Q3 2024 Provider Newsletter

Date: 08/22/24

Serving Our Providers is a Priority

Our mission is to transform the health of the communities we serve, one person at a time. Ambetter of Tennessee is growing in membership and number of providers. Growth can bring challenges big and small, but we are rising to the occasion with a curious mindset and a focus on service. We support providers through education, in-person opportunities, updates on legislation, and define ways to earn incentives. Read more below in our newsletter to find important links and relevant documents to support your practice. Highlights in this issue:

• *We are offering our first Provider Summit and you are invited - you must register below before August 18th! 
• *Is your roster up to date with your newest providers or demographic changes? Learn how to make easy updates to ensure claims are processed timely. 
• *Have you reviewed our latest clinical policies? Several recent policy updates are below including Tennessee legislative changes. 
• *Are you familiar with the best way to close care gaps and our Quality & Risk Adjustment incentives? 

Community Collaboration

Did you know there’s an Ambetter car racing at NASCAR events? Have you seen it on the screen? Earlier this summer we had the privilege to participate in the Nashville event with an educational table. Our leadership team had a blast networking, meeting members, dancing, and talking to potential members. Do you have an event coming up this fall where we can partner with you? We are excited to discuss this further. 

Clinical Policy Updates 

Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules. Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information. For a list of all active clinical policies, visit the Clinical & Payment Policies page.

Ambetter of Tennessee continuously updates select clinical policies on an annual basis with some added criteria requirements that may impact the prior authorization process. Please see the revision log within each policy to review the changes. This Clinical Policies Update page reflects upcoming clinical policy changes. Please refer to this page for recent policy updates and reach out to your Provider Relations representative if you have any questions. 

Quality & Risk Adjustment

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). You can learn more about our resources on our website. Scroll down to the Risk Adjustment section to find the Continuity of Care (CoC) program description and the Tiered Incentive Payments explanation. 

Mammogram Facility Improvement Program

As a part of our commitment to Quality care, we are implementing the Mammogram Facility Incentive Program (MFIP). Our Ambetter Mammogram Incentive Program recognizes facilities like yours that deliver and appropriately document that quality care. The measure period for the Ambetter Mammogram Incentive Program is from August 19th, 2024 to December 31st, 2024.

The program leverages your existing workflow as follows:

1. Schedule and conduct patient mammograms.
2. Submit a claim/an encounter containing all appropriate diagnostic and procedure codes
3. Document in the Member’s medical record.

Payment will occur in Quarter 2, 2025. All claims/encounters must be submitted by Jan. 31, 2025. They will be used in calculating the payment. Please note that only screenings completed for assigned members August 19, 2024 to December 31, 2024 are eligible.

Risk Adjustment Data Validation (RADV)

We have officially launched 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. 

Pilot Project with 86Borders 

Ambetter of Tennessee is excited to announce a new partnership with 86Borders, a member relationship and care coordination company, to enhance member engagement and improve health outcomes in Shelby, Davidson, Knox, and Hamilton counties. The pilot project, running from August 5th to December 31st, 2024, will focus on a targeted group of approximately 5,200 members with gaps in care and Social Determinants of Health (SDOH) needs. 

Care Coordinators from 86Borders will provide personalized communication to members, ensuring they receive the support they need to address barriers to care, while connecting them to their attributed primary care providers and other health  services for preventative and chronic care management. This service is offered free of charge to members. 

Reproductive Health Services 

As of March 1, 2024, the billing requirements for Reproductive Health Services changed in the State of Tennessee. Claims will adjudicate in accordance with state and federal laws. The below information offers further detail on specifics that are required to review and adjudicate the claim appropriately.

Please see page 147 of our 2024 Provider Manual (PDF) for additional details. See tables below for information on codes. 

The following procedure codes are impacted by these changes: 

Claims for these services must be presented with a condition code: 

Hyde Procedures

Non-Hyde Futile Pregnancy Procedures

Claims for these services must be presented with a modifier code:

• Procedures that are elective in nature, or the result of incest or rape will not be covered. 

Consent for Sterilization

Ambetter of Tennessee requires providers to submit a Consent for Sterilization form for any service that may render the member sterile (male and female), including hysterectomies. This form is available under the Claims and Claim Payment section of the Ambetter of Tennessee website or you can download the form (PDF).

Consent for Sterilization form (PDF) is REQUIRED in these conditions:

• on any procedure during which the beneficiary elects to become sterile. See page 58 of the 2024 Provider Manual (PDF)
• when a hysterectomy is performed on a member who is not already sterile.  

If the member is sterile prior to the hysterectomy, the provider can note this on the claim. Documentation must be kept on file including a signed statement from the physician, certifying the individual was already sterile and stating the cause of sterility. This documentation must be available upon request. 

DRG and Cotiviti Update

A prepay medical record review of inpatient claims program will be implemented October 1, 2024. This review will determine if the billed DRG is supported by the medical record. If the medical record does not support the DRG, a corrected DRG will be assigned and the difference in payment will be recouped or reduced for the approved DRG. Providers have the opportunity to appeal through Cotiviti. 

Provider Network Operations

Have you had recent changes to your practice such as new providers, new locations, or similar? We are glad to help you with making those changes effective to prevent delays in processing claims. Our Provider Network Operations team supports our providers by assisting with the following: 

• Demographic Updates and Changes
• Adding Providers to existing Groups or Practices
• Provider Termination Requests
• New Network Contract Inquiries

Please submit updates within 30 days of data change becoming effective to our Provider Network Operations team by emailing your request or use our roster form if you have a large amount of updates.

For new contract requests: Join Our Network

Provider Summit: You are invited!

You are invited to our first Provider Summit, with two options serving the Memphis and Nashville (Smyrna) area. Please click the link below to learn more about the agenda and target audience. Lunch will be provided and you must register by August 18th, 2024. Space is limited. We look forward to seeing you there. 

MEMPHIS - Wednesday, August 28th, 2024 

NASHVILLE - Thursday, August 29th, 2024

LEARN MORE AND REGISTER

Reminders

• We transitioned to 6 Degrees Health for clean claims on June 1st, 2024
• Remember to submit any demographic updates to Provider Engagement Administrator 
• Providers can create an account or login to our portal
• Concert Genetics is now Centene’s chosen partner for genetic testing policy and strategy. The portal: Concert Genetics Portal. You can find all clinical policies including those from Concert Genetics by expanding “clinical policies” on our Clinical Policy page.