Provider News & Updates – September 2023

Home Provider News & Updates – September 2023

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Optum Specialty Fusion to Manage Prior Authorizations

On Aug. 1, 2023, Optum Specialty Fusion began managing prior authorization requests for select outpatient provider-administered specialty and oncology drugs for Samaritan Health Plans and InterCommunity Health Network Coordinated Care Organization. Prior authorization requests for these services must now be submitted using the Specialty Fusion platform for dates of service on or after Aug. 1. Authorizations that were active prior to this date will remain in effect through any approved dates of service. You will not need to submit a new request until the existing authorization expires, even if the dates of service on the approved authorization are after Aug. 1.

A current list of drug codes and procedures requiring Specialty Fusion review is available and can be accessed by visiting samhealthplans.org/Find-a-Drug. Due to quarterly code changes and FDA newly approved drugs, the code list will be updated on a periodic basis. Providers are responsible for verifying authorization requirements and criteria by visiting samhealthplans.org/Authorizations and navigating to the appropriate plan’s authorization and benefit information.

Specialty Fusion will not be reviewing prior authorizations for:

Services or procedures that are included as part of an inpatient hospitalization or skilled nursing stay.
Services or procedures provided during an emergent, urgent or observation service.
Prescription pharmacy drugs that are currently reviewed and managed by OptumRX, Surescripts or CoverMyMeds.

Contracted providers can access the Specialty Fusion platform through the SHP provider portal, Provider Connect. As part of the request intake, clinical requirements can be documented within the required fields of the platform, including medical records attachments when requested or as appropriate.

If you are not already a subscriber to the provider portal, please visit Provider Connect to create an account. For help with creating an account or navigating the application, please refer to our Provider Connect tutorial.

For more information about the new prior authorization process with Optum Specialty Fusion, please contact SHP Provider Relations at [email protected] or contact SHP Customer Service at 541-768-5207 or toll free 888-435-2396.

In-home Health Assessments to Be Offered to Select Samaritan Advantage Members

Samaritan Health Plans is excited to offer our Medicare Advantage members a comprehensive health assessment at no cost through our partner, Focus Care. This bonus preventive checkup will allow members to see a nurse practitioner in the privacy of their home or virtually.

Here’s how it works:

Members with outstanding care gaps and members that have not seen their primary care provider are selected for a visit opportunity.
Once selected, members will receive an initial outreach letter to introduce the program and outline visit expectations.
SHP’s partner, Focus Care, will perform telephone outreach and schedule the visit, allowing the member to choose an in-home or a virtual visit.
On the scheduled date, a nurse practitioner will perform a comprehensive health assessment. This includes a brief physical exam, a review of the member’s medical history and medications and a comprehensive assessment of the member’s health.
A summary of the visit will be sent to the member, the member’s PCP and SHP Care Coordination.
SHP Care Coordination will support members by helping them schedule urgent or non-urgent follow-up visits with their PCP or other providers, as needed.

This program does not replace routine visits with a member’s PCP, nor does it replace their Annual Wellness Visit. Rather, this is an opportunity for Samaritan Advantage members to spend extra time with a health care practitioner to fully discuss medical concerns, review medications, complete preventive screenings and address any safety issues.

SHP is committed to working closely with providers to answer questions, address concerns and communicate about the health of their patients to ensure the success of this program.

SHP is excited about this new endeavor and confident that it will positively impact the health and well-being of our members. If you are interested in learning more about this program, please email us at [email protected].

Mid-year Revisions Made to IHN-CCO Outpatient Rehabilitation Services Prior Authorization Requirements

InterCommunity Health Network Coordinated Care Organization has reevaluated the prior authorization requirements for outpatient rehabilitation therapy services. Effective July 1, 2023, prior authorizations were updated for contracted providers as follows:

Physical therapy, occupational therapy and speech therapy: one evaluation visit and the first 30 visits per therapy per calendar year, do not require prior authorization. Prior authorization is required after 30 visits.
Evaluation and re-evaluation do not require prior authorization and do not count toward the visit limit.

This change is similar to the prior authorization requirement list changes in place at the first of the year. This means that the prior authorization requirements for the first part of the year will remain in effect through June 30, 2023. Any prior authorization requirements, retroactive authorization rules and the first 10 visits where no authorization was required are applied to visits that occurred Jan. 1 through June 30, 2023.

The 30-visit count includes visits used between Jan. 1 and June 30. This will include visits that were the initial 10 that didn’t require prior authorization and additional visits or units authorized during this time.

Providers who had approved authorizations that included visits past July 1, 2023, will have the end date changed to June 30, 2023, if the 30-visit limit has not already been met. Authorization for additional visits should only be requested if therapy services are planned to exceed 30 visits per year, per service type (for example, more than 30 physical therapy visits in 2023 from January to December).

Please visit the frequently asked questions related to prior authorization on our website at samhealthplans.org/Authorizations.

Scholarships Available to Professionals Working With Children With Autism for Certification in Qigong Sensory Therapy

The Oregon Autism Family Access Initiative is offering six to eight scholarships for professionals interested in becoming a certified Qigong Sensory Therapist. This
evidence-based sensory treatment is shown to reduce autism severity by up to 44% and reduces stress experienced by parents of children with autism. The six-month training and certification program is facilitated by Oregon’s Qigong Sensory Training Institute.

Providers who work with children with autism, ages 12 and younger are encouraged to take advantage of this opportunity. Training is designed for full-time professionals to complete while they are working. This sensory treatment is a billable service for sensory and
self-regulation challenges.

Scholarships may be given to anyone currently working as a personal support worker, occupational therapist, physical therapist, licensed professional counselor, licensed clinical social worker, speech and language therapist, alternative therapist or to those who have at least two years of experience working with children with autism.

This training is funded and open for up to eight professionals. The program begins at the end of September 2023 and includes one month of online training followed by five months of clinical supervision. This training may qualify for up to 80 continuing education hours. For more information about certification, please visit the Qigong Sensory Treatment Institute’s website.

Clinical Practice Guidelines Updated, Adopted for Preventive Screenings, Immunizations & Diabetes

Samaritan Health Plans develops and adopts evidence-based clinical practice guidelines, also known as CPGs. The CPGs are meant to assist providers in making decisions about appropriate health care for specific clinical circumstances. They are also intended to improve the quality and consistency of care provided to members. Each CPG developed and adopted by SHP is endorsed by a physician champion and adopted by SHP’s Quality Management Council.

The QMC recently adopted the following CPGs:

Recommended Adult and Child Preventive Screening Guideline. No changes made to references.
Recommended Pediatric Preventive Screening Guideline. Updated reference to reflect guideline updated in April 2023.
Recommended Adult Immunization Guideline. Updated reference to 2023.
Recommended Childhood Immunization Guideline. Updated reference to 2023.
Diabetes Guideline. Updated both references and links to the newest versions of each guideline.

To review all CPGs, please visit samhealthplans.org/Clinical Guidelines and click the down arrow to view the Clinical Guidelines section. There you’ll find medical, behavioral health and dental health guidelines.

Medical Coverage Policies Reviewed, Updated for Clinical Trials & Cosmetic/Reconstructive Procedures

In the absence of primary clinical criteria, Samaritan Health Plans develops medical coverage policies to communicate decisions about coverage and benefits for various medical services. Medical coverage policies are reviewed annually. In 2023, SHP reviewed or updated the following medical coverage policies:

Coverage of Routine Care for Members Enrolled in Qualifying Clinical Trials Policy. Annual review determined that consequences and/or complications of clinical trials are covered services.
Cosmetic and Reconstructive Procedures Policy. Annual review updates includes the Early and Periodic Screening, Diagnostic and Treatment Program. References were also updated.

To review all of the medical coverage policies, please visit the Care Management webpage and click the down arrow to view the medical coverage policies section.

Claims & Billing Tips to Improve Efficiency

Claims submitted with a claim frequency code of “7” on a CMS-1450 claim form require an appropriate condition code to be considered valid corrections. Corrected claims that fit criteria should be billed with the appropriate condition code D0 through D9 or E0. Please review the new and updated CMS billing guidelines, effective Jan. 1, 2022, to determine the condition code that is appropriate for the medical situation. Claims without the appropriate condition code will be denied with a clinical edit and require resubmission for reimbursement.

SHP Adopts OHA Guidelines for Substance Use Coding & Billing Limits

Since Jan. 1, 2023, Samaritan Health Plans has followed the Oregon Health Authority’s guidelines regarding billing codes for substance use. Refer to the table below for codes, code descriptions and daily limits for each service.

Substance use codes and claim billing limits

H0005	Group counseling by clinician	Per service	Two per day
H0006	Case management	Per service	Two per day
H00015	Intensive outpatient treatment (a program that operates at least three hours/day and at least three days/week and is based on an individualized treatment plan)	Per service	One per day

Important Updates & Reminders

Proactive Prior Authorization Request Documentation Improves Efficiency

When requesting prior authorization for a patient who is ready for discharge to a skilled nursing facility, but must remain in the acute hospital setting due to lack of an available bed, the following documentation in the chart will be helpful during Utilization Management review:

Is the member stable for discharge?
Is discharge to skilled nursing the only safe discharge plan available?
What continued efforts have taken place to secure a bed for the patient in a participating SNF and any additional follow up while awaiting a bed.
How many facilities have been contacted and which ones?
If a bed is available from a contacted facility, how soon can the member be transferred?

The Utilization Management team will look for this information when reviewing the prior authorization request. Being proactive in documentation can help engage all the right parties to work as efficiently and effectively as possible for the member to move to the most appropriate level of care as soon as possible.