For information on how to submit a preauthorization for frequently requested services/procedures for your patients with Humana follow the links below.
Month: September 2023
Health Plan Representatives Updated
The Health Plan Representative list has been updated. Please give a copy to everyone that might need it in your office.
Medicare Advantage Audits
In response, the Texas Medical Association has developed free CME to help member physicians prepare for such audits.
POET phones are out again!
We are in the office but once again our phones are not working. This also means we are unable to send or receive faxes.
Please feel free to contact us on our personal cell phones, if you have the number.
September 12, 2023
HCC Tip Card
Hierarchical Condition Categories (HCCs) aren’t a new concept, but as more and more organizations shift to value-based care, the lack of a foundational knowledge of HCCs, could result in lower rates of reimbursement, or sometimes not getting paid at all.
Hierarchical Condition Categories, are sets of medical codes that are linked to specific clinical diagnoses.
HCCs are used by CMS as part of a risk-adjustment model that identifies individuals with serious acute or chronic conditions. This allows Medicare to project the expected risk and future annual cost of care.
A RAF, (Risk Adjustment Factor) score is a measure of the estimated cost of an individual’s care based on their disease burden and demographic information. Each HCC associated with a patient is assigned a RAF that is averaged with any other HCC code factors and a demographic score. The resulting score is the payment amount a provider receives for a patient. Healthier patients will have a below average RAF while sicker patients will have a higher one, which impacts the calculated payment amount.
The below linked HCC Tip Card is a few years old, but maybe it can help us understand how HCC is weighted.
Notice of Data Breach Update
Texas physician practices and other health care facilities soon will be required to give more timely and public notice of any breaches of computerized data, including electronic health records (EHRs) and billing information.
During the 2023 regular legislative session, state lawmakers passed Senate Bill 768 by Sen. Tan Parker (R-Flower Mound), which takes effect Sept. 1. The law requires anyone doing business in Texas to notify the state attorney general of computer security breaches involving the sensitive, personal information of at least 250 individuals as soon as possible, and not later than 30 days after discovery, down from 60 days.
BCBS RSV Vaccine Update
Sept. 1, 2023
RSV Vaccine Coverage Update
Applies to all non-grandfathered groups
Beginning Sept. 1, 2023, we will cover the Respiratory Syncytial Virus (RSV) vaccine without cost sharing for adults, as recommended by the Advisory Committee on Immunization Practices (ACIP).
What you need to know:
- This year, the Food and Drug Administration (FDA) approved two new RSV vaccines, Abrysvo and Arexvy, for the prevention of lower respiratory tract disease caused by RSV in those age 60 and older.
- We will cover both RSV vaccines without cost sharing when obtained at a doctor’s office (as a medical claim) or at a participating pharmacy (as a pharmacy claim) for groups that have Prime® Therapeutics as their Pharmacy Benefits Manager (PBM).
- Groups that have carved-out pharmacy benefits should check with their PBM to confirm their coverage and implementation of this update.
- As with any preventive service, the vaccine must be obtained from an in-network provider to be covered without cost sharing.
- This coverage update is effective Sept. 1, regardless of renewal date for all non-grandfathered ACA-compliant plans.
Note: The RSV vaccine for infants (Beyfortus) is a different drug and is covered under the medical plan only.
Blue Cross and Blue Shield of Texas (BCBSTX) contracts with Prime Therapeutics to provide pharmacy benefit management and related other services. BCBSTX, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics. MyPrime.com is an online resource offered by Prime Therapeutics.
We apologize for the inconvenience
POET IS HAVING PHONE ISSUES AGAIN. ONLY SOME OF OUR LINES ARE WORKING.
Recent Comments