Connect Archives

March 2010

Wednesday, March 17, 2010


With the notification that effective July 1, 2010, Health First Network will begin processing claims for physician extenders in the same manner as Medicare, Health First Network has received a number of questions and inquiries from several offices regarding CMS requirements on Billing and Supervision for Non-Physician Extenders. For further information, please review the Frequently Asked Questions (FAQ’s) and General Medicare Guidelines on Billing for Non-Physician Extender Visits.

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On February 1, 2010, CMS notified all Medicare Advantage Plans by memo of a recent national coverage decision (NCD) to require the coverage of HIV screening to Medicare-eligible enrollees with high risk profiles.

Generally, Medicare Advantage Plans are required by law to cover all Original Medicare benefits, including new services covered under NCD’s, whether or not the cost of the new service or benefit was accounted for in their original bids.

Consequently, effective January 1, 2010, all MAO’s must cover both standard and FDA-approved (HIV) rapid screening tests for:

1) Annual voluntary HIV screening of Medicare beneficiaries at increased risk for HIV infection per USPSTF guidelines, including:
Men who have had sex with men after 1975;
Men and woman having unprotected sex with multiple partners;
Past or present injection drug users;
Men and woman who exchange sex for money or drugs, or have sex partners who do;
Individuals whose past or present sex partners were HIV-infected, bisexual or injection drug users;
Persons being treated for sexually transmitted diseases;
Persons with a history of blood transfusion between 1978 and 1985;
Persons who request an HIV test despite reporting no individual risk factors, since this group is likely to include individuals
not willing to disclose high-risk behaviors

2) Voluntary HIV screening of pregnant Medicare beneficiaries when the diagnosis of pregnancy is known, during the third trimester, and at labor.

CMS notified MAO’s that they expected all Medicare Advantage Organizations to notify enrollees about this new screening test and eligibility for coverage as soon as possible, through whatever means is practical including on their websites, or through plan newsletters.

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WellCare announces Formulary Updates for 2010. These changes represent positive improvement to the WellCare Formulary Preferred Drug List and show important changes such as Tier lowering, Prior Authorization Removal, Additions to the Formulary List, Quantity limit increases, etc. Please share this list with all Clinicians in the office who see WellCare members.

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Harmony Behavioral Health, the mental health services provider for WellCare members, has provided a revised Behavioral Health Referral Form for Health First Network Physicians to use when referring WellCare members for Behavioral Health services. This form can be faxed to Harmony Behavioral Health using the fax number listed on the form.

Harmony has indicated they are willing to provide more transparency and partnership in the coordination of behavioral health services, in response to Health First Network’s continued requests to obtain more information about the Behavioral Health Process, points of access, care coordination and feedback.

If Health First Network Physicians wish to refer their WellCare member to MED3000 Case Management when the member is being referred for behavioral health services, a process has been outlined between Harmony Behavioral Health Nurse Case Managers and MED3000 Nurse Case Managers that will allow care coordination care plans to be exchanged between Case Managers of both organizations. To refer a WellCare member to Case Management Services, Physicians should call 850-478-6060, ext. 3162.

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Health First Network has been notified by WellCare and HealthSpring Health Plans that CMS now requires that Medicare Advantage Members must be notified in writing regarding the status of pre-service approval requests no later than 14 days following the request. These approval letters are for pre-auth and pre-certification services only (such as pre-service Physical Therapy, Home Health and Non-Par Requests), and do not pertain to concurrent review/discharge planning requests or retro requests. For HealthSpring members, the letters will be coming directly from HealthSpring. For WellCare members, Health First Network, will be sending out these letters as a delegated entity, and will comply with this “14 day notification requirement”. Implementation date is scheduled for April 1, 2010. HFNI Physicians submitting requests for services on WellCare members are currently notified by phone, fax, or electronically of auth approvals. The direct member notification is a new requirement. CMS is not requiring a copy of the member letter to be mailed to Physicians. If your patient receives such a letter and has questions, you may refer them to the Medical Department at MED3000.

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As part of our continuous commitment to improve your website experience, Health First Network has added a new “Provider Updates/Change Request” page to the website. This page will assist your office in reporting provider updates and changes in a more efficient manner. The Provider Update/Change Form can be completed on line. Please note, an updated W-9 must be faxed to 850-438-0298 in order for the changes to be completed.

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As a training resource to provider offices, HFNI has added an eINFOsource on line training module. EINFOsource is an online resource for provider offices to check eligibility, co pays, claims status and enter referrals to Network physicians. If you have any question please feel free to contact the Help Desk at Med3000 (850-505-4090). Follow the link provided below to access the training module.

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