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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.
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Anthem Out of Network Denial Issue for The Home Depot
TCCN sent out a recent update on an issue involving The Home Depot’s Employee benefit plan through Anthem that may have affected your practice.
- Due to a benefits configuration error at Anthem, some TCCN practices were incorrectly listed as out-of-network for The Home Depot employee health plan beginning 1/1/2025. Anthem Customer Service informed both patients and practices that these practices were out of network as The Home Depot had moved their employees to a narrow network product effective 1/1/2025.
- This resulted in some claims processing at the lower out-of-network rate for the affected practices.
- TCCN Anthem-participating practices are contracted as in-network providers for this product, and Anthem has confirmed that the issue was corrected on 2/19/2025.
- The issue was not related to providers being out-of-network but rather due to how member benefits were configured in the health plan system, leading to significant claim denials
- Claims impacted by this error will be reprocessed at the in-network rate, with resolution expected to begin on Tuesday, March 4, 2025. The finalization of the reprocessing is anticipated to be completed between March 7, 2025, and March 14, 2025.
No action is required by practices at this time. If your practice continues to have issues following March14, please contact your TCCN Provider Relations Representative for support.
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CareSource Fee Schedule Loaded and Claims Project Impact
CareSource confirmed that TCCN’s January 1, 2025 contractual rates were loaded on 3/3/2025. CareSource is initiating a claims project for date of service 1/1/2025 to 3/3/2025 to pay at the new fee schedule. TCCN is pending the start date of the claims project and will track it through completion. There is no action required by the practices.
The Per Member Per Month (PMPM) fee change, effective 1/1/2025, is now loaded as well. Practices will see a decrease in their upcoming monthly PMPM reports. Please note, our analysis confirms that the decrease in PMPM is fully offset by the increase in the fee-for-service rate. To review the new contract terms and fee schedule, please login to Luviel (https://fsapp.luvielhealth.com/tccn/fs/index.asp). Contract terms are found under the “View Fee Schedule Menu” at the top.
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Aetna
Beginning June 1, 2025, you may see new claim edits. These are part of our CCRP. These edits support Aetna continuing effort to process claims accurately for their commercial, Medicare and Student Health members. You can view these edits on their provider portal on Availity.*
For coding changes, go to Aetna Payer Space > Resources > Search > Expanded Claim Edits. OfficeLink Updates
On July 1, 2025, there will be updates to Aetna pharmacy drug lists. Changes may affect all drug lists, precertification, step therapy and quantity limit programs. You’ll be able to view the changes as early as May 1, 2025. They’ll be on their Formularies and Pharmacy Clinical Policy Bulletins page. OfficeLink Updates
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Amerigroup
Changes to Vision and Hearing Policy – Effective 3/1/2025
Interperiodic vision and hearing screenings - Provider News
Behavioral health rate increases
Amerigroup is aware that CMS approved the DCH Community Behavioral Health Rehabilitation (CBHR) Fee Schedule increase, effective July 1, 2024. Amerigroup is currently evaluating this change to ensure that proportional increases and adjustments are made to their fee schedule, retroactive to July 1, 2024.
Enhance billing and coding accuracy with new Payment Integrity training
Amerigroup introduced two new Payment Integrity training courses available on their Digital Solutions Learning Hub to amplify their billing and coding accuracy.
- Payment Integrity: Emergency Dept Evaluation and Management Services
- Payment Integrity: Outpatient Evaluation and Management Services
Provider Education and Training - Amerigroup Real Solutions
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Medicaid
Save the date for DCH’s Face-to-Face Medicaid Fair.
New Date: Tuesday, April 22, 2025
UGA Tifton Conference Center
15 RDC Road, Tifton, GA 31794
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If you have questions about any payors, their plans, or contracts, KHF is happy to assist you. Send us a message! | |
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BEST PRACTICES & QUICK TIPS
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Coding Guidelines for CPT 99188 – Topical Fluoride Varnish
Source 2/12/2025 GAAAP Webinar
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Georgia Medicaid reimbursement rate is $17.59 per the Schedule of Maximum Allw Pymt Physician Fee Schedule 20250131165253.xlsx.
- Application of topical fluoride varnish is completed by a physician or other
- qualified health care professional.
- Delegation to RN, LPN, CMA, MA and billed by MD allowed in Georgia.
- This varies by state.
- CPT 99188 only includes the fluoride varnish application. It does not include risk assessment, education, or referral to a dentist.
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Who is your Provider Relations Representative for Kids Health First? We’ve provided a list to help you. | |
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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.
Attention Practice Managers! To add staff members to regularly receive the Billing & Coding Newsletter or KHF Roundup, please go to the Kids Health First website, select Members and log in to Contact Management. Need instructions? Email information@khfirst.com.
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