November 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

Save the Date: Pediatric Coding Webinar


Join Kids Health First on Thursday, November 21 from 10 am to Noon, as they host a pediatric coding webinar to prepare for 2025 coding updates and guidelines. In this webinar they will focus on:

  • 2025 CPT and Diagnosis Code updates
  • Understanding best practices in billing and coding to maximize revenue while adhering to coding regulations

The presenter for this event is Mary Suhr, Director, Revenue Cycle Consulting with Revenue Cycle Coding Strategies.


Who can attend?

This webinar is designed for practice administrators, lead physicians, and billing and coding team members, but everyone from your practice is welcome to join.


Register

PAYOR UPDATES

Anthem


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


Cigna + Oscar Discontinuing Small Group Plans – Effective 1/1/2025

https://www.beckerspayer.com/payer/cigna-oscar-health-to-shutter-small-group-business.html


Download resources including:


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:

Peach State Health Plans


Denials and Claim Project for CPT 90460

Some practices recently received claim denials from Peach State for CPT 90460, vaccine administration. Peach State confirmed the incorrect denials of CPT 90460 were due to a manual processing error. All impacted claims were corrected the week of 10/28/2024. Approximately 5,000 claims were adjusted and payments sent the week of 11/4/2024.  No action is required by practices.


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.

United Healthcare


Anatomical Modifier Requirement Policy, Professional – Effective 11/1/2024

9/1/2024 – UnitedHealthcare Commercial Reimbursement Policy Update Bulletin: September 2024 (uhcprovider.com)

 

New GA Modifier requirement – Effective 2/1/2025

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

BEST PRACTICES & QUICK TIPS

January 1, 2025 is the beginning of a new coverage year for many members. Here is the list of payors Kids Health First is contracted with. 

What to do if a payor sends you contract documents?

There are small payors recruiting providers in our area. Examples are:

  • XO Health
  • Prime Health Services
  • Oscar Insurance
  • Claim Doc
  • Partners Direct Health

 

These small payors may have an employer group in your area utilizing their network. Neither TCCN nor KHF are signing a contract with them. Practices are free to sign a direct agreement if they feel it is a business need. If you receive a recruitment request from one of these payors, we recommend asking them a few questions as part of your decision making.

  • Are there any employer groups in your immediate area that have the payors insurance?
  • If so, how many members (specifically pediatric members) are there in your area?
  • You can provide your top codes and ask them for a fee schedule. Does it meet your needs?
  • Any other “headaches” you experience with other payors (like authorizations)? You can ask if they have similar issues.

 

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

 

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