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.

Flu Code Denials

KHF practices have reported claim denials for flu code this fall. We are researching this issue, but also received information from the National Adult and Influenza Immunization Summit citing numerous known payor issues surrounding flu codes.

Save the Date: Annual Coding Updates Webinar

November 21, 2024

10am to Noon

Meeting will be held virtually.

Registration TBA

Sneak Peek at CPT 2025

Get a Sneak Peek at CPT 2025

AMA releases CPT 2025 code set | American Medical Association (ama-assn.org)

Aetna

Webinar – Claim Management Using Availity

Third Thursday of every month at 2pm

Aetna Webex Enterprise Site

Anthem

Incident To Services Update Effective October 1, 2024

Reimbursement policy update: Incident to Services — Professional - Provider News (anthem.com)

CareSource

New Claims Editing for Excludes1 Notes – Effective 10/1/2024

ga-multi-p-3229734-excludes1-network-notification.pdf (caresource.com)

Single Dose Vial – Claims Modifiers

ga-med-p-3159869-single-dose-vials-claim-modifiers-network-notification.pdf (caresource.com)

PeachCare for Kids – Copay Reinstatement- Effective 10/1/2024

ga-med-p-3106946-peachcare-for-kids-copayment-network-notification.pdf (caresource.com)

Humana

Effective December 31, 2024, Humana is exiting the Employer Group Commercial Medical plans. It is important to prioritize Humana claims prior to 12/31/2024 termination date.

• Pay close attention to 90-day timely filing period. 
• Submit claims to Humana as quickly as possible.
• Post EFT/Check payments when received.
• When working Remittance/EOBs, prioritize Humana accounts.
• All dispute and appeal requirements will remain the same.

o  File any disputes/appeals as quickly as possible.

Pull A/R reports

• Humana Aging by Open Claims and Date.
• If the practice does not work their claims and follow claims guidelines before the runout period, Humana will not pay the final claims.

If you have specific questions about Humana exiting commercial insurance, please email payorconcerns@khfirst.com.

Medicaid

Register for Face-to-Face Medicaid Fair

Register online here.

 Atlanta Marriott Northwest at Galleria

Thursday, October 31, 2024

200 Interstate N Pkwy E SE, Atlanta, GA 30339

The Medicaid Fair will offer important updates on emergent issues by DCH leadership and several break-out sessions covering a variety of topics. Attendees must register to reserve a seat for each individual session selected.

PeachCare for Kids Copayments- Effective 10/1/2024

Collection of PeachCare for Kids® Co-Payments will resume on October 1, 2024, for all non co-pay exempt PCK enrollees. Premium Payment collection will resume on October 1, 2024, for new enrollees and for renewals completed on or after October 1, 2024.

Peach State Health Plans

KHF is monitoring an ongoing issue with Peach State. On 2/21/2024, DCH released a message on GAMMIS on health Check reimbursement for E&M Codes and Preventative Visits (Provider Messages (georgia.gov). The Peach State rep for KHF confirmed on 8/6/2024 that Peach State had not removed the claim editing in their processing system. Claim examples were submitted to Peach State with an inquiry asking when Peach State will remove their claims edit. KHF is pending a response from Peach State. Status updates will be posted to the KHF Payor Issue Database once received

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

Improve your Revenue Integrity Program using KPIs

https://www.aapc.com/blog/91055-improve-your-revenue-integrity-program-using-kpis/

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.