Provider News & Updates – July 2024 - Samaritan Health Plans

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New Medicare-eligible Behavioral Health Providers Reminded to Bill Medicare as Primary Payer

As of Jan. 1, 2024, Medicare is the primary payer for the following behavioral health services provided to Medicare members:

Behavioral health services rendered by marriage and family therapists and mental health counselors, known as MFTs and MHCs respectively, as defined by the Centers for Medicare & Medicaid Services. In Oregon, this includes services rendered by licensed MFTs and licensed professional counselors, known as LMFTs and LPCs respectively.
Intensive Outpatient Program services furnished by hospital outpatient departments, community mental health centers, rural health clinics, federally qualified health centers or opioid treatment programs as described in the November 2023 news release from CMS.

Why is this happening?

The Mental Health Access Improvement Act expanded Medicare coverage to include these behavioral health professionals in Medicare coverage services as of Jan. 1, 2024. The Medicare Learning Network’s guide to Medicare and Mental Health Coverage includes details on these changes to coverage, reimbursement and eligible provider types.

What should you do?

Oregon LMFT and LPC providers who meet federal education and experience requirements should enroll in Medicare. This document lists the education and experience requirements and how to enroll. It may take up to 60 days to complete Medicare enrollment.

Clinics and programs with new Medicare-eligible providers rendering behavioral health services should ensure all applicable staff enroll in Medicare and bill Medicare as primary coverage. Please remember that Medicaid is the payer of last resort.

Behavioral health services billing tips:

Bill Medicare as primary for IHN-CCO members with the BMM or BMD benefit package. You can verify this coverage in the Medicaid Management Information System (MMIS) Provider Portal at or-medicaid.gov.
For members with Medicare Advantage, communicate with the plans before rendering services for any authorization or process required.
Once you bill for Medicare fee-for-service members, claims will automatically crossover to CCOs or the Oregon Health Authority. The CCO or OHA then cover cost-sharing amounts from Medicaid for qualified Medicare beneficiaries (BMM, MED).
To learn more about billing, review the Oregon Health Plan’s Keys to Success manual, dual eligible guidance from CMS and OHP crossover claim guidance. Contact the member’s CCO for any additional information on billing or behavioral health wraparound payments.

Article source: Medicare is the primary payer for some outpatient behavioral health services for Medicare-Medicaid members, effective Jan. 1, 2024 (Sharepoint.com).

Samaritan Advantage Tier 6 Medications Offer Cost-sharing Benefits & Greater Refill Options for Members

As of Jan. 1, 2024, Samaritan Advantage Health Plans’ drug formulary covers specific maintenance medications under the Tier 6 benefit for some plans, which makes these prescriptions eligible for up to 100-day refills. Providing refills at 100-day supply increments provides Samaritan Advantage members with a larger quantity of medication on hand. This means less frequent trips to the pharmacy and the opportunity for improved refill request turnaround times. It also saves on out-of-pocket costs for members due to lower cost-shares for diabetic, hypertension or statin drug classifications.

Providers who take time to understand the Samaritan Advantage drug formulary will help reduce barriers to patient care, such as financial costs, and facilitate patient adherence to medication, prescription compliance and an increase in
overall wellness.

The Tier 6 pharmacy benefit is available to Samaritan Advantage Premier and Premier Plus members. Tier 6 is not available to Samaritan Dual Advantage members. Dual Advantage members will continue to be eligible for up to 90-day refills with little to no cost-sharing under other pharmacy tiers. Please review the Samaritan Advantage drug formularies to determine if a specific medication qualifies under your patient’s plan. All qualifying medications will be listed under Tier 6.

If you have questions regarding medication adherence for select care drugs, you may call the SHP Medication Adherence Line at 541-768-1848. Please leave a voicemail and your call will be returned within one business day. General questions from providers can be directed to SHP Customer Service at 541-768-5207 or 888-435-2396 Monday through Friday, 8 a.m. to 5 p.m.

For more information on Samaritan Advantage drug tiers, please reference the SHP Q1 Provider Webinar held in April 2024. If you have questions related to Medicare Stars and its other measures, please email [email protected].

Medicare Updates Billing & Reimbursement Rules for HCPCS G2211 & Accepts New CPT 99459

HCPCS code G2211 was published on Jan. 1, 2021, as an add-on code to report the complexity of evaluation and management associated with continuing care or with services that are part of ongoing care related to a serious or complex condition. Medicare assigned a status of “B” (bundled) to this code until Jan. 1, 2024. For detailed information on how this code was applied during this time frame, please access the Centers for Medicare & Medicaid Services and the U.S. Department of Health & Human Services rule report published by the Federal Register.

Providers should refer to Medicare’s Claim Processing Manual 100-04, Chapter 12, for circumstances that qualify for reporting HCPCS code G2211 as of Jan. 1, 2024. Samaritan Health Plans is following Medicare’s policy and has removed HCPCS code G2211 from bundled status as of this date. SHP will allow HCPCS code G2211 for services that meet Medicare’s criteria for using this code. SHP will not pay HCPCS code G2211 when billed on the same date of service as another office or outpatient evaluation and management visit (CPT codes 99202-99205 and 99211-99215) when reported with modifier 25 when it is for the same beneficiary and performed by the same practitioner or nonphysician practitioner.

Additionally, the American Medical Association’s CPT editorial panel created the new add-on code 99459 to be reported with preventive and problem-focused evaluation and management codes. Code 99459 is used to report pelvic examinations and is intended to capture the direct practice expense associated with performing a pelvic exam.

HCPCS code G2211 and CPT code 99459 are both present on the Oregon Health Authority’s Prioritized List of Health Services. To decrease IHN-CCO claim denials for these codes, providers should verify covered diagnosis pairings.

Claims & Billing Tips to Improve Efficiency

Billing Medicare-covered and Routine Chiropractic Services for Samaritan Advantage Plans

Medicare-covered chiropractic services have separate billing requirements from routine chiropractic services when billed to Samaritan Advantage Plans. Medicare guidelines specify that Medicare-covered chiropractic services, which include CPT codes 98940-98942, must be identified by the addition of modifier AT.Medicare-covered chiropractic services must also be billed with an appropriate primary diagnosis code that identifies the precise level of subluxation. Evaluation and management codes, also known as E/M codes, are not separately payable when billed with a
Medicare-covered chiropractic service.

The Samaritan Advantage benefit for routine chiropractic services includes CPT codes 98940-98943 without the modifier AT. The absence of modifier AT designates the service as routine and allows for billing of E/M codes that will be separately payable. The routine chiropractic benefit is provided for Samaritan Advantage Premier, Premier Plus and Valor plan members. Routine chiropractic services are not a benefit for Dual Advantage members.

Important Updates & Reminders

As of April 22, 2024, the electronic data interchange, known as EDI, clearinghouse Change Healthcare Relay Exchange, previously known as CHC1, is available for electronic data submission, including claims. This affects payer IDs 2122 (professional) and 5952 (institutional), both of which are now accepted. Relay Exchange is one of four EDI clearinghouses used by Samaritan Health Plans to receive electronic data from providers. Due to the cyberattack against Change Healthcare in February 2024, SHP was forced to disable two of its four clearinghouses, causing a severe disruption in data exchange between SHP and providers. At the time of this publishing, one of SHP’s clearinghouses remains disabled and three are enabled for providers. Additional information and updates can be found at samhealthplans.org/Claims.

Samaritan Employer Group Plans to Implement PCP Requirement for Members

Oregon Senate Bill 1529, also known as SB 1529, requires medical insurance carriers to assign a primary care physician to commercial plan members who have not chosen one within 90 days of enrollment. Both the member and assigned provider will be informed of the PCP assignment once it is made. Members have the right to change their PCP at any time. SHP is currently developing processes that support compliance with this bill and providers will be updated as SHP begins to implement this new requirement.

Both SB 1529 and Oregon House Bill 3008 will also regulate the amount of copay allowed for the first three PCP visits for Employer Group plan members. SHP’s claims processing system is configured to assess a $5 copay from Large Employer Group plan members. This rule does not apply to Samaritan Choice members as the Choice plans are
self-funded plans.