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. You will find key dates, issue descriptions, current action, resolution when obtained, and practices impacted. When you identify a claim issue in your review, you can check the Payor Issue Database to see if the issue is known and identified by another practice within the KHF network. This may decrease your research time and offer next steps. Please encourage your billing staff to reference this helpful resource!

You can add your practice to an existing issue or submit a new issue for research by emailing PayorConcerns@khfirst.com.

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

Beyfortus

Sanofi has distributed a Beyfortus Billing and Coding Sheet to answer your questions.

Aetna



Aetna supplied an educational presentation for their Marketplace plans offered to individuals via the Affordable Care Act. This includes information on their new bronze plan and other helpful Marketplace information for Georgia.  

Anthem

Anthem Reimbursement policy update: After-Hours, Emergency, and Miscellaneous E/M Services – Professional: Effective January 1, 2024, Anthem will allow separate reimbursement for after-hours services when the service is billed on a CMS-1500, billed with a place of service 11, and rendered between 5pm and 8am on weekdays or anytime on weekends. Specific CPT codes apply. https://www.anthem.com/docs/public/inline/C-07001.pdf

Anthem has a new Marketplace exchange plan in 2024 called Blue Value. This network is found in South Georgia. TCCN is not participating in the Blue Value Marketplace plan.

CareSource

CareSource VBR Quality Enhancer (QE) Program Discontinued in 2024:

CareSource is discontinuing their annual Quality Enhancer (QE) program in 2024 for practices participating in a value-based contract. This includes TCCN. Effective January 1, 2024, practices will no longer need to bill the QE trigger code and two-digit modifier on claims. Practices will continue to have the opportunity to earn incentive distributions through TCCN’s value-based agreement by meeting quality performance measures. 

Humana

Q4 2023 Physician News: 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.

• DCH and Gainwell will update GAMMIS with the 2024 Healthcare Common Procedure Coding System (HCPCS) codes around January 1, 2024. This update should result in additions, changes, and deletions that will be effective for dates of service on or after January 1, 2024. Deleted procedure codes will no longer be reimbursable or covered by the Georgia Medicaid program as of December 31, 2023.

United Healthcare

Surest by United Health Care Provider Guide and FAQ for FedEx employees effective 1/1/2024. Documents include how Surest works, sample ID cards, and other helpful information. 

• Provider copays are individually set at the National Provider Identifier (NPI) level, regardless of Tax ID. 
• Every 3 months the copays are reevaluated, and new copay values may or may not be set. 
• If a member selects a certain provider through Surest to get the desired copay, they must see that specific provider. It is important to check current insurance benefits at each visit.
• IMPORTANT: Surest does not apply uniform copays across the Tax ID level. Copays can be different between providers in the same practice.
• Surest is driven by the employer and the benefit plan.  

Secure your PHI

When submitting data to KHF, TCCN, payors, or other outside entities, please secure your PHI. If you need to submit claim examples or other patient information, please ask your Provider Relations Representative for a secure email. Please be aware, the payor concerns email is not secure. The KHF intranet is not HIPAA compliant. 

The Department of Health and Human Services (HHS) lists the 18 HIPAA identifiers as:



1. Patient names  
2. Geographical elements (such as a street address, city, county, or zip code)
3. Dates related to the health or identity of individuals (including birthdates, date of admission, date of discharge, date of death, or exact age of a patient older than 89)
4. Telephone numbers
5. Fax numbers
6. Email addresses
7. Social security numbers
8. Medical record numbers
9. Health insurance beneficiary numbers
10. Account numbers
11. Certificate/license numbers
12. Vehicle identifiers
13. Device attributes or serial numbers
14. Digital identifiers, such as website URLs 
15. Internet Protocol (IP) addresses
16. Biometric elements, including finger, retinal, and voiceprints
17. Full face photographic images 
18. Other identifying numbers or codes 

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.