Provider Bulletin Q2 2025

Published April 2, 2025

In this bulletin, we’ll share details of important Medically Unlikely Edits (MUE) updates, along with ways we can help your patients save money on prescriptions, X-rays and labs, and get free care for Type 1 diabetes. We’ll also share updates on Prior Authorization and coverage for certain codes, our credentialing process, and medications coverage changes, along with links to recent blogs providing helpful information for your patients.

Community Health Options to implement MUE updates

We will be implementing an update regarding the CMS (MUE) as part of our ongoing work related to claim edits. MUE edits, used to validate the accuracy and reasonableness of reported services, will be turned on in the third quarter once we have finished testing and validation.

Key changes include:

Updated MUE thresholds: Updates from CMS relating to MUE thresholds for certain procedures will be updated in the system as they are received to better reflect current clinical practices and utilization patters. This could affect how claims are processed, particularly for high-volume or high-cost services.
Edit messaging: You’ll see detailed and actionable error messages when a claim is denied because of an MUE issue, helping to streamline the appeal and correction process.

Impact on claims processing

Claims exceeding MUE thresholds will be flagged for further review, and affected claims could be returned with a specific denial code or reduced payment. Please ensure you submit claims with accurate information to reduce the risk of edits.

Action required

Review and update claims submissions: Please ensure you submit all claims in compliance with the updated MUE thresholds and guidelines. It’s essential to review the revised MUE limits for relevant codes and to avoid submitting claims that exceed established thresholds.
Monitor and quickly address errors: If MUE edits flag a claim, you can promptly address the issue by reviewing the claim, providing necessary documentation and submitting a corrected claim, if applicable.

For more details on CMS MUE edits and updates, please see the CMS website or call our support team at (855) 351-6254.

Saving tips: Helping your patients save on prescriptions

We give Members several ways to make it easier to get and afford their medications:

With ScriptSaver, our Pharmacy team works with you, your patients and pharmacies to lower out-of-pocket costs, including finding manufacturers’ coupons. Our Maine-based team saved Members more than $200,000 in 2024, and more than $680,000 since launching the program.
Accredo, our only in-network option for specialty medications, ensures medications are mailed directly to Members. Pharmacists, nurses and clinicians support Members every step of the way, including coordinating insurance coverage, finding manufacturers’ discounts and exploring ways to lower costs through financial assistance through community resources. Copay assistance programs have so far saved Members $2.2 million. Information is available at Accredo’s website or by calling (877) 895-9697.
Price Assure guarantees Members the lowest possible cost for generic medications when they take prescriptions to in-network pharmacies that also accept GoodRx. By simply using their Express Scripts pharmacy card, Members can be sure they’ll pay the lowest price—whether it’s the GoodRx or Express Scripts price. Importantly, unlike using a GoodRx card alone, the cost applies to their deductible, accumulator and maximum out-of-pocket costs.
Through our Medication Synchronization Program, our Pharmacy team works directly with Members to coordinate refills when they’re prescribed three or more maintenance medications. That way, they can pick up everything at their local pharmacy at once and avoid the hassle of multiple trips. If you have patients on multiple medications, encourage them to contact us.

Free Type 1 diabetes care for Community Health Options Members

Community Health Options’ Members over the age of 18 with Type 1 diabetes can get free virtual care, education and support through a new partnership with Blue Circle Health, which offers services including diabetes counseling, help with nutrition and coordination of care.

Working closely with Community Health Options’ Care Management team, Blue Circle will begin contacting Members with Type 1 diabetes on Monday, April 7.

The Blue Circle team will coordinate with the Member’s existing care team to provide additional support. Through phone, text and video calls, they’ll provide endocrinology care, nutrition advice, peer support, counseling, financial assistance, access to insulin and education, including how to use glucose monitoring tools and insulin pumps.

“For many adults, managing their disease understandably takes a back seat to the complexities of life—work, family responsibilities and even social activities. We are thrilled to partner with Blue Circle Health to provide extra support at no cost to our adult Members with Type 1 Diabetes,” said Dr. Lori Tishler, chief medical officer at Community Health Options.

Learn more from our news release.

Site of Service benefit: Members pay low-copays at specific lab and X-ray locations

Most Members can save money on labs and X-rays if they go to certain locations instead of going to the hospital. Almost all non-HSA plans offer X-rays at specified locations with a $75 copay, while labs at select Nordx and Quest locations have a $25 copay per visit. HSA Members pay a copay or coinsurance after they’ve met their deductible. For help finding a location closest to them, you and your patients can contact our Maine-based Member Services team at (855) 624-6463 from 8 a.m. to 6 p.m., Monday to Friday.

Medical management Prior Approval and coverage updates

Effective 7/1/2025

The following codes will be no auth required (change from auth required) and limit is changing from 1 every 3 years to 1 every 5 years.

A4660 Sphygmomanometer/blood pressure apparatus with cuff and stethoscope
A4663 Blood pressure cuff only
A4670 Automatic blood pressure monitor

92137 Computerized ophthalmic diagnostic imaging (e.g., optical coherence tomography [OCT]), posterior segment, with interpretation and report, unilateral or bilateral; retina, including OCT angiography Changed from PA Required to No Auth required

95803 Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording) Changing from PA Required to Experimental/Investigational, Non Covered

A9293 Fertility cycle (contraception & conception) tracking software application, FDA cleared, per month, includes accessories (e.g., thermometer); Natural Cycles
Added to preventive benefit as form of “contraception”
Reimbursement is provided via Member reimbursement claim form with the following:
Receipt of paid yearly subscription
Prescription from provider with Dx Code Z30.8
Reimbursement $$ limit is $130 / year

The following codes will be Non-Covered, Experimental and Investigational

0070U CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (e.g., drug metabolism) gene analysis, common and select rare variants (i.e., *2, *3, *4, *4N, *5, *6, *7, *8, *9, *10, *11, *12, *13, *14A, *14B, *15, *17, *29, *35, *36, *41, *57, *61, *63, *68, *83, *xN)
0071U CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (e.g., drug metabolism) gene analysis, full gene sequence
0072U CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (e.g., drug metabolism) gene analysis, targeted sequence analysis (i.e., CYP2D6-2D7 hybrid gene)
0073U CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (e.g., drug metabolism) gene analysis, targeted sequence analysis (i.e., CYP2D7-2D6 hybrid gene)
0075U CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (e.g., drug metabolism) gene analysis, targeted sequence analysis (i.e., 5' gene duplication/multiplication)
0076U CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (e.g., drug metabolism) gene analysis, targeted sequence analysis (i.e., 3' gene duplication/multiplication)
0173U Psychiatry (i.e., depression, anxiety), genomic analysis panel, includes variant analysis of 14 genes
0175U Psychiatry (e.g., depression, anxiety), genomic analysis panel, variant analysis of 15 genes
81418 Drug metabolism (e.g., pharmacogenomics) genomic sequence analysis panel, must include testing of at least 6 genes, including CYP2C19, CYP2D6, and CYP2D6 duplication/deletion analysis

Credentialing policy revisions and updates

Our credentialing policy has been revised to align with Maine statutes, NCQA standards and Maine Bureau of Insurance regulations. These updates enhance clarity and compliance while ensuring consistency in our credentialing process.

Significant changes include:

• Credentialing application defined: Application requirements and expectations have been clearly outlined.

• Nurse Practitioners: All NPs will now be credentialed, regardless of whether they practice under supervision.

• Locum Temens updates:

Locum providers practicing more than 60 days will be fully credentialed.
Locum providers practicing less than 60 days will be provisionally credentialed.

Note that it is important to list clear “to” and “from” dates on the add forms for locum providers, because of the two distinct paths.

These updates currently apply to new practitioners joining, and we will be working throughout the year to capture others that were previously in the network. We appreciate your attention to these changes and continued cooperation in maintaining compliance with our credentialing standards.

The National Committee for Quality Assurance (NCQA) has announced significant updates to its credentialing and monitoring requirements, effective July 1, 2025. These changes are designed to enhance patient safety, data accuracy, and compliance efficiency for health plans. Key updates include: