What's new

Provider appeals must be submitted via Availity Essentials

Effective March 1, 2023, we will require all post-service provider appeals to be submitted using the Appeals application on Availity Essentials.

The only disputes and appeals that should not be submitted via Availity Essentials are:

  • Pricing disputes, which are not appeals and are subject to a separate pricing dispute process
  • Disputes that meet our Extenuating Circumstances exception criteria, which must be submitted via fax
  • Appeals that Availity cannot process because of file size limits, which may be submitted via secure file transfer protocol (SFTP)

All other provider appeals must be submitted via the Availity Essentials Appeals application. Provider appeals sent via an improper method will be returned with directions to submit using the Appeals application on Availity Essentials.

The Appeals application is a more efficient way of receiving appeals and communicating determinations to providers. The application:

  • Streamlines the appeals process by making it easy to submit appeals directly from the Claim Status screen
  • Gathers all required information about the claim being disputed
  • Prevents submission of duplicate appeals

The Appeals dashboard also shows the status and history of submitted appeals, eliminating the need for you to contact us for status information.

If an appeal is unable to be submitted through the Appeals application, you will receive a message indicating this when attempting to submit the appeal.

More information

Appeals application and exception criteria

Accessing the Appeals application
The Appeals application is available on Availity Essentials: Claims & Payments>Appeals. If you do not have access to the Appeals application, please contact your Availity Essentials administrator and request the Claim Status role.

Appeals can be initiated from the Claim Status screen by selecting Dispute Claim.

Training resources
View guides on Availity Essentials: Help & Training>Find Help>Appeals. A recorded training demonstration is also available by searching for Appeals: Help & Training>Get Trained.

12/1/2022

Commercial risk adjustment medical record reviews beginning

In November 2022, we will begin requesting and reviewing medical records to support the diagnosis data we submit to HHS for dates of service in 2022. We have partnered with the vendors Advantmed LLC and Episource LLC to assist us in the collection of medical records for this audit. Learn more about our Risk Adjustment Program.

11/14/2022

Changes to DME coverage for continuous glucose monitors in 2023

DME coverage for continuous glucose monitors (CGMs) will transition into a pharmacy-only benefit in 2023. This change will apply to fully insured Individual and group members with both medical and pharmacy benefits through Regence.

As plans renew on or after January 1, 2023, medical benefits will state that non-therapeutic CGM machines are excluded as a treatment option and cannot be billed as medical. Pharmacy will also only cover therapeutic machines and supplies.

  • Beginning January 1, 2023, Medtronic will no longer be a covered CGM supply brand.
  • Dexcom and Freestyle Libre are comparable products and can be conveniently purchased from a pharmacy without pre-authorization.
  • Members using a Guardian CGM will need to switch to Dexcom or Freestyle Libre before January 1, 2023, and will need to request a new pharmacy prescription from their provider.

Exceptions:

  • Children under six that meet criteria for an insulin pump
  • Certain administrative services only (ASO) groups with customized benefits that have elected to include DME coverage under their medical benefit

Note: If a member does not have Regence pharmacy benefits and only has a medical benefit, the CGM and supplies will be covered under the DME benefit in 2023.

10/24/2022

2023 brings code changes for many services and supplies

Please remember to review your 2023 CPT, HCPCS and CDT coding publications for codes that have been added, deleted or changed and to use only valid codes.

You can purchase the:

  • CDT manual by calling the American Dental Association at 1 (800) 947-4746 or online at ebusiness.ada.org
  • CPT and HCPCS manuals through your preferred vendor or online through the American Medical Association (AMA) at commerce.ama-assn.org/store

Reimbursement information is available on Availity Essentials.

This notice serves as an Amendment to your Participating Agreement. You have the right to terminate your Agreement in accordance with the amendment provisions of the Participating Agreement.

10/11/2022

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