September 2020 - Provider - REG ANH BSH

September 2020

In addition to the summary of monthly changes below, please also review our monthly Bulletin for recent and upcoming changes to our medical and dental policies, and associated changes to pre-authorization requirements. The Medical Policy Manual includes a list of recent updates and archived policies.

eviCore to review surgery sites of service

When you request pre-authorization from eviCore healthcare (eviCore) for a spinal or joint surgery with a date of service of September 1, 2020, or later in an inpatient setting, eviCore will review and issue an authorization for both the professional service and the site of service. This change will result in some site-of-service denials if the requested service should be performed in an outpatient setting.

eviCore will begin reviewing and applying site of service determinations on July 20, 2020, for dates of service on or after September 1, 2020.

eviCore’s review will only determine whether the procedure should be performed outpatient; it will not direct providers to a specific type of outpatient setting.

Read the June 2020 issue of our newsletter for details.

Changes to outpatient facility MUEs

For claims received on or after September 1, 2020, editing for outpatient facility medically unlikely edits (MUEs) will move to ClaimsXten clinical editing. The ClaimsXten MUE edits will allow reimbursement up to the specified MUE limitation and deny any units exceeding the specified value.

Using modifier GZ on facility claims to bill units exceeding MUE limits will no longer be required. For more information, read our Maximum Daily Units (Administrative #120) reimbursement policy.

Pre-authorization updates

Uniform Medical Plan Pre-authorization List
Adding CPT codes effective September 1, 2020:

  • Implantable Drug Delivery System HTCC

    • Effective September 1, 2020, CPT 62350, 62351, 62360, 62361 and 62362 will require pre-authorization from Regence; codes are subject to HTCC decision and coverage criteria

Medicare Pre-authorization List
Adding codes effective September 1, 2020:

  • Bone Growth Stimulators (Osteogenic Stimulation) (Medicare Durable Medical Equipment #83.12)

    • CPT 20979; HCPCS E0747, E0760

Pre-authorization for specialty medications

Effective September 1, 2020, the following will be added to the specialty medication pre-authorization lists for CHG Healthcare Services (group #70000004), IEC Group (group #70000000) and Alsco Inc. (group #70000002) members: HCPCS A9508, A9513, A9606, G9033, J0179, J0202, J0517, J0565, J0570, J0584, J0593, J0606, J0775, J0882, J0887, J0888, J1301, J1446, J1447, J1560, J1570, J1599, J1652, J2265, J2278, J2315, J2503, J2504, J2562, J2597, J2724, J2820, J2860, J3145, J3245, J3304, J3396, J3398, J3489, J3590, J7175, J7177, J7178, J7188, J7203, J7208, J7311, J7313, J7316, J7318, J7320, J7328, J7336, J7340, J7401, J7504, J8999, J9022, J9023, J9032-J9034, J9039, J9043, J9120, J9153, J9155, J9173, J9176, J9178, J9179, J9199, J9203-J9207, J9218, J9228, J9229, J9245, J9261, J9285, J9293, J9295, J9301, J9302, J9307, J9308, J9325, J9330, J9352, J9354, J9356, J9395, J9400, L8605, Q2041, Q2042, Q2049, Q5105, Q5110, Q5113-Q5116, Q9991, Q9992, S0088, S0137, S0140 and S0182.

View the complete list of specialty medications that require pre-authorization for these members.

DMEPOS fee schedule update

Regence reserves the right to set a fee schedule amount for codes not listed or listed without a fee in the CMS Durable Medical Equipment Prosthetics, Orthotics and Supplies (DMEPOS) fee schedule.

Effective September 1, 2020, for many codes that do not have a CMS fee, we are establishing fees for our commercial lines of business. View our fees on the Availity Portal : Payer Spaces> Resources. Select Reimbursement Schedules, then DMEPOS Reimbursement Schedule for Unlisted Codes/Codes with no Fees. We will continue to notify you of new fees that are established in this newsletter.

View our DMEPOS Reimbursement (Administrative #118) reimbursement policies for group and Individual and Medicare Advantage members.

Medical and dental reimbursement policy updates

We review our reimbursement policies on an annual basis. Included below are changes to our policies.

View our Reimbursement Policy Manual or our Dental Reimbursement Policy Manual.
To see how a medical claim will pay, access the Clear Claim Connection tool on the Availity Provider Portal.

Revised medical reimbursement policies effective September 1, 2020:

  • Preventable Adverse Events (Administrative #106)
  • Non-Reimbursable Services (Administrative #107)

Read the June 2020 issue of our newsletter for details.

Medication policy updates

Listed below is a summary of medication policy additions and changes. View our June 2020 newsletter for details.

Revised medication policy effective September 1, 2020:

  • Chimeric Antigen Receptor (CAR) T-cell Therapies, dru523