Q2 2024 PROVIDER NEWSLETTER

Date: 07/10/24

June is Men's Health Month! 

1. Eat Healthy - Men's Health Month is a great opportunity to change the way you eat. Cut back on processed foods. Incorporate different types of foods to get all vitamins and mineral you need. You can do anything for a month, and if you do it for a month, you can do it for life!
2. Set some goals - Use this month to take stock of your health now and think about where you want it to be. Do you want to lose weight? Gain muscle? Simply eat more vegetables. Set small and achievable goals and work with your doctor to make them a reality.
3. Get educated - Take this opportunity to read about the common health issues that are specific to men and how you can prevent yourself from getting hurt! Check out the resources for information on health issues that men face.

American Medical Association Current Procedural Terminology (CPT®) Update (Effective 7/1/24)

The following new CPT Proprietary Laboratory Analyses (PLA) codes and CPT Category III codes will require prior auth, unless determined to be a non-covered service, upon their effective date of 7/1/2024.

 For other established codes, please use the Pre-Auth Check Tools on our websites to confirm if the code(s) requires prior authorization. Prior authorization requirements vary based on the line of business, so please select the applicable Pre-Auth Check Tool by the line of business. 

Claim Denials & Rejects

Why do claims deny or reject? Based on recent analytics, the list below highlights the top reasons why you may experience a claim denial or a claim rejection. If you are experiencing denials or rejects, please double check the following: member date of birth, date of service, member ID number, taxonomy code, original claim number, authorizations, missing modifiers, diagnosis codes, and PAR status. Please contact Provider Services at 1-800-442-1623 if you have questions. You can also find additional information in the 2024 Provider and Billing Manual (PDF). 

Top 3 Reject Reasons

1. Invalid or Missing Taxonomy Code
2. Member not valid at DOS
3. Invalid member DOB

Top 3 Denial Reasons

1. Denied: Out of Network Provider 
2. Denied: No record of prior authorization for service billed
3. Provider Billing Error

Another way to ensure all of your claims will pay timely and accurately, please confirm that we have you most current practitioner roster!

Introducing Dawn Massey Clinical Operations Manager

We are thrilled to announce that Dawn Massey has joined our Health Plan in the role of Manager, Clinical Operations. Dawn is joining us from Flowers Hospital, which is part of a larger hospital system (CHS).  Dawn has over 25 years of experience in case management, and clinical operations (pre-hospital emergency services).  Dawn has been a nurse for over 15 years.  Over her 25-year career, she has worked with Medicare, Medicaid, and Marketplace members. Her background has been extensive in PHCO with a heavy focus on Case Management and Utilization Management.  This is a very exciting hire for our Alabama Health Plan, and I know that we’ll benefit greatly from Dawn’s leadership. In her new role, Dawn will work with our Alabama Provider Hospital case managers and clinical leaders to address CM and UM issues.  We have listened to our hospital partners, and they need a single point of contact when there are difficult member situations and placements.  This role will work with our internal Corporate PHCO (Care Management, Utilization Management, Behavioral Health, Case Managers, and Pharmacy) teams to ensure we are staying in front of clinical trends and to address related issues.  We expect this role will help us improve member health outcomes by meeting our members where they are. Please join us in officially welcoming Dawn to the team!

Quality Improvement

The Healthcare Effectiveness Data and Information Set (HEDIS®) provides a standardized set of measures from the National Committee of Quality Assurance (NCQA) to measure clinical quality performance. HEDIS® helps health plans and network providers to understand the quality of care being delivered to members, identify network performance gaps, and drive the design of programs and interventions to improve quality outcomes. Since May is Mental Health Awareness Month, Ambetter of Tennessee is committed to providing helpful Behavioral Health resources aimed at improving quality outcomes for our members. We encourage you to socialize the Behavioral Health and other HEDIS® resources with your office staff, including helpful HEDIS® guides, tip sheets and checklists.

How can I improve my HEDIS® scores?

• Submit claim/encounter data for each and every service rendered
• Make sure that chart documentation reflects all services billed
• Bill (or report by encounter submission) for all delivered services, regardless of contract status
• Ensure that all claim/encounter data is submitted in an accurate and timely manner
• Include CPT II codes to provide additional details and reduce medical record requests
• Respond timely to medical records requests
• Submit supplemental data throughout the measurement year
• Early Engagement with Pharmacy Adherence is key – once a member loses days on a prescription, those days cannot be recovered
• Speak with the members about any barriers to adherence 

CAHPS® Experience of Care and Health Outcomes (ECHO) Survey

Annually, NCQA directs health plans to conduct a survey about the member’s experience with behavioral health services. The ECHO Behavioral Health Member Experience Survey measures members’ experiences and identifies opportunities for health plans and providers to improve quality of care and access to mental health and substance use services. Your patients may be asked the following sample questions below in the image. How do you rate?

Please use the following suggestions to improve your ratings:

• Offer extended hours, telehealth, and various treatment options when possible.
• Let patients know your office hours and how to get after-hours care.
• Partner with the health plan and coordinate care with other specialists and primary care physicians to address whole person health and access to timely care.
• Assess culture and linguistic needs and ask your patients what is important to them.
• Obtain release of information forms and explain the purpose of releasing information to other providers.
• Include family/caregivers/identified support in the treatment plan.
• Invite questions and encourage your patient to take notes.
• Use the “teach-back” method.

https://www.ambetterofalabama.com/provider-resources/providing-quality-care.html

NCQA

NCQA: Ambetter of Alabama is dedicated to quality measurement and improvement of health plan operations to drive positive outcomes for high quality health care and services. To realize our goal of being the preferred Marketplace carrier in Alabama, we will be going through our first Health Plan Accreditation survey with the National Committee for Quality Assurance (NCQA) in September 2024. As a part of our survey process, your practice may be contacted to confirm Accessibility of Services: Appointment Availability & Wait Times. If you have any questions related to our requirements, please contact Provider Relations.

EMR Access & Supplemental Data Feeds

Did you know? Your partnership in granting remote EMR (Electronic Medical Records) access and/or a Bi-Directional Data Feed is the most direct and efficient way to close Quality and Risk Adjustment care gaps, improve quality of care, and reduce administrative burden. For more information on the benefits of remote access and improving accuracy/completeness of patient data or to get started.

Provider Experience Study: Please Share Your Feedback

Thank you for being a valued partner in our provider network!
In the coming weeks you may be among a select group of providers to receive a survey from us that will allow you and your staff the opportunity to provide honest feedback regarding your experience with us. Sharing your experience in this brief survey is how you can help us gain valuable insights to enhance and improve provider tools, resources, and operations to better support you.

To make it easier for you to participate in this survey, below is how you will receive it.
Email address: noreply@survey.centene.com

We look forward to receiving your valuable feedback.

• Please utilize all features & functions found in our Ambetter of AL website.
• Remember to contact your Provider Engagement Administrator with any demographic updates.
• Providers can create an account or login to our portal.