Category: Medicaid
Updated Clinical Prior Authorization
Assistance Chart Now Available
An update to the Clinical Prior Authorization Assistance Chart is available. The chart identifies which clinical prior authorization each MCO uses and whether the MCO uses all or some of the steps in the evaluation process.
New Prior Authorization Ruling Applies to Some,
But Not All.
In December 2022, I reported on a proposed rule from the Centers for Medicare & Medicaid Services (CMS) about updating requirements for prior authorization (PA), a process that many providers and patients consider to be a roadblock to obtaining care. Now, CMS has published the Final Rule (020824) on this topic, which contains significant requirements for health plans to follow to improve the process.
The rule only applies to a set of Impacted Payers: Medicare Advantage (MA) organizations, state Medicaid and Children’s Health Insurance Program (CHIP) Fee-for-Service (FFS) programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan (QHP) issuers on the Federally Facilitated Exchanges (FFEs).
Legally, these are the plans for which CMS can set requirements. However, it is expected that many commercial plans will voluntarily adopt some of these provisions.
The rule also adopts a new measure for Merit-Based Incentive Payment System (MIPS)-eligible clinicians under the Promoting Interoperability performance category of MIPS, as well as for eligible hospitals and critical access hospitals (CAHs), under the Medicare Promoting Interoperability Program.
For more information and detail, follow this link to the article written by Stanley Nachimson, MS
Don’t Miss UHC Updates
Texas Medicaid: Adjustment reimbursement methods coming soon
Texas Medicaid: Prior autorization updates for certain medications
CMS Extends Telehealth Flexibilities to Protect Physician Privacy.
Following staunch advocacy by the Texas Medical Association, the Centers for Medicare & Medicaid Services (CMS) will not require physicians to list their home address as a practice location on Medicare enrollment forms for another year when providing telehealth services, safeguarding their privacy and safety.
During the COVID-19 pandemic, CMS allowed physicians to offer telehealth services from their homes without reporting their home address on their Medicare enrollment. However, that flexibility was set to expire Dec. 31.
Superior: Avoid Claim Denials
BILLING: Avoid Claim Denials
As a reminder, claims submitted with invalid or unclean data will result in denial or rejection of an entire claim. Superior has provided a list of important claim submission tips and common billing errors to help ensure your claims are processed quickly and efficiently.
Review the full list of tips to ensure your claims are not denied. Just click the link.
Superior Pediatric Vaccines 11/1/2023
For questions, please contact Pharmacy Provider Services
Updated: Vaccine Information
Date: 11/01/23
The best way to stay protected against COVID-19 and flu is by staying updated on vaccines. Superior HealthPlan would like to inform providers about current COVID-19 and flu vaccine coverage.
COVID-19 Vaccines
The United States Food and Drug Administration (FDA) approved updated versions (2023-2024 formulation) of the COVID-19 vaccines; both the Pfizer and Moderna versions were approved in September and the Novavax version was approved in early October.
The Vendor Drug Program (VDP) is still working on getting the new COVID-19 vaccines added to the pharmacy formulary with no provided ETA. Superior Medicaid and CHIP members can obtain the new COVID-19 vaccines through their medical provider in the meantime or wait and return to the pharmacy once the VDP and the Texas Health and Human Services Commission have added the new vaccines to the pharmacy benefit. Please check the VDP Product Search for the most updated coverage of vaccines.
Flu Vaccines
The 2023-2024 flu vaccine formulations were added by the VDP to the pharmacy benefit on September 1, 2023. Similar to last year’s flu season, Medicaid and CHIP members who are 3 years of age and older can obtain their flu vaccine from a participating pharmacy. All members under 3 years of age will need to obtain a flu vaccine from their medical provider.
Superior Prior Auth Changes Eff. 1/1/2024
For some services, utilization review is necessary to determine the medical necessity and appropriateness of a covered health care service for Superior HealthPlan’s managed care members. For those services, utilization review is performed BEFORE (prior authorization), during (concurrent review) or after (retrospective review) the service is delivered.
Medicaid and CHIP Program Revalidation
IMPORTANT:
During the Public Health Emergency (PHE), Provider
Revalidation was waived by HHSC.
The PHE ended May 11, 2023
Beginning May 12, 2023, Provider Revalidation Requirements were resumed.
Providers must ensure Medicaid and/or CHIP enrollment revalidation is completed on or before the provider’s scheduled revalidation date.
Providers that do not complete the revalidation process by their deadline are DISENROLLED from all Texas state healthcare programs, including Medicaid and/or CHIP managed care programs.
Visit the Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment webpage to view and confirm your upcoming Medicaid and /or CHIP program revalidation date, verify current enrollment is active and verify all information in the PEMS system is accurate.
CMS Efforts to Reduce Prior Auth Burden
Insurers must halve the length of time they take to respond to prior authorization requests
Insurers may no longer require preapproval for emergency behavioral healthcare.
Insurers have to explain denials and publish data on their decisions.
Patients in active treatment who change carriers must be given at least 90 days before the new insurer can require another prior authorization.
Click the below articles for more information.
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