Your source for important provider news and updates.
August 2024
Office Visit
Feature Stories
It’s widely accepted that an ounce of prevention is worth a pound of cure. Yet many people struggle with adopting lifestyle changes that can help lower their risk of developing chronic conditions and other adverse health issues.
For some, a lack of knowledge stands in their way. They do not know what their measures are, what they mean, and what they should do. For others, they know what they should do but lack the motivation to act.
That is why WellSpark Health is part of the EmblemHealth family of companies. WellSpark offers wellness programs and resources to adults (over age 18). These services support our provider community by helping your patients implement their preventive care recommendations.
We are committed to meeting our members where they are to support them in their health care journeys. We have begun offering the WellSpark programs and resources with some of our health plans in addition to working directly with employer groups. We have updated the 2024 Summary of Companies, Lines of Business, Networks, & Benefit Plans to show you which benefit plans may use the program.
We ask that you use this summary and encourage eligible members to take advantage of the resources available to them. Members can get to these resources by signing in to their member portal.
Learn more about WellSpark resources that may be available:
As announced last month, we are working on provider portal enhancements that will allow users to save draft preauthorization requests and emergent inpatient admission notifications (requests/notices). This will allow you time to collect the clinical information or hand off the case to someone who has the clinical expertise to address the clinical criteria and supporting documentation.
While we are developing the new portal feature, we would like to make some recommendations to help you prepare for this new way of creating a request/notice.
Note: One user will still be able to complete a request, from start to finish in one sitting if they have all the necessary information. This new portal update, though, is designed to help organizations that divide responsibilities between nonclinical and clinical staff.
You should make sure:
- Everyone who may contribute to a request/notice is set up with a provider portal account and assigned to the Administrator/Office Manager or Clinical Staff role.
- Workflows are in place so there are clear hand-offs and responsibilities defined so request/notice drafts are completed and submitted within the 96-hour time frame.
- Workflows are in place for addressing expired drafts.
- Staff responsible for adding clinical information are trained on finding incomplete drafts, addressing clinical criteria, and attaching supporting documentation.
- Everyone is aware that the portal will not allow a request to be submitted without expected clinical criteria addressed and supporting documents attached.
- Everyone is aware that once a draft expires, a new request/notice will need to be entered.
To help you manage the new process, we will send an email to the person identified in a draft request/notice as the Contact to remind them that there are incomplete drafts that require their attention. We will also send them an email when any of their drafts expire.
By the year 2030, adults aged 65 and older are projected to outnumber children for the first time in U.S. history.
Promoting health and preventing disease in older Americans is key to the nation’s health. As we age, physical and cognitive function may decline, and pain may affect quality of life. Older people may also have more complex medication regimens.
Here are some best practices to consider to help your 65-and-over patients age healthfully:
- Incorporate a standardized checklist to capture functional status, pain status, and any medications the member may take.
- Complete a functional status assessment and pain assessment at every face-to-face and telehealth visit.
- Ensure the medical record contains the member’s medication list.
- Document in the medical record if the member is not taking any medication.
The Centers for Disease Control and Prevention’s (CDC) Still Going Strong campaign speaks directly to older adults and their caregivers. Resources are available to download and share. Please also see information about EmblemHealth’s free Care for the Older Adult Program.
Raising awareness about preventable injuries among older adults, how common injuries can be prevented, and simple steps people can take to stay healthy and independent longer can be found in the campaign. Getting older doesn’t mean your patients have to give up the activities they enjoy.
The Office of Inspector General (OIG) Office of Audit Services has identified acute stroke and sepsis as not supported in an outpatient setting. These conditions are typically treated in an inpatient hospital setting and rarely, if ever, occur in an outpatient setting.
EmblemHealth and ConnectiCare recognize the need for accurate coding and documentation. It’s an important part of patient care. We have taken the OIG Office of Audit Service findings into consideration and are making updates to our claims processing system.
Starting Dec. 6, 2024, we will deny any claims that have a diagnosis of acute stroke (I63.-) or sepsis (A41.-) when billed with the following place of service (POS) codes.
- Office (POS 11).
- Telehealth (Use POS 2 when patient and provider are in a facility; POS 10 for patients at home).
- On Campus - outpatient hospital (POS 22).
- Skilled nursing facility (POS 31).
- Federally Qualified Health Center (POS 50); Off-campus outpatient hospital (POS 19).
The denial reason will be listed as “diagnosis/place of service mismatch.”
We appreciate your assistance with this important issue. If you have questions or concerns, sign in to emblemhealth.com/providerportal or connecticare.com/providerportal and please use our live agent chat or Message Center to contact us. A Provider Customer Service representative will be happy to help.
See coding edits policies:
ConnectiCare: Coding Edits Policy
EmblemHealth: Coding Edits Policy
Thank you for your partnership and the care you provide our members.
EmblemHealth and ConnectiCare are dedicated to delivering high-quality service to our valued members. As part of this commitment, we’ve enhanced the Quality Measure Resource Guide to not only ensure that our members receive proper care but also provide you with a toolkit that simplifies understanding and compliance of quality measures. This guide will help you satisfy national and state quality measures* that evaluate various domains of preventive, acute, and chronic care. Our updated 2024 Quality Measure Resource Guide provides details of quality measures, description of documentation/coding, best practices, and steps to close care gaps.
JP66620