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February 2024

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Welcome to the Kids Health First's Billing & Coding Connection newsletter- an all-in-one resource dedicated for all things billing and coding.


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


To add billing staff members to the distribution list, please also email us at Payorconcerns@khfirst.com

CURRENT TRENDS

The Payor Issue Database is found in the Members section of the 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.

Fee Schedules

KHF commercial payor fee schedules are found in the KHF intranet under the Financial Menu. 

  • The Aetna fee schedule includes the First Health network.
  • Humana and Cigna fee schedules experienced delays in 2023 due to missing/incomplete information from the payors. KHF is working diligently to publish these schedules as we receive the necessary data.

 

The Medicaid fee schedule is published on GAMMIS. Users do not need to log in to access the schedule. CMO’s do not publish their own fee schedules and refer providers to GAMMIS. To determine the rates for a contracted CMO, multiply the Medicaid rate with the contracted percentage. 

 

TCCN publishes contracted payor fee schedules on Luviel. Currently this includes the Anthem, Cherokee County, Northside Health Network, and QuikTrip fee schedules.

Meningitis Vaccine NDC Update

The pediatric vaccine MenQuadfi for meningitis had a National Drug Code (NDC) update. The NDC number identifies the manufacturer, drug name, dosage, strength, package size, and quantity. This affects billing and payment because NDCs are required on the claim for payment. If your practice uses this code, please ensure your billers are aware of the NDC change for claim submission purposes. 

AAP Advocating for PCV20

Most payors are processing and paying PCV20 at the current time. The AAP is advocating for the remaining. Attached is the letter from the AAP sent to payers regarding denials for PCV20. 


The intent from the AAP is for this letter to be used as an attachment for claims appeal when sent to the payor.

PAYOR UPDATES

Humana


Q1 2024 Provider Newsletter: Click here to access

Medicaid


RSV Vaccine, CPT 96380 Per the Department of Community Health (“DCH”), the new administration codes for Beyfortus (CPT codes 96380 and 96381) are expected to be loaded in GAMMIS in March 2024 with a January 1, 2024, effective code. Until all systems updates are completed, Health Check providers should code the Beyfortus product (CPT codes 90380 or 90381 w/EP modifier) and report the administration of Beyfortus with code 96372.


Click here to access GAMMIS to view updated provider messages:

 

Save the Date –for the Spring Medicaid Fair - March 21, 2024 - Macon Marriot City Center in Macon, GA.

 

  • The Spring Medicaid fair is the same day as the KHF Practice Administrator meeting with a speaker presenting. If possible, practices may want to send a billing representative to the Medicaid meeting to allow the PA to attend the KHF PA meeting.


United Healthcare


PCV20 - On 1/22/2024 UHC updated CPT 90677's age range to 2 months and older. The effective date of the age range change is 6/27/2023. For denied claims, please use Availity to submit a reconsideration. Multiple claims can be submitted in one reconsideration. Fax (801-938-2100) submission is also available. This update is also found on the Payor Issue Database.

BEST PRACTICES & QUICK TIPS

How to create a custom fee schedule list in Luviel.


When selecting the fee schedule in Luviel, it populates the 250 most frequently used CPT codes in pediatric medicine. You can also access fee schedules for codes not found on the top codes list by creating a custom fee schedule. 

 

Per the TCCN Luviel User Manual:

To create, or modify, a custom list you must enter a procedure code, a modifier (if appropriate) and a quantity (if appropriate). After doing so, click the "Add Single CPT" button and the procedure code will be added to your list, which appears on the right-hand side of the web page. Should there be a problem with what you entered, you will receive an error message stating what the problem is under the "Message" column on the left side of the page. If you wish to reset your list, you can click the "Clear All CPT Codes" button; this will clear your entire list. To remove a single item from the list, type in the procedure code and modifier (if applicable) and click the "Remove Single CPT" button.

 

After you have finished adding your procedure codes, it is time to save the list. If you had chosen to modify a previously created a list, there is already a name for the list and all you must do is click the "Continue" button. However, if you selected to create a new list, you must first name the list by typing in a name into the "Save list as" field and then clicking "Continue". After clicking "Continue", any changes you made to your custom list will be saved and you will continue on to either the compare fee schedules page or elect fee schedules page based on you selection in the main menu.


NOTE: Be careful when naming a new list. If you choose a name of a previously saved custom list, then you will overwrite that list. If the code does not populate in the custom list, it was not indicated on the fee schedule received from the payor.  

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