December 2024

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The Payor Issue Database is found in the Members section of the Kids Health First (KHF) Intranet under the Financial menu. If you need access to the KHF Intranet, please email PayorConcerns@khfirst.com.

 

The Payor Issue Database contains a current list of payor and claim issues KHF is tracking on behalf of the practices. The issues were identified by your KHF network peers and escalated to KHF for research. In the Payor Issue Database you will find:

  • Key dates (issue identified, most recent update, resolution date)
  • Claim issue descriptions
  • Current action
  • Resolution (when received)
  • Practices impacted


When you identify a claim issue during your EOB review, check the Payor Issue Database for known issues and their status. This may decrease your research time and offer next steps. Please encourage all billing staff to reference this helpful resource!

 

Is your issue not found on the Payor Issue Database? Let us know! You can add your practice to an existing issue or submit a new issue for research by emailing PayorConcerns@khfirst.com


Reminder

Please submit your PHI and claims examples securely. KHF can provide a secure email for you if needed.

CURRENT TRENDS

New Hire Announcement: Meet Glenda Hale



Kids Health First (KHF) is thrilled to announce that Glenda Hale has joined our team as a Provider Relations Representative. Glenda brings a wealth of experience in billing and claim issue resolution, front office practice, and most recently, accounts payable at Children’s Healthcare of Atlanta. She will begin working with KHF practices in January 2025. We are excited about the positive impact she will make on our team!

Kids Health First’s New Aetna Amendment


Kids Health First is pleased to announce we successfully completed a new Aetna amendment! The amendment is effective 12/15/2024 and secures an overall 13% increase over current rates. Aetna is preparing the new fee schedule and KHF will send it to contracted practices once received.

State Medicaid RFP Award Announcement from TCCN


TCCN has executed Memorandums of Understanding (MOUs) with the three new potential awardees: Humana, Molina, and United Healthcare. It is TCCN’s intention to negotiate full agreements based on these MOUs and have contracts in place for the start of the new CMO agreements with the State of Georgia. TCCN will continue to work with Amerigroup and Peach State, as the state has not yet announced a final award decision or a transition timeline.


statement from the Georgia Department of Community Health regarding a contract notice of intent to award announcement

Amerigroup Base Contract Announcement from TCCN


TCCN is pleased to announce the signature of a base contract with Amerigroup. The agreement includes base contract terms for primary care members that have delegated to TCCN. TCCN holds a value-based agreement for all TCCN members. The agreement is projected to have an effective date of January 1, 2025. More details will be forthcoming as we implement this new agreement.

PAYOR UPDATES

Aetna


Mid-level Professionals Payment Policy

Anthem


Blue HPN Claim Processing Update – Effective 12/14/2024

Important update: Blue High Performance Network claims submission guidelines and provider information - Provider News

 

Postal Employees in New Benefit Plan - Effective 1/1/2025

FEP excited to join PSHB program in 2025 - Provider News

 

Quest Diagnostics Joining Anthem Network – Effective 1/1/2025

Quest Diagnostics is joining our network on January 1 - Provider News


Blue Value Plans Expanding in Georgia

TCCN is not contracted for the Blue Value Individual Plans (Bronze, Silver or Gold).

2025 Individual ACA updates: Blue Value network expanding, Georgia moving to a state-based exchange - Provider News


Reimbursement Change for APP’s – Effective 2/1/2025

Reimbursement policy update: Nurse Practitioner and Physician Assistant Services - Provider News


Nurse Practitioner and Physician Assistant Services Commercial Reimbursement Policy: https://www.anthem.com/docs/public/inline/C-20001_ABCBS.pdf

CareSource


New Policy – Influenza Testing Reimbursement Policy – Effective 1/1/2025

medicaid-ga-policy-reimburse-py-1543-20250101


New Policy - CLIA-Waived Testing in Office Setting – Effective 12/1/2024

medicaid-ga-policy-reimburse-py-1462-20241201

Cigna


**Updated!** Cigna + Oscar Discontinuing Small Group Plans

KHF received additional information about the Cigna + Oscar coverage ending. Cigna will continue to serve Cigna + Oscar members until their renewal date in 2025. KHF is updating the recent flyer to reflect this information.

Humana


Humana Exiting Employer Group Commercial Plans – Effective 12/31/2024

https://press.humana.com/news/news-details/2023/Humana-to-Exit-Employer-Group-Commercial-Medical-Products-Business/default.aspx#gsc.tab=0


Download resources including:

Medicaid


Trivalent Flu Vaccine CPT 90656 Medicaid FFS

Medicaid Fee for Service denied claims including the trivalent flu vaccine CPT 90656. Georgia Medicaid reports the issue causing the denial has resolved. All denied claims should now pay.  

Peach State Health Plans


Health Check Reimbursement for E&M Codes and Preventative Visits

Peach State removed a claim edit on 8/28/2024 allowing CPT 99214 and 99215 to be paid with well visit. This is in accordance with DCH policy that became effective on 1/1/2024. Peach State will complete a project to reprocess claims for dates of service 1/1/2024 through 8/28/2024. No action is required by practices. KHF is pending confirmation of project closure.

United Healthcare


Vaccine Policy Update


Update to their commercial and individual exchange plan policies on preventive vaccines. Vaccines are considered covered after all the coverage rationale in the policy is satisfied:

  • The FDA has approved the vaccine; and
  • The vaccine is subject to explicit ACIP recommendations, and not permissive recommendations, for routine use, as published in the Morbidity & Mortality Weekly Report of the CDC; and
  • The vaccine is listed on the applicable immunization schedule of ACIP; and (new)
  • The vaccine is not otherwise excluded by the Plan as explained in the member specific benefit plan document. (new)


Commercial: Preventive Vaccines (Immunizations) – Commercial Medical Benefit Drug Policy


Individual Exchange: Preventive Vaccines (Immunizations) – Individual Exchange Medical Benefit Drug Policy

 

New GA Modifier requirement – Effective 2/1/2025

New GA modifier requirement for UnitedHealthcare commercial plans | UHCprovider.com

If you have questions about any payors, their plans, or contracts, KHF is happy to assist you. Send us a message!

BEST PRACTICES & QUICK TIPS

The American Academy of Pediatrics (AAP) introduced new ICD-10-CM codes for BMI classifications in pediatric obesity, effective October 1, 2024. Please update your EMR/Practice Management system accordingly. The HEDIS BMI measures is a contracted metric for TCCN.

BMI Coding Changes

 

Remember to check the KHF Intranet for updated fee schedules.

We Want To Hear From You!


Do you have billing topics, best practices, claim questions, or good news to share? Email KHF at PayorConcerns@khfirst.com.

RESOURCES

Kids Health First Intranet Page