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Monthly Changes

Our at-a-glance summary of monthly changes to our policies, pre-authorization requirements, Administrative Manual and other programs or initiatives that impact your office are published:

  • Monthly in our bulletin
  • Bi-monthly in our newsletter
  • On this page within two weeks of our newsletter publication

Subscribe to receive newsletters and bulletins via email. View the changes listed by effective date below:

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August, 2019

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.

Pre-authorization updates

The following codes were added to our pre-authorization lists effective August 1, 2019:

  • Commercial and Uniform Medical Plan
    • Balloon Ostial Dilation for Treatment of Sinusitis (Surgery #153)
      • CPT 31295-31298
    • Hypoglossal Nerve Stimulation (Surgery #215)
      • CPT 64568, 0466T
  • Medicare
    • Hypoglossal Nerve Stimulation (Medicare Surgery #215)
      • CPT 64568

Effective August 1, 2019, we revised several of our radiation oncology medical policies, allowing certain indications to receive automatic approval when medical policy criteria are met for requests submitted using our electronic authorization process in the Availity Portal, availity.com. Changes include:

  • Four new policies that replace existing Intensity Modulated Radiotherapy (IMRT) policies
  • Two new policies that replace the existing Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy policy

We expect these changes will help expedite the pre-authorization process for you and our members. Please read the August 2019 issue of The Bulletin for more information.

New electronic authorization features

We're pleased to share that on August 19, 2019, 250 CPT codes will be added to the list of codes that, when entered as part of an electronic authorization request, are routed to MCG Health where you can document specific clinical criteria about your patient. If all criteria are met, you will be able to see the approval on the Auth/Referral Dashboard soon after you click submit.

This applies to electronic authorizations submitted on the Availity Portal for members on our commercial products, including UMP.

Provider Access and Experience Study

Each year, we conduct a Provider Access and Experience Study of primary care providers, behavioral health providers and providers in high-volume specialties.

One area of focus for this survey is appointment scheduling availability. Questions reflect the appointment standards published on our website. Please review the appointment wait time standards appropriate for your practice, and take any action needed to ensure that your patients, our members, have access to care in a timely manner.

Other important topics included in the survey are:

  • Communication
  • Continuity and coordination with other professionals involved in the care of your patients
  • Your experience with the Regence utilization management (UM) process

Our next survey will begin this month, and you may be contacted by our vendor, DSS Research, to participate. We look forward to your responses, which will help us evaluate and improve key aspects of care and service for our members.

Medical Policy update

We publish updates to medical policies, dental policies and Clinical Position Statements in our monthly publication The Bulletin.

We provided 90-day notice in the May 2019 issue of The Bulletin about the following
medical policy:

  • Rhinoplasty (Surgery #12.28), effective August 1, 2019

You can read issues of The Bulletin or subscribe to receive an email notification when issues are published on our website. The Medical Policy Manual includes a list of recent updates and archived policies. All policies and Clinical Position Statements are available on our website.

Gap closure deadline coming

To qualify for the Hierarchical Condition Category (HCC)/chronic diagnosis gap closure performance bonus including in our Medicare Quality Incentive Program, you must have 66% of your total HCC gaps closed by August 31, 2019 (and 79% of gaps closed by December 31, 2019).

To ensure that we have the information necessary to count your gaps as closed, please adhere to the following deadlines for each method of gap closure submission:

  • Claims–August 15, 2019
  • Supplemental electronic medical record (EMR) data extract–August 15, 2019
  • Care gap management application (CGMA)–August 31, 2019

Administrative Manual updates

The following sections were updated effective August 1, 2019:

  • Fraud and abuse
  • Medical Management

Read the August, 2019 issue of our newsletter for details.