Featured story: tips for taking your medication for depression—from a psychiatrist
If you have patients that have questions about depression medication, we've put together some best practices along with lifestyle habits to share with insight from board-certified general and child adolescent psychiatrist, Debra Katz.
In this issue:
- Lyra
- Cultural competency training
- Allies reminder
- Mobile cardiac outpatient telemetry authorization clarifications
- Annual updates to physician and outpatient fee schedules
- Medical policy updates
- Code updates
New mental health solution coming through Lyra Health
Responding to a crisis in access to mental health services, we are pleased to announce a partnership with Lyra Health to offer a new, comprehensive solution for AllWays members that will expand the availability of high-quality mental health services and promote overall health and well-being.
Through Lyra, members can securely and confidentially seek clinically proven mental health services, find high-quality providers tailored to their individual needs, and book appointments quickly with a therapist or coach by video or in-person.
Features include: Fast access to appointments, personalized navigation, and comprehensive care options.
Lyra will be rolled out in phases beginning June 2022. It will initially be available to Mass General Brigham employees and expanded to other AllWays Health Partners commercial members in January 2023. This new program will add to members’ current mental health and substance use coverage and resources through Optum.
To learn more about the many resources we currently offer to help members get the mental health and substance use support they need, please visit allwayshealthpartners.org/members/behavioral-health.
More information about Lyra will be provided to our customers in the coming months.
Cultural competency training for providers
Visit Health Equity Resources on the Provider Resources page at allwayshealthpartners.org/providers/provider-resources to explore free online training options regarding Cultural Competency. There is also an opportunity to earn credits depending on the program.
According to the training offered by the Department of Health and Human Services, “the e-learning program will equip you with the knowledge, skills, and awareness to best serve all patients, regardless of cultural or linguistic background”.
You may also sign up for the free virtual conference on May 23rd-24th offered by Mass General Brigham: Achieving Research Equity & Inclusion
Reminder: Allies expansion
We've officially expanded AlliesSM to Salem Hospital. This is another way that we are creating a highly integrated model of value-based care and transforming the healthcare experience with Mass General Brigham.
Starting on June 1, this high-performance network product will be offered to small and large groups within the Salem Hospital service area. The offering will feature Salem Hospital PCPs and specialists—in addition to those at Newton-Wellesley Hospital—to provide world-class care and an exceptional customer experience at lower costs.
Mobile cardiac outpatient telemetry authorization clarifications
Please be advised that the following outpatient cardiac monitoring modalities with CPT codes do not require authorization:
Holter monitoring
CPT codes: 93224-93227
Event Recorder (including Zio Patch) or |External Loop Recorder (ELR)
CPT codes: 93241-93248; 93268; 93270-03271
If these testing modalities are appropriate to evaluate your patient, please request these codes through your vendor to prevent unnecessary delays.
Please be advised the following CPT codes require authorizations and medical necessity is determined through InterQual criteria:
Annual updates to physician and outpatient fee schedules
AllWays Health Partners reviews its physician and outpatient fee schedules quarterly, to ensure that they are current, comprehensive and consistent with industry standards, to the extent supported by its systems. In most cases, changes involve adding fees for new or existing codes to supplement the fees already on the fee schedule.
Consistent with prior years, AllWays Health Partners updated its Commercial/PPO physician, ambulance, drug, DME, laboratory, radiology and outpatient hospital fee schedules to incorporate new codes, effective January 1, 2022.
With a few exceptions, AllWays Health Partners will continue to base fees on the Centers for Medicare & Medicaid Services (CMS) and MassHealth fee schedules, adjusted to achieve the contracted level of reimbursement.
Commercial/PPO Physician Fee Schedules
• Rate updates to existing CPT and HCPCS codes will occur on July 1, 2022.
• AllWays Health Partners will continue to base physician reimbursement on CMS RVU’s & anesthesia conversion factor.
• AllWays Health Partners will continue to base drug, vaccine and toxoid reimbursement on CMS Part B levels, as indicated on the CMS Part B drug quarterly notices. If no CMS pricing is available, drug pricing will be set in relation to average wholesale price (AWP). Reimbursement for vaccines and toxoids will continue to be updated on a quarterly basis.
• AllWays Health Partners will continue to base DME reimbursement on the CMS DME POS/PEN fee schedules.
Commercial/PPO Outpatient Fee Schedules
• Consistent with prior years, reimbursement will be based on a combination of outpatient, ancillary and surgical fee schedules.
• AllWays Health Partners will continue to base drug, vaccine and toxoid reimbursement on CMS Part B levels, as indicated on the CMS Part B drug quarterly notices. If no CMS pricing is available, drug pricing will be set in relation to average wholesale price (AWP). Reimbursement for vaccines and toxoids will continue to be updated on a quarterly basis.
• AllWays Health Partners will continue to base DME reimbursement on the CMS DME POS/PEN fee schedules.
My Care Family Fee Schedules
• AllWays Health Partners will continue to base physician reimbursement on MassHealth published rates, where published rates exist.
• Consistent with prior years, AllWays Health Partners updated its Medicaid physician, ambulance, drug, DME, laboratory, radiology and outpatient hospital fee schedules to incorporate new codes, effective January 1, 2022. Rate updates to existing CPT and HCPCS codes will occur within 30 days of receipt of notification of rate change from MassHealth.
Medical policy updates
Three medical policies were reviewed and passed by the AllWays Health Partners Medical Policy Committee. These policies are now posted to allwayshealthpartners.org. The table below is a summary of the policies and the changes.
For more information or to download our medical policies, go to allwayshealthpartners.org/providers/medical-policies and select the policy under the medical policy listings.
Code updates
The following services as a reminder to the network are not covered for all lines of business:
Drug code updates
The following drug(s) are now covered under the medical benefit with prior authorization for Commercial (including ASO) lines of businesses only.
Please see the coverage summary for Jan 2022 Codes as below:
Formulary updates: effective 07/01/2022
Definitions
- Formulary: These drugs are included in AllWays Health Partners’ covered drug list.
- Non-Formulary: These drugs are not included in AllWays Health Partners’ formulary. AllWays Health Partners would only cover formulary alternatives. Providers can request Non-Formulary drugs as an exception, and AllWays Health Partners would require trial of all appropriate formulary alternatives prior to approving coverage of a Non-Formulary drug. If a Non-Formulary drug is approved, the member’s cost sharing would be the highest tier.
- Preferred: These drugs are on AllWays Health Partners’ formulary and offer a lower cost to members.
- Non-Preferred: These drugs are on AllWays Health Partners’ formulary but offer a higher cost to members.
- Excluded: AllWays Health Partners does not cover these drugs. Members will receive a denial for all Excluded drug requests.
Updates for My Care Family Members
The following changes are being made to the listed medications:
MassHealth Unified Pharmacy Product List (UPPL) Updates
