News

Q2 2024 PROVIDER NEWSLETTER

Date: 05/13/24

Mental Health Awareness

May marks Mental Health Awareness Month, a time when we are reminded of the daily challenges our healthcare providers encounter. Our team wants to offer support to our providers and administrative staff through a variety of resources. We encourage you to take a moment to explore the following links and disseminate the valuable information within your teams. These include the 988 document and information from the CDC, NAMI, AHRQ, and ACOG about physician burnout. Sharing may help a teammate navigate the complexities of your roles while prioritizing mental health.

Community Collaboration

Ambetter of Tennessee is committed to supporting the community. Below are three very different spring events we supported in Nashville. We are excited about future opportunities across Tennessee and would love to know more about what you’re doing.

Nashville Pinnacle

Pinnacle is focused on enhancing education, transportation, and economic development. In March, our team had a chance to emphasize the Centene-Ambetter commitment to Nashville and across the state with Mayor Freddie O’Connell.

March for Babies Walk

In April, we were a proud sponsor of the annual March for Babies walk with a fantastic turnout. Their mission is to prevent birth defects and premature birth.

Baby Shower Support

Ambetter of Tennessee was in attendance for the “Mommy to Bee” baby shower at the end of April, complete with bumblebees and support for new moms. It was held at the Matthew Walker Comprehensive Health Center on April 26th. Their team did a wonderful job in supporting over 100 in attendance. Do you know some creative ways we can partner with you to support our members? We’d love to hear your ideas!

Risk Adjustment

Continuity of Care (CoC)

Ambetter of Tennessee is committed to supporting your efforts to provide the highest quality care to our members. As a result, we have launched our Continuity of Care (CoC) program for 2024. This initiative incorporates Appointment Agendas, HEDIS measures and pharmacy metrics into one comprehensive view. The CoC program is designed to support your outreach to members for annual visits and condition management, which will help us better identify members who are eligible for case management. Please refer to your provider portal, your health plan representative, or 2024 COC Program Review (PDF).

Risk Adjustment Data Validation (RADV)

In June, we will be launching our annual RADV Audit Chart Chase Project, and we need your assistance in responding to a Department of Health & Human Services (DHHS) mandated audit. The HHS initiates audits of health plans subject to risk adjustment under the Affordable Care Act (ACA). Ambetter of Tennessee is included in the audit and we, along with our contracted providers, must fully comply. Please prioritize the medical record requests coming from the vendor Optum.

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.

Composite Measures	Sample Questions
Getting treatment quickly	How often did you get the professional counseling you needed on the phone? When you needed counseling or treatment right away, how often did you see someone as soon as you wanted?(Always, Usually, Sometimes, Never)
How well your clinician communicates	How often did the provider listen carefully to you? How often did the provider explain things in a way that you could understand? How often did the provider show respect for what you had to say? How often were you involved as much as you wanted in your counseling or treatment? (Always, Usually, Sometimes, Never)
Information about treatment options	Were you told about self-help or support group? Were you given information about different kinds of counseling or treatments that are available? (Yes, No)
Access to treatment and information from health plan	How much of a problem, if any, were delays in counseling or treatment while you waited for approval from your help plan? (A big problem, A small problem, Not a problem)

Concert Genetics and Lab Testing

Concert Genetics will be Centene’s chosen partner for genetic testing policy and strategy due to their evidence-based medical necessity criteria and systematic approach to addressing unwarranted variation in billing.

Beginning August 1st, 2024, Ambetter of Tennessee will expand the requirements for billing of genetic and molecular testing. In accordance with the Reimbursement Policy for Genetic/Molecular Test Coding Policy, all providers billing for genetic and molecular testing services will be required to adhere to the coding recommendation in the Concert Genetics portal.

The portal can be accessed here: Concert Genetics Portal. The quality and billing integrity requirements in the reimbursement policy will be facilitated by Concert Genetics--our partner and a software and managed services company that promotes health by providing the digital infrastructure for reliable and efficient management of genetic testing and precision medicine.

You can find all clinical policies including those from Concert Genetics by expanding “clinical policies” on our Clinical Policy page.

We are asking you, our laboratory partner, to do the following:

Register with Concert Genetics via the portal linked above
Self-report on quality metrics in a common framework supplied by Concert
Verify accuracy of test catalog and view coding recommendations and fee schedule
Utilize Concert’s recommended codes when billing for genetic and molecular tests

Concert is extending its targeted, minimally-abrasive genetic testing solution to routine labs. This solution will include coding- and medical policy- based edits, supported by payment and clinical policy, to reduce reimbursement for tests that are not medically necessary or incorrectly coded.

Ambetter of Tennessee presents new clinical payment policies to provide payment protocols for Infectious Disease Primary and Preventive Care Lab Screenings and Lab Testing related to Infectious Diseases. The following policies have been posted on our Clinical and Payment Policies website.

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 1-833-709-4735 if you have questions. You can also find additional information in the 2024 Provider and Billing Manual (PDF).

Top 5 Reject Reasons

member not valid at date of service
invalid member date of birth
invalid or missing taxonomy code
original claim # required
invalid member ID number

Top 5 Denial Reasons

over timely filing limit
missing authorization
out-of-network provider
missing modifier
incorrect diagnosis code

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, please review the SUDS document (PDF).

Learning Opportunities

Ambetter of Tennessee provides a variety of learning opportunities on our website. We have cultural humility training info, health equity trainings, as well as the Choosing Wisely initiative available and ready for use.

Health Literacy & Cultural Competency resources can be found under Cultural Humility Resources on our website and in this Health Literacy and Culture (PDF) document.
Did you miss an earlier issue of the newsletter or a provider alert? Visit our library of news and updates on our website.
Need a refresher on using our portal? Schedule a 1:1 with your Provider Engagement Administrator to review all features & functions in our Secure Provider Portal.

REMINDERS

We transition to 6 Degrees Health for clean claims starting June 1st, 2024
Remember to submit any demographic updates to Provider Engagement Administrator - click for document (same one as last issue)
Providers can create an account or login to our portal.
Do you have ideas for the newsletter?
How many Ambetter members in the United States? As of May 3rd, 2024 there are 273,241 Ambetter members in Tennessee and over 4.4 million Ambetter members across 29 states!