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Federal changes providers should know about in the new year
There are two federal changes that impact the health care industry, effective January 1, 2022: the No Surprises Act (as part of the Consolidated Appropriations Act of 2021) and the Transparency in Coverage rule. Both directly apply to commercial and self-insured coverage. Continue reading to learn more about how these federal changes impact you as a provider.
In this issue:
- Verify your directory entry
- Mandated reimbursement for services related to testing and treatment for COVID-19
- Site of service feature
- Hospital inpatient utilization report
- New ID cards
- My Care Family transplant process
- Annual Updates to Physician and Outpatient Fee Schedules
- Available provider resources
- Medical policy updates
- Code updates
Verify your directory entry by completing survey
AllWays Health Partners is performing an annual assessment on the accuracy of data in our provider directory. In order to better support our members and providers, we ask that you verify that your directory entry is complete and correct.
Complete your provider directory survey here.
Mandated reimbursement for services related to testing and treatment for COVID-19
AllWays Health Partners will adopt DOI-mandated reimbursement levels for COVID-19 testing and treatment. We will not make any adjustment to these rates. We are also in the process of completing a retrospective review of payments to resolve administrative coding issues related to COVID-19 testing and vaccine administration. We will provide more information when it is available.
Site of service
As of January 1, 2022 many of our merged market Complete plans will include a site of service feature, which offers lower cost sharing for high tech radiology and outpatient surgery services when members have them at non-hospital based facilities.
Members can find lower cost facilities by searching "diagnostic imaging center" or "ambulatory surgical center" in our provider directory.
Click here for more information, or find it in the provider portal on the plan information page for participating members.
Hospital inpatient utilization report
The latest quarterly hospital inpatient utilization report is now available. To review this report, click on the Reports tab in the Provider Portal and select Clinical Reports. If you do not have access to the Provider Portal, you may register online at allwaysprovider.org.
New ID Cards
Take a look at our new 2022 member ID cards your patients will be bringing to their upcoming appointments. Also, remember to check eligibility because many members change coverage this time of year.
My Care Family transplant process
For transplant authorization dates on or after January 15, 2022, please submit all transplant claims for My Care Family members directly to AllWays Health Partners. Optum will no longer be processing these claims on our behalf.
For information about submitting claims to AllWays, visit
allwayshealthpartners.org/providers/claims-information.
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 will update its Commercial/PPO 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 on July 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
- AllWays Health Partners will continue to base physician reimbursement on CMS RVU’s.
- 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.
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.
My Care Family Fee Schedules
- AllWays Health Partners will continue to base physician reimbursement on MassHealth published rates, where a published rate exists.
- Consistent with prior years, AllWays Health Partners will update 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.
Available provider resources
Our website (provider.allwayshealthpartners.org) provides you with important resources and information to support you and your staff. Here's a sample of what resources are available:
Clinical Resources:
- Medical Policies - Medical policies provide you with the coverage criteria for specified conditions. You can find more information on the utilization management (UM) decision making process and how to obtain UM criteria in the Provider Manual.
- Clinical Contact Information - Clinical staff is available at 855-444-4647 Monday-Friday (8:30 AM - 5:00 PM). After hour coverage is available after 5 PM on weekdays and on the weekends.
- Case Management Programs - You can get more information on specific programs and how you can refer a member into one of our case management programs. Providers can refer by emailing caremanagement@allwayshealth.org
- Tobacco Cessation - For members who are trying to quit tobacco, we offer a tobacco cessation program run by our Certified Tobacco Treatment Specialists. Providers can refer by email: quitsmoking@allwayshealth.org
- Health Coaching - Health coaching is available for members trying to improve eating habits, increase their physical activity, manage weight and decrease stress. Our health coaches have all completed the rigorous Wellcoaches® school of coaching training program. Providers can refer by emailing: healthandwellness@allwayshealth.org
Provider Manual
The Provider Manual includes important information on how you can support your patient. Topics in the Provider Manual include:
- Quality Improvement Program
- Utilization Management Decision-Making - This includes information regarding our decision-making process and procedures. We do not specifically reward practitioners or other individuals conducting utilization review for issuing denials of coverage or service, nor do we provide financial incentives to UM decision-makers to encourage decisions that result in under-utilization.
- Credentialing and Recredentialing Processes
- Member Rights & Responsibilities
- Practitioner Rights & Responsibilities
- Interpreter Services
Pharmacy Benefit Program
Our website gives you the most up-to-date information about our Pharmacy programs, covered medications and the current medical necessity criteria. Pharmacy programs include:
- Excluded Medication - A medication which is considered to be excluded from the pharmacy benefit.
- Pharmacy & Therapeutics Committee - This Committee is chaired by the Medical Director responsible for pharmacy and is composed of practicing pharmacists and practicing providers with varying specialties, including behavioral health, internal medicine and pediatrics. It meets regularly throughout the year, no less frequently than quarterly.
- Prior Authorization - A pharmacy program which limits access to a medication by establishing criteria for appropriate use of a medication. These criteria must be met and documentation sent to us before the medication will be covered. Prior authorization is also required for exception to our mandatory generic medication pharmacy benefit.
- Quantity Limit - A pharmacy program that limits the number of units per time period for a specific medication based on recommended doses.
- Step Therapy - A pharmacy program which allows patients who meet criteria to have coverage for their prescription adjudicate without review based on available medication history.
- Mandatory Generic - A pharmacy program which requires a trial of an FDA approved generic substitution for a brand name medication, if it is available.
- Tier Placement - A pharmacy program that places medications in one of six co-payment tiers for benefit plans with a six-tier pharmacy benefit.
- Therapeutic Interchange/Substitution - A pharmacy program that involves the dispensing of a chemically different drug, considered therapeutically equivalent, i.e., will achieve the same outcome, in place of a drug originally prescribed by a physician. The drugs are not generically equivalent. Therapeutic substitutions are done in accordance with procedures and protocols set up and approved by physicians in advance. Therefore, the pharmacist would not have to seek the prescribing physician's approval for each interchange.
Medical policy updates
Six 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 https://www.allwayshealthpartners.org/providers/medical-policies and select the policy under the medical policy listings.
Code updates
New CPT codes
HCPCS codes
