What's new

What's new

Dental claims with PPE charges to be reprocessed

We recently identified an error in how personal protective equipment (PPE) charges were processed on dental claims to indicate patient responsibility. Claims with dates of service on and after April 21, 2020, are being reprocessed to deny those charges because they are considered a provider write-off and not eligible for reimbursement as stated in our Non-Reimbursable Dental Services dental reimbursement policy.

If you submitted any claims with PPE charges after April 21, 2020, you will see a claims adjustment on your remittance advice because of this error.

We apologize for any inconvenience this may cause and appreciate your patience as we work to ensure the correct benefits are applied.


Critical access hospitals should check type of bill to avoid denials

Critical access hospitals (CAHs) should follow Centers for Medicare & Medicaid Services (CMS) guidelines when submitting the correct type of bill to ensure accurate adjudication of claims. For example, outpatient hospital claims submitted by a CAH with bill type 013X may result in denials.


ACP conversations now covered at no cost share for Medicare Advantage members

In light of the demand triggered by COVID-19 and to better support our Medicare Advantage members, we are now covering goals of care/ACP conversations at no cost share ($0 copay), regardless of the visit type or place of service.

  • This benefit enhancement applies to telehealth (conducted via audio and video) and in-person visits with dates of service on or after January 1, 2020.
    • Any impacted claims submitted this year with CPT 99497 or 99498 will automatically be reprocessed.
  • To ensure members are supported if their health status and/or wishes regarding care planning change, the benefit covers one ACP conversation per day with no annual limit.


Medicare Quality Incentive Program: Early bird bonus deadline for closing HCC gaps has moved to September 30, 2020.

To earn the early bird bonus of $25 per member, you must close 66% of gaps by September 30, 2020. To receive credit toward the early bird bonus, submit documentation by the following dates:

  • Electronic medical record (EMR) supplemental data files: September 15, 2020
  • Claims: September 15, 2020
  • Supporting documentation uploaded to CGMA: September 30, 2020

Only documentation that meets Risk Adjustment standards will count toward the gap closure.

Because we receive information throughout the year, you may see new HCC gaps appear in the care gap management application (CGMA) throughout the year. You can access the CGMA from Payer Spaces in the Availity Provider Portal.

Qualification for the early bird bonus is based on attribution/assignment effective September 30, 2020. Payment will be calculated based on final attribution/assignment effective December 31, 2020. As a reminder, to earn the early bird bonus, you must close 79% of HCC gaps by the final Medicare Quality Incentive Program (QIP) submission deadline.