Category: Business
Aetna Changes in NPL
Changes in National Precertification List
As of August 1, 2025, we require precertification for the following:
- Conexxence (denosumab-bnht, J3490, J3590, C9399)
- Bomyntra (denosumab-bnht, J3490, J3590, C9399)
- denosumab-bnht (biosimaliar Prolia, J3490, J3590, C9399)
- denosumab-bnht (biosimaliar Xgeva, J3490, J3590, C9399)
- Omlyclo (omalizumab-igec, J3490, J3590, C9399) (precertification includes the site of care)
- penpulimab-kcqx (J3490, J3590, C9399) (precertification includes the site of care)
- ustekinumab-stba (J3490, J3590, C9399)
- ustekinumab (J3490, J3590, C9399)
- Starjemza (ustekinumab-hmny, J3490, J3590, C9399)
Submitting precertification requests:
Submit precertification requests at least two weeks in advance and include the actual date of service in the request. To save time, request precertification online through our provider portal on Availity.* Doing so is fast, secure and simple.
You can also use your practice’s Electronic Medical Record (EMR) system if it’s set up for electronic precertification requests. Use our “Search by CPT® code” function on our Precertification Lists page to find out if the code requires precertification.***
If you need precertification for a specialty drug for a commercial or Medicare member, submit your request through Novologix®, which is also available on Availity®.
Note to Texas providers: Changes described in this article will be implemented for fully insured plans written in the state of Texas only if such changes are in accordance with applicable regulatory requirements. Changes for all other plans will be as outlined in this article.
Availity Portal Issues
It appears that Availity is having some issues.
If you have went in to Availity to complete an action, and it has your physician’s specialty wrong, this is an Availity issue. It seems to be across multiple insurances.
Please call Availity Customer Service (800) 282-4548.
POET is being told, it is not a credentialing or Healthplan issue.
Health Plan Representatives Updated 8/4/2025
The Health Plan Representatives List has been updated. This is a good tool to print and have close by when you have an issue.
The biggest change for claims issues will be HealthSpring (HCSC) formerly Cigna MA. Here is how:
- Email ALL claims issues to [email protected]
2. HealthSpring has supplied the spreadsheet that MUST be used. A link is provided below, or you may call POET, we will be glad to email you an electronic copy.
Only the columns with Red Lettering, need to be filled out by the Physician’s office.
4. Always feel free to copy [email protected] if you would like POET to be in the loop.
5. If you have a time sensitive, special, or just an issue you would like to discuss with POET, please call (936) 637-7638.
Check Your Gold Card Eligibility
Last fall, UHC introduced the first national Gold Card program, reducing prior authorizations in favor of advance notification for provider groups consistently adhering to evidence-based care guidelines. They are happy to announce that in the 2nd year of the program, starting Oct. 1, 2025, additional provider groups will be eligible.
On Sept. 1, UHC will publish details on how to determine if your provider group has qualified for the program.
Check your Gold Card eligibility status starting Sept. 1
Provider groups can view their Gold Card program status in the UnitedHealthcare Provider Portal.
Renewing Oct. 1, 2025, the program simplifies the prior authorization process for qualifying providers and eligible services. Qualifying providers will need to submit advance notification, which confirms eligibility and network status, but no clinical information will be requested. We’ve updated the program protocol for the renewal period.
Visit our national Gold Card program page in September for detailed instructions on how to identify Gold Card status and access to an interactive guide that can help you navigate our resources.
Staff Motivators That Beat a Pay Raise
Say “thank you,” loudly and in technicolor.
Public praise is free but priceless. Instead of a vague “good job,” spotlight the exact behavior you want copied: “Ana stayed late to troubleshoot a claim and saved the patient a $300 bill.” Physicians Practice Pearls expert Neil Baum, MD, calls the morning huddle “the best two minutes you can spend with your staff.” A quick shout-out there—or on a break-room whiteboard—tells people you notice the details.
Keep a stack of blank note cards on your desk. Hand-written kudos feel personal and often end up taped to monitors for months.
Invite staff to hack the workflow.
Front-desk teams see caller logjams first; billers spot denial patterns in real time. Bring them into the fix. Start simple: Post a sticky-note board labeled “Kill a Hassle,” review ideas every Friday and act quickly on the easy wins. Seeing suggestions adopted fuels the next wave of improvements.
Swap rigid shifts for micro-flexibility.
Eighty-two percent of clinicians say flexible hours would ease burnout, yet only 29 percent receive them, according to a survey on curbing staff turnover. You can close that gap without blowing up the schedule:
- Let billers log in from home during blizzards.
- Approve a lunch-hour swap so a nurse can make the daycare pickup.
- Offer Friday half-days when patient volume is light.
Generational staffing research shows that many employees will trade modest raises for autonomy nearly every time
Rotate “stretch” assignments.
Cross-training keeps boredom at bay and coverage steady when someone is out sick. This blueprint for cross-training for productivity walks through mapping every role and pairing mentors with learners—no tuition required. Try a 90-day rotation: a receptionist shadows the billing manager on prior auths; a medical assistant learns vaccine fridge logs. You build a talent bench, and staff see a career path instead of a dead end.
Hold five-minute stay interviews.
Exit interviews happen too late. Stay interviews—quick, quarterly check-ins that ask “What still excites you here? What might tempt you to leave?”—surface fixable irritants early. In one case study on hiring during the Great Resignation, a practice saved two senior coders after discovering their chief complaint was a squeaky chair and thermostat wars. Block 10 minutes every Friday for one informal chat. Bring a pen, not a form; the goal is conversation, not paperwork.
Celebrate life outside the practice.
People stay where they feel seen. A birthday cupcake, a shout-out for a child’s graduation or public applause when someone passes a credentialing exam costs pennies. A how-to on recognizing staff milestones reminds managers that re-recruiting existing employees starts with asking about their families, hobbies and pain points—then acting on the answers.
Create a shared calendar labeled “Wins & Milestones” so teammates can add their own moments worth cheering.
Protect two “dark” hours a week.
Constant interruptions tank productivity and morale. Clinicians who tested “quiet blocks” reported faster chart closure and happier teams, according to this roundup on burnout beyond physicians. Pick a mid-afternoon slot twice a week: no phone transfers, no walk-ins, no inbox pings. Nurses use it to stock rooms, assistants catch up on vaccine logs and doctors finish notes—everyone leaves on time.
Turn transparency into a super-power.
When staff understand the financial picture, they’re far less likely to assume the boss is hoarding cash. Share payer-mix trends, new-patient counts or denied-claim rates at monthly meetings. This budget guide argues that candid dashboards spark solutions long before a staffing crisis erupts. If numbers feel intimidating, start with one metric—say, days in A/R—and ask for ideas to nudge it down. The dialogue is the point.
Crowdsource micro-wins every week.
Keep a stack of Post-its at each workstation and invite anyone to jot a nagging inefficiency. Review three notes at the Friday huddle and green-light at least one. Employees who hear “Yes, let’s try it” stay longer than those who hear excuses
UHC July Overview
Policy and protocol updates
Medical policy updates
Medical policy updates for July 2025 for the following plans: Medicare, Medicaid, Exchanges and commercial.
Reimbursement policy updates
See the latest updates for reimbursement policies.
Specialty Medical Injectable Drug program updates
See the latest updates to requirements for Specialty Medical Injectable Drugs for UnitedHealthcare members.
Pharmacy and clinical updates
Access upcoming new or revised clinical programs and implementation dates for UnitedHealthcare plans
Call Now to Reserve Your Seat
Limited Seating
2025 Washington Policy Mid-Year Update – MGMA Webinar
Where: POET Office
When: July 22, 2025, Tuesday
Time: 12 noon
Lunch will be served
Limited Seating Available
During this webinar, MGMA Government Affairs staff will provide an update on current and potential policy developments impacting medical group practices. The speaker will discuss the latest legislative and regulatory issues covering topics such as Medicare reimbursement, telehealth, quality reporting, and surprise medical billing.
This 60-minute webinar will provide you with the knowledge to:
Identify key regulatory developments
Discuss legislative issues impacting medical groups
Describe MGMA advocacy initiatives
Please call (936) 637-7638 or Email [email protected]
Cigna Comm. New Reimbursement Policy for E/M
Cigna Healthcare® will implement a new reimbursement policy, Evaluation and Management Coding Accuracy (R49), to review professional claims billed with Current Procedural Terminology (CPT®) evaluation and management (E/M) codes 99204-99205, 99214-99215, and 99244-99245 for billing and coding accuracy in alignment with American Medical Association (AMA) E/M services guidelines.
Effective for dates of service on or after October 1, 2025, services may be adjusted by one level to reflect the appropriate reimbursement when the AMA guidelines are not met.
What this means to you
Cigna Healthcare will conduct periodic claim reviews to verify compliance. Based on that review, providers may be eligible to be removed from the program. Supporting documentation will be requested should we determine the established guidelines were not followed.
Reconsideration requests
Providers who believe their medical record documentation supports reimbursement for the originally submitted level for the E/M service should follow the reconsideration and appeals processes.
To request a reconsideration, please submit the customer’s full record of the encounter to the secure Cigna Healthcarefax number 833.392.2092. Should the original determination be overturned, claims will be adjusted, and an updated explanation of payment will be issued.
Administrative appeal rights are available if the original determination is upheld.
Cigna Comm. Removes 96 Codes from Prior Auth. List.
To help reduce the paperwork and time providers (and patients) spend seeking approvals for more routine services, Cigna Healthcare will remove 96 codes from the list of services that require prior authorization for dates of service on and after May 31, 2025. These codes include commonly requested cardiology, otolaryngology (ENT), and other routine services.
How to Search the BCBS Fee Schedule for Quarterly HCPCS (Updated)
Choose “Standards and Requirements”
Then “General Reimbursement Information”
Scroll to the Bottom and enter the password “Manual”, then click submit
Read the Policies Disclaimer or scroll to the bottom and click “Continue”
Then choose “Blue Choice PPO, Blue Essentials, Blue Premier, Blue Advantage HMO, MyBlue Health, Blue High Performance Network Schedules”
Directly under that, select “2024 Schedules effective 2/1/2024”
Scroll down to “CPT/HCPCS Drug Schedule” click
The schedule will open in a PDF. You may search by using “CTRL F”
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