historical disciplinary actions.
As a reminder, please review CAQH applications for practitioners in a timely manner. Any expired application can delay processing.
Sync Instamed and Claim Forms Information to Receive Payments Your Way
To ensure claim payments are received the way you want to receive them—whether EFT or paper check— it is critical that you update Instamed and Community Health Options simultaneously when there is a change in any of the data relating to “pay to” information.
Changes to payment information can include addresses, TIN or additions/removal of location or practitioner NPIs. Payments are issued after comparing the “pay to” information submitted on the claim and information within Instamed. It’s important for that information to be the same, because when the information on the claim form doesn’t match Instamed the payment is made based on the claim form, rather than what you’ve set up in Instamed.
Community Health Options Partners With Firefly Health To Expand Access To Care
Community Health Options this year has begun giving Members 18 and over the option of using a virtual first primary care team, expanding access to care. Alongside its traditional provider network, Community Health Options now offers Members 18 and older the option to choose a virtual-first primary care team through Firefly Health. No matter which plan Members have, they can choose a virtual primary care team for ongoing care from a team that includes a primary care provider, nurse practitioner, behavioral health specialist and health guide. Learn more here.
Community Health Options Continues to Expand its EMS Network
Community Health Options added 18 EMS providers to its emergency medical services network in 2023, after Gov. Janet Mills signed a new law that creates opportunities for greater reimbursement for EMS providers—and better coverage for Community Health Options’ Members.
Mills signed LD 1602 on July 7, 2023, paving the way for health insurers and EMS providers to come together through a new standard contract, and includes information on reimbursement for services, along with certain changes to Prior Authorization requirements for covered transportation services. Community Health Options has developed a new contract that includes the provisions of the standard contract referenced in the legislation.
The Community Health Options team continues to look to welcome all EMS providers. To learn more, please send an email to: contracting@healthoptions.org.
Community Health Options Ranks Among Best Places to Work in Maine
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