May 1, 2024

May 2024 Provider Newsletter

Featured Articles

Digital SolutionsMedicare AdvantageMedicaidMay 1, 2024

Digital Request for Additional Information is now available for all lines of business

AdministrativeMedicare AdvantageMedicaidApril 22, 2024

2023 Advancing Health Together: Progress Report released

PharmacyMedicare AdvantageMedicaidApril 5, 2024

CarelonRx, Inc. Mail changed to CarelonRx Pharmacy on January 1, 2024


Administrative

AdministrativeMedicare AdvantageMedicaidApril 22, 2024

2023 Advancing Health Together: Progress Report released

AdministrativeMedicare AdvantageMedicaidMay 1, 2024

Inaccurate laterality and diagnosis combination

Digital SolutionsMedicare AdvantageMedicaidMay 1, 2024

Roster automation update

Digital SolutionsMedicare AdvantageMedicaidMay 1, 2024

Digital Request for Additional Information is now available for all lines of business

Digital SolutionsMedicare AdvantageMedicaidApril 26, 2024

Introducing new functionality for non-medical providers

Digital SolutionsMedicare AdvantageMay 1, 2024

Personalized Match update

Behavioral Health

Behavioral HealthMedicaidApril 1, 2024

Attention: Applied behavior analysis providers

Education & Training

Education & TrainingMedicaidJanuary 1, 2024

Ready, set, renew!

Education & TrainingMedicare AdvantageMedicaidMay 1, 2024

Rotary to ground educational message

Policy Updates

Policy UpdatesMedicaidApril 24, 2024

Clinical Criteria updates — November 2023

Policy UpdatesMedicaidApril 19, 2024

Carelon Medical Benefits Management, Inc. updates

Reimbursement PoliciesMedicaidMarch 1, 2024

Applied behavior analysis providers

Products & Programs

PharmacyMedicare AdvantageApril 8, 2024

Wellpoint expands specialty pharmacy precertification list

PharmacyMedicare AdvantageMedicaidApril 5, 2024

CarelonRx, Inc. Mail changed to CarelonRx Pharmacy on January 1, 2024

Quality Management

Quality ManagementMedicaidMay 1, 2024

Take action to improve adolescent immunizations rates

Quality ManagementMedicaidMarch 26, 2024

HEDIS spotlight

WAWP-CDCR-056131-24

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

AdministrativeMedicare AdvantageMedicaidApril 22, 2024

2023 Advancing Health Together: Progress Report released

Discover how a focus on whole health in partnership with care providers drives outcomes

With 80% of health driven by what happens outside the doctor’s office1, healthcare is not just about treatments and tests; it’s about caring for the entire person.

The Advancing Health Together: Progress Report summarizes the meaningful, measurable progress that Wellpoint’s parent company, Elevance Health, and its care provider partners achieved together in 2023. We’re improving whole health one person at a time, going beyond contractual agreements to create a real impact together.

Delivered via a dynamic website, the 2023 report features videos and engaging content detailing how we’re working with care providers to improve whole health for the people and communities we mutually serve by:

  • Committing to whole health: To truly advance whole health, we must look at the physical, social, behavioral, and pharmacy drivers of each person’s health, as well as any health inequities that may exist for them.
  • Contracting for outcomes: Changing how healthcare is paid for may be the single most impactful lever for improving the healthcare system. We are “all in” on leading the move to value-based reimbursement.
  • Collaborating for success: Advancing health together means supporting care providers by lessening their administrative burden and providing the data, insights, and tools they need to deliver exceptional care.
  • Connecting for health: Connecting the dots when a patient needs care outside of the care provider’s office helps ensure they receive the right service at the right time in the right place, seamlessly — making it easier to deliver whole health.

Learn about our active approach to care provider partnerships and the meaningful progress we're making together to improve the health of humanity by visiting advancinghealth.elevancehealth.com.

1 U.S. Department of Health and Human Services. Community Health and Economic Prosperity: The Problem, the Causes, the Opportunities, and the Solutions—At a Glance (January 2021): hhs.gov/sites/default/files/chep-sgr-at-a-glance.pdf.

Coverage provided by Wellpoint Washington, Inc.

MULTI-WP-CDCR-056366-24-CPN54413

AdministrativeMedicare AdvantageMedicaidMay 1, 2024

Inaccurate laterality and diagnosis combination

Providers must code their claims to the highest level of specificity in accordance with industry standard coding guidelines such as ICD-10-CM coding guidelines and reporting. When an ICD-10-CM diagnosis code has a specified laterality within the code description, the modifier that is appended to a CPT® or HCPCS code must correspond to the laterality within the ICD-10-CM description.

On a CMS 1500 form, for professional submitted claims processed on or after June 1, 2024, Wellpoint will apply these correct coding ICD-10-CM guidelines and deny claim lines that have a laterality diagnosis submitted with a CPT or HCPCS modifier that does not correspond to the diagnosis.

See examples below

Reported diagnosis: E11.3593 (Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral):

  • Billed CPT code: 67228-RT Treatment of extensive or progressive retinopathy (for example, diabetic retinopathy), photocoagulation.
  • Determination: It is not appropriate to report the RT modifier when the laterality of bilateral is identified in the ICD-10-CM diagnosis. Therefore, the claim line will be denied.

Reported diagnosis: S91.011A (Laceration without foreign body, right ankle, initial encounter):

  • Billed CPT code: 27786-LT (Closed treatment of distal fibular fracture: lateral malleolus; without manipulation)
  • Determination: It is not appropriate to report a LT modifier when the laterality of right is identified in the ICD-10-CM diagnosis. Therefore, the claim line will be denied.

Additionally, the ICD-10-CM diagnosis code should correspond to the medical record, CPT, HCPCS code(s), and/or modifiers billed.

Wellpoint will continue to enhance its editing system to automate edits and simplify remittance messaging supported by correct coding guidelines. The enhanced editing automation will promote faster claim processing and reduce follow-up audits and/or record requests for claims not consistent with correct coding guidelines.

EOB message

Diagnosis codes with a specified laterality description should be submitted with the appropriate modifier of specificity and procedure code. Ex codes: v19 and 00V19

If you have questions about this communication or need assistance, contact your provider relationship account manager. We are committed to a future of shared success.

Coverage provided by Wellpoint Washington, Inc.

WAWP-CDCR-057423-24-CPN52942

AdministrativeMedicare AdvantageMay 1, 2024

Carelon Post Acute Solutions, LLC will begin operating as Carelon Medical Benefits Management, Inc.

On April 1, 2024, Carelon Post Acute Solutions, LLC (formerly known as myNexus) began operating as Carelon Medical Benefits Management, Inc.

Provider materials that formerly included the Carelon Post Acute Solutions name, such as determination letters and provider forms, have adopted the new name. However, there will be no changes in the way you submit a case nor to the contact information you use for checking case status.

Please see below for a list of FAQ. Additional questions can be directed to our Health Care Networks team using the contact information below:

  • Home health providers: HHprovider_relations@carelon.com
  • Post-acute institutional management (PAC-IM) providers: PACprovider_relations@carelon.com
  • Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) providers: DMEprovider_relations@carelon.com

Thank you for your continued partnership.

Carelon Medical Benefits Management transition FAQ

Q: Will there be any changes to the Carelon Post Acute Solutions provider website?

A: The name of our website has been updated to reflect Carelon Medical Benefits Management branding. Additionally, the web address you use today will automatically redirect to a new Carelon Medical Benefits Management site. There will be no changes to the case submission process.

Q: Are any phone number changes planned as part of this transition?

A: No, our inbound phone numbers will not change. The reference to Carelon Post Acute Solutions in recorded scripting will use the Carelon Medical Benefits Management name.

Q: How will third party websites, such as Availity, be impacted?

A: There will be no change to the way you access these websites. Within the sites, any reference to Carelon Post Acute Solutions will be replaced with the new name. This may take some time to fully complete.

Q: Will references to Carelon Post Acute Solutions on health plan websites and other materials be changed?

A: Yes, while you may continue to see the Carelon Post Acute Solutions company name on health plan websites for some time, these references will be updated over time through scheduled content update cycles. If your office includes the Carelon Post Acute Solutions name in any materials or web properties, we encourage you to update them to Carelon Medical Benefits Management during your next update cycle.

Q: Will information about Carelon Post Acute Solutions continue to be found on the corporate website?

A: Yes, post-acute care will be part of the Carelon Medical Benefits Management portfolio of solutions. You can learn more at careloninsights.com.

Q: Will provider resources, such as key documents and the provider finder, be impacted?

A: Our provider resources will continue to be available through our corporate website and our Provider Resources site.

Q: Does this impact provider agreements with Carelon Post Acute Solutions? Will I need to sign a new agreement?

A: No, there is no impact to provider agreements. You do not need to sign a new agreement regardless of whether your current contract is with MyNexus, Inc. or Carelon Post Acute Solutions.

Q: Do I need to complete credentialing again through Carelon Medical Benefits Management?

A: No, providers will not need to re-credential until their normal credentialing cycle.

Q: Will my claims be impacted?

A: No, claims are not impacted. Payer IDs will remain the same.

Q: Will I need to update my W-9?

A: Providers may need to update their W-9. If you need an updated W-9 from Carelon Medical Benefits Management, please contact the Carelon Provider Relations department at HHprovider_relations@carelon.com.

Coverage provided by Wellpoint Washington, Inc.

MULTI-WP-CR-054835-24-CPN53974

Digital SolutionsMedicare AdvantageMedicaidMay 1, 2024

Roster automation update

Roster Automation is our technology solution designed to streamline and automate provider data additions, changes, and terminations that are submitted using a standardized Microsoft Excel template.

On March 29, we introduced a new Roster Automation functionality on the Upload Roster File page of Availity PDM. With this enhancement, you can view:

  • Date received and status of rosters submitted in the last 12 months.
  • Errors in submitted rosters that result in the need of manual intervention to process. The types of issues included in the error report will be incorrectly formatted data and required data elements that are missing from the roster.

Understanding the errors made when completing a roster allows you to ensure subsequent submissions do not contain those issues. Error-free rosters reduce the need for manual intervention, which improves data accuracy and processing time.

As you learn how to use the information available in the new error reports, we will continue to correct issues on your behalf.

In the future, you will need to correct any errors submitted in a roster (for example, missing data, incorrectly formatted data). Rows in a roster that contain an error will not be processed and the addition, change, or termination will not be updated in our systems. More information about when you will need to correct errors, and how to do so, will be sent in future communications and covered in future virtual webinars.

Utilize the Roster Submission Guide

Find it online: On Availity.com > Payer Spaces > Select Payer Tile > Resources > Roster Submission Guide using Provider Data Management.

Coverage provided by Wellpoint Washington, Inc.

MULTI-ALL-CDCR-057943-24-CPN57211

Digital SolutionsMedicare AdvantageMedicaidMay 1, 2024

Digital Request for Additional Information is now available for all lines of business

Digital Request for Additional Information (RFAI) is the easiest way to submit attachments requested by your payer using Availity Essentials. There is no need to fax or mail paperwork to complete your claim submissions anymore; just use the digital channels provided for your organization.

Availity Essentials notification center

The notification center is located on the top of the Availity Essentials homepage. If your payer has requested documentation, there will be a message stating there are requests in your work queue. Simply select the hyperlink to be navigated to the Attachment Dashboard to view the request.

Availity Essentials Attachment Dashboard

The Attachment Dashboard is where all attachment requests are displayed. You can use the hyperlink in the notification center or navigate to Claims & Payments > Attachments New.

To locate a specific RFAI request, the request number will begin with RFAI. If you notice multiple requests in your dashboard, take advantage of the filters. You have the option to search, filter, and sort for multiple values, such as Tax ID, NPI, and Request Type.

Select Upload Attachment to view the type of document requested. Your uploaded requests will be visible in the History tab once accepted. Select the Record History icon on the right side of the request to view the Availity Transaction ID for specific Availity Essentials questions or Health Plan Transaction ID if you need to contact your payer for questions.

Get trained

Availity Essentials has training on-demand. This includes a pre-check for administrators and a Learn How to Submit Digital Requests for Additional Information training. Log in to Availity Essentials > Help & Training > Get Trained > enter RFAI in the keyword search.

If you have questions, call Availity Client Services at 800-Availity (800-282-4548). Availity Client Services is available Monday to Friday, 8 a.m. to 8 p.m. ET.

With your help, we can continually build toward a future of shared success.

Coverage provided by Wellpoint Washington, Inc.

WAWP-CDCR-052603-24-CPN52155

Digital SolutionsMedicare AdvantageMedicaidApril 26, 2024

Introducing new functionality for non-medical providers

Save time and get faster results by using Availity Essentials to submit disputes for atypical care providers.

As part of our ongoing efforts to optimize and enhance the Claims Status application in Availity Essentials, we recently launched the ability for non-medical/atypical care providers — such as providers of non-emergency transportation, case management, or environmental modifications — to use the Dispute functionality in the enhanced Claims Status app. This new functionality allows atypical care providers to be more efficient and accurate in their dispute submission process.

Below are a few simple and important steps and reminders to follow for the best experience and results.

First step

Register with Availity Essentials

Non-medical/atypical care providers can submit a dispute using Availity Essentials. Care providers need to first register an organization with Availity Essentials, ensuring an administrator is chosen and their provider information — including tax ID — is added to Manage My Organization.

Once the organization is set up as Non-Medical/Atypical on Availity Essentials, it can use various functions, such as submitting disputes. Atypical care providers do not use an NPI to bill claims; therefore, it's important that the setup is completed.

Second step

Go to the Claims Status app:

  • Navigate from the home page to Claims & Payments > Claim Status > select your organization and payer > Claim Status Inquiry page will open.
  • When Manage My Organization has been completed, you can select the care provider from the drop-down menu and the tax ID field will display.
  • Complete an inquiry by entering the required fields and selecting Submit for requested claims to display.

Third step

Select Dispute

To complete a dispute:

  • Locate the claim and, if there is an option to appeal, select Dispute to initiate.
  • Select Go to details to be navigated to the Appeals Application.
  • Locate your initiated dispute and select the action menu to complete the dispute request.
  • Choose the request reason, upload supporting documents, and submit the request.

Once completed, your progress will appear in the Notifications Center on the Availity Essentials home page when Web is selected in the contact field.

Explore training and resources

We are here to support you along the way through on-demand training and resources.

Availity Essentials offers keyword search assistance with the option to attend live or recorded demos:

  • On the Availity Essentials home page, select Help & Training, then select Get Trained to register for upcoming live and recorded training demos for all Availity Essentials capabilities.
  • Use the search bar to locate specific appeals training.
  • The Availity Learning Center user guide will assist with how to locate training.

For questions, contact Availity Client Service:

  • Online: Help & Training > Availity Support > Contact Support > Create a case or Chat with Support
  • By phone: Call 800-AVAILITY (282-4548) Monday through Friday from 8 a.m. to 8 p.m. Eastern time

Coverage provided by Wellpoint Washington, Inc.

WAWP-CDCR-054934-24-CPN54404

Digital SolutionsMedicare AdvantageMay 1, 2024

Personalized Match update

Find Care, the doctor finder and transparency tool in the Wellpoint online directory, provides Wellpoint members with the ability to search for in-network providers using the secure member website. This tool currently offers multiple sorting options, such as sorting providers based on distance, alphabetical order, and provider name.

We previously introduced you to Personalized Match, an additional Find Care sorting option for Medicare Advantage members, which was based on provider efficiency and quality outcomes, in addition to member search radius. Personalized Match was initially limited to PCP searches and was later expanded to include certain specialists.

Beginning in June 2024 or later, we will further enhance Personalized Match. Provider availability and STARS rating scores will now more directly influence provider rankings. Additionally, provider recommendations will be driven in part by knowledge about member history derived from claims and other available clinical data. Personalized Match will continue to display providers with the highest overall ranking within the member’s search radius at the top of search results. Members may continue to sort based on distance, alphabetical order, and provider name:

  • A copy of the Personalized Match phase two methodology will be posted in Availity in the coming weeks.
  • If you have general questions regarding this new sorting option, please submit an inquiry via the web at Availity.
  • If you would like information about your quality or efficiency scoring used as part of this sorting option or if you would like to request reconsideration of those scores, you may do so by submitting an inquiry to Availity.

Wellpoint will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized healthcare decisions. We are committed to helping patients more easily access the care they need.

Services provided by Wellpoint Washington, Inc.

MULTI-WP-CR-052332-24-CPN52048

Digital SolutionsMedicare AdvantageMedicaidApril 15, 2024

Coming soon — Submit behavioral health authorizations through the Authorization application on Availity

Soon, you will be able to submit all your authorizations in one application on Availity.com.

You may already be submitting your physical health authorizations through the Availity Essentials multi-payer Authorization application — taking advantage of the time savings and speed to care through digital authorization submissions. You will soon be able to submit both your physical health and behavioral health authorizations through one Authorization application on Availity.com.

Using the Availity Authorization application to submit your behavioral health authorizations will not be much different from the process you follow today. You may enjoy more intuitive screens or learn sooner if an authorization is required, but the digital submission process is still the best way to submit your authorization requests and the fastest way to care for our members.

You will continue to use Interactive Care Reviewer (ICR) to submit an appeal or authorization for medical specialty prescriptions.

Accessing the Availity Authorization application is easy. Ask your organization’s Availity administrator to ensure you have the Authorization role assignment. Without the role assignment, you will not be able to access the Authorization application. Then, log on to Availity.com to access the app through the Patient Registration tab by selecting Authorizations and Referrals.

Training is available

Training is available for the Availity Authorization application. Once registered with the authorization role assignment, visit the training site to enroll for an upcoming live webcast or to access an on-demand recording at the Availity Authorization Training Site.

We are focused on reducing administrative burdens, so you can do what you do best — care for our members.

Coverage provided by Wellpoint Washington, Inc.

WAWP-CDCR-049448-23-CPN48753

Behavioral HealthMedicaidApril 1, 2024

Attention: Applied behavior analysis providers

This article was updated as of July 11, 2024.

This notice provides an update to the June 2023 provider alert regarding which applied behavioral analysis (ABA) care providers must enroll with the Medicaid program, Apple Health, and which individual care providers must be identified as servicing care providers on ABA claims.

Care providers who render services to Apple Health clients must be enrolled with the Health Care Authority (HCA) under the billing care providers’ Core Provider Agreement (CPA) — See WAC 182-502-0005(2). All ABA care providers, including certified behavior technicians (CBTs) and licensed assistant behavior analysts (LABAs), must be enrolled with Apple Health as a servicing care provider (also known as rendering or performing provider) and their NPI must be listed on claims for services provided.

Effective July 1, 2024, all CBTs and LABAs working with Apple Health clients must meet the following requirements:

  • Have an active CBT or LABA license with the Department of Health (DOH).
  • Have an NPI.
  • If part of a healthcare group or organization with a CPA, enroll with HCA as a servicing care provider or non-billing care provider under the group’s CPA.
  • If applicable, be listed as a servicing care provider on the healthcare group’s roster submitted to the MCO.
  • For dates of service on and after July 1, 2024, have their NPI captured on the claim as the servicing care provider for services rendered.

Additional information:

Email aba@hca.wa.gov with any questions or comments.

Services provided by Wellpoint Washington, Inc.

WAAGP-CD-041239-23, WAWP-CD-049209-24, WAWP-CD-050917-24, WAWP-CD-052819-24, WAWP-CD-055808-24, WAWP-CD-060501-24, WAWP-CD-057272-24

Education & TrainingMedicaidJanuary 1, 2024

Ready, set, renew!

It’s time for some of your patients to renew their Medicaid benefits. As states begin to recommence Medicaid renewals, we want to ensure you have the information needed to help your Medicaid patients renew their healthcare coverage. Some patients have never had to renew their coverage at all, while other patients may have forgotten the process entirely.

We’re here to help.

What steps do my patients need to take?

  • Ready: Patient gets their documents ready.
  • Set: Patient ensures their form is all set.
  • Renew: Patient sends renewal form:

What if I need assistance?

Availity Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity Essentials,* go to availity.com and select the appropriate payer space tile from the drop-down. Then, select Chat with Payer and complete the pre-chat form to start your chat.

For additional support, visit the Contact Us section at the bottom of our provider website for the appropriate contact.

* Availity, LLC is an independent company providing administrative support services on behalf of the health plan.

Services provided by Wellpoint Washington, Inc.

CPN16407, WAAGP-CD-017950-22, WAWP-CD-047522-23-CPN047298, WAWP-CD-039578-23, WAWP-CD-056733-24-CPN56608

Education & TrainingMedicare AdvantageMedicaidMay 1, 2024

Rotary to ground educational message

When determining transportation to an alternative hospital and to help avoid medical necessity denials for rotary wing air ambulance transports to another hospital, please remember the criteria below.

The use of air and water ambulance services is considered medically necessary when all the following criteria are met:

  1. The ambulance must have the necessary equipment and supplies to address the needs of the individual; and
  2. The individual’s condition must be such that any form of transportation other than by ambulance would be medically contraindicated; and
  3. The individual’s condition is such that the time needed to transport by land poses a threat to the individual’s survival or seriously endangers the individual’s health*; or the individual’s location is such that accessibility is only feasible by air or water transportation; and
  4. There is a medical condition that is life threatening, or first responders deem to be life threatening, including, but not limited to, the following:
    1. Intracranial bleeding; or
    2. Cardiogenic shock; or
    3. Major burns requiring immediate treatment in a burn center; or
    4. Conditions requiring immediate treatment in a hyperbaric oxygen unit; or
    5. Multiple severe injuries; or
    6. Transplants; or
    7. Limb-threatening trauma; or
    8. High risk pregnancy; or
    9. Acute myocardial infarction; if this would enable the individual to receive a more timely medically necessary intervention (such as percutaneous transluminal coronary angioplasty [PTCA] or fibrinolytic therapy).

* Air transportation may be appropriate if the time between identification of the need for transportation until arrival at the intended destination for ground ambulance would be at least 30 minutes longer than air transport.

For additional details on Clinical UM Guideline CG-ANC-04 Ambulance Services: Air and Ground, please visit the Wellpoint provider site.

Clinical UM guidelines are subject to change. Administrative services only (ASO) accounts may utilize alternate criteria. All terms and conditions of the member’s benefit plan apply.

For more information please contact Provider Services:

Medicaid — 833-731-2274
Medicare Advantage — 866-805-4589

Coverage provided by Wellpoint Washington, Inc.

WAWP-CDCR-057447-24-CPN51828

Policy UpdatesMedicaidApril 24, 2024

Clinical Criteria updates — November 2023

Summary

On February 24, 2023, and November 17, 2023, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Wellpoint. These policies were developed, revised, or reviewed to support clinical coding edits.

Visit Clinical Criteria to search for specific policies. If you have questions or additional information, use this email.

Please see the explanation/definition for each category of Clinical Criteria below:

  • New: newly published criteria
  • Revised: addition or removal of medical necessity requirements, new document number
  • Updates (marked with an asterisk [*]): notate that the criteria may be perceived as more restrictive

Please share this notice with other providers in your practice and office staff.

Please note:

  • The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
  • This notice is meant to inform the provider of new or revised criteria that has been adopted by Wellpoint only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.

Effective date

Clinical Criteria number

Clinical Criteria title

New or revised

June 25, 2024

*CC-0252

Adzynma (ADAMTS13, recombinant-krhn)

New

June 25, 2024

*CC-0253

Aphexda (motixafortide)

New

June 25, 2024

*CC-0254

Zilbysq (zilucoplan)

New

June 25, 2024

CC-0130

Imfinzi (durvalumab)

Revised

June 25, 2024

CC-0223

Imjudo (tremelimumab-actl)

Revised

June 25, 2024

*CC-0059

Selected Injectable NK-1 Antiemetic Agents

Revised

June 25, 2024

CC-0074

Akynzeo (fosnetupitant and palonosetron) for injection

Revised

June 25, 2024

*CC-0065

Agents for Hemophilia A and von Willebrand Disease

Revised

June 25, 2024

CC-0124

Keytruda (pembrolizumab)

Revised

June 25, 2024

CC-0150

Kymriah (tisagenlecleucel)

Revised

June 25, 2024

CC-0187

Breyanzi (lisocabtagene maraleucel)

Revised

June 25, 2024

CC-0133

Aliqopa (copanlisib)

Revised

June 25, 2024

CC-0205

Fyarro (sirolimus albumin bound)

Revised

June 25, 2024

CC-0127

Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj)

Revised

June 25, 2024

*CC-0226

Elahere (mirvetuximab)

Revised

June 25, 2024

CC-0125

Opdivo (nivolumab)

Revised

June 25, 2024

CC-0058

Sandostatin and Sandostatin LAR (Octreotide) / Octreotide Agents

Revised

June 25, 2024

*CC-0009

Lemtrada (alemtuzumab) for the Treatment of Multiple Sclerosis

Revised

June 25, 2024

*CC-0014

Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis

Revised

June 25, 2024

*CC-0011

Ocrevus (ocrelizumab)

Revised

June 25, 2024

*CC-0174

Kesimpta (ofatumumab)

Revised

June 25, 2024

*CC-0020

Natalizumab Agents (Tysabri, Tyruko)

Revised

June 25, 2024

*CC-0032

Botulinum Toxin

Revised

June 25, 2024

*CC-0068

Growth Hormone

Revised

June 25, 2024

*CC-0173

Enspryng (satralizumab-mwge)

Revised

June 25, 2024

*CC-0170

Uplizna (inebilizumab-cdon)

Revised

June 25, 2024

*CC-0199

Empaveli (pegcetacoplan)

Revised

June 25, 2024

*CC-0041

Complement Inhibitors

Revised

June 25, 2024

*CC-0071

Entyvio (vedolizumab)

Revised

June 25, 2024

*CC-0064

Interleukin-1 Inhibitors

Revised

June 25, 2024

*CC-0042

Monoclonal Antibodies to Interleukin-17

Revised

June 25, 2024

*CC-0066

Monoclonal Antibodies to Interleukin-6

Revised

June 25, 2024

*CC-0050

Monoclonal Antibodies to Interleukin-23

Revised

June 25, 2024

*CC-0078

Orencia (abatacept)

Revised

June 25, 2024

*CC-0063

Ustekinumab Agents

Revised

June 25, 2024

*CC-0062

Tumor Necrosis Factor Antagonists

Revised

June 25, 2024

CC-0003

Immunoglobulins

Revised

June 25, 2024

*CC-0002

Colony Stimulating Factor Agents

Revised

June 25, 2024

CC-0247

Beyfortus (nirsevimab)

Revised

June 25, 2024

CC-0072

Vascular Endothelial Growth Factor (VEGF) Inhibitors

Revised

June 25, 2024

CC-0010

Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors

Revised

June 25, 2024

CC-0209

Leqvio (inclisiran)

Revised

June 25, 2024

*CC-0086

Spravato (esketamine) Nasal Spray

Revised

Coverage provided by Wellpoint Washington, Inc.

WAWP-CD-050631-24-CPN49889

Policy UpdatesMedicaidApril 19, 2024

Carelon Medical Benefits Management, Inc. updates

Effective on June 30, 2024, the following Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guideline updates for medical necessity review will apply for Wellpoint:

  • Genetic Testing:
    • Hereditary Cancer Testing
    • Carrier Screening in the Prenatal Setting and Preimplantation Genetic Testing
    • Genetic Testing for Inherited Conditions

Existing precertification requirements have not changed. Please share this notice with other members of your practice and office staff.

Coverage provided by Wellpoint Washington, Inc.

WAWP-CD-050477-24-CPN49779

Reimbursement PoliciesMedicaidMarch 1, 2024

Applied behavior analysis providers

This article was updated as of April 11, 2024

This notice provides an update to the April 2023 provider alert instructing applied behavior analysis (ABA) providers to enroll with Washington’s Medicaid program, Apple Health. Individual providers were also instructed to identify as servicing providers on ABA claims.

Providers who render services to Apple Health members must be enrolled with the Health Care Authority (HCA) under the billing provider’s Core Provider Agreement (CPA). See WAC 182-502-0005(2) for more information about the CPA.

Certified behavior technicians (CBT) and licensed assistant behavior analysts (LABA) must be enrolled with Apple Health as a servicing provider (also known as rendering or performing provider) and their National Provider Identifier (NPI) must be listed on claims for services provided.

Effective July 1, 2024, all CBTs and LABAs working with Apple Health members must meet the following requirements:

  • They must have an active CBT or LABA license with the Department of Health (DOH).
  • They must have an NPI.
  • If part of a healthcare group or organization with a CPA, they must enroll with the HCA as a servicing provider or non-billing provider under the group’s CPA.
  • If applicable, they must enroll with the managed care organization (MCO) as a servicing provider.
  • For dates of service on and after July 1, 2024, they must have their NPI captured on the claim as the servicing provider for services rendered.

Please refer to the HCA Applied Behavior Analysis Program Billing Guide for more information.

Services provided by Wellpoint Washington, Inc.

WAWP-CD-049209-24, WAWP-CD-050917-24, WAWP-CD-055808-24

PharmacyMedicare AdvantageApril 8, 2024

Wellpoint expands specialty pharmacy precertification list

Effective for dates of service on and after August 1, 2024, the specialty Medicare Part B drugs listed in the table below will be included in our precertification review process.

Federal and state law, as well as state contract language and CMS guidelines — including definitions and specific contract provisions/exclusions — take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

HCPCS or CPT® codes

Medicare Part B drugs

J9286

Columvi (glofitamab-gxbm)

C9162, J3490, J3590, J9999

Izervay (avacincaptad pegol)

J9333

Rystiggo (rozanolixizumab-noli)

J9334

Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-gvfc)

We look forward to working together to achieve improved outcomes.

Coverage provided by Wellpoint Washington, Inc.

MULTI-WP-CR-052693-24-CPN52693

PharmacyMedicare AdvantageMedicaidApril 5, 2024

CarelonRx, Inc. Mail changed to CarelonRx Pharmacy on January 1, 2024

CarelonRx mail service pharmacy changed to CarelonRx Pharmacy on January 1, 2024.

This pharmacy change does not affect the way CarelonRx works with care providers. There are no changes to the prior authorization process, how claims are processed, or level of support.

This change does not impact your patients’ benefits, coverage, or how their medications are filled.

When e-prescribing orders to the mail service pharmacy:

Prescribers will need to choose CarelonRx Pharmacy, not CarelonRx Mail, if searching by name.

If searching by NPI (National Provider Identifier), the NPI is changing to 1568179489.

We are taking steps to ensure a smooth transition to our new home delivery pharmacy for your patients:

  • Patients will receive a letter to alert them of their new pharmacy.
  • If a patient has refills left, we will move them to CarelonRx Pharmacy.
  • If a patient does not have any refills left of their medication(s), CarelonRx Pharmacy will contact you to obtain a new prescription.
  • If a patient is taking a controlled substance, CarelonRx Pharmacy will contact you to obtain a new prescription.
  • All prior authorizations will be transitioned to CarelonRx Pharmacy.

CarelonRx Pharmacy delivers an enhanced, digital-first solution to your patients to improve adherence and lower costs, while removing barriers associated with traditional retail and mail order pharmacy models. Some highlights include:

  • 24/7 text or chat (digitally) directly with our pharmacists at any time.
  • Enhanced end-to-end order status tracking from prescription order to delivery.
  • Free delivery of their 90-day supply, directly to a patient’s door.

CarelonRx, Inc. is an independent company providing pharmacy benefit management services on behalf of the health plan.

Coverage provided by Wellpoint Washington, Inc.

WAWP-CDCR-045483-23-CPN45113

Quality ManagementMedicaidMay 1, 2024

HEDIS spotlight: Initiation and engagement of substance use disorder treatment, follow-up care for children prescribed ADHD medication, and health equity

In the past, identifying members’ physical health needs and treatment was managed by PCPs, while behavioral health (BH) care providers identified and managed members’ BH needs and treatment. We know now that early identification and treatment for substance use can often get at the root cause of the addiction. In addition, it can prevent further escalation of dependence and other health consequences. Having an integrated approach between the PCP and the BH care provider is crucially important to manage this population.

Below are some specific measures to capture compliance for your patients and our members. For all codes pertaining to the below noted measures, please reference the 2024 HEDIS® Benchmarks and Coding Guidelines for Quality Care and any applicable billing guides. The codes listed are for informational purposes only and are not intended to suggest or guide reimbursement. If applicable, refer to your care provider contract or health plan contact for reimbursement information. For a complete list of CPT® codes, visit the American Medical Association website.

Initiation and Engagement of Substance Use Disorder Treatment (IET)

HEDIS description

The percentage of new substance use disorder (SUD) episodes that result in treatment initiation and engagement. Two rates are reported:

  • Initiation of SUD treatment: The percentage of new SUD episodes that result in treatment initiation through an inpatient SUD admission, outpatient visit, intensive outpatient encounter, partial hospitalization, telehealth visit, or medication treatment within 14 days.
  • Engagement of SUD Treatment: The percentage of new SUD episodes that have evidence of treatment engagement within 34 days of initiation.

Once there is identification of an SUD, the IET HEDIS measure provides some guidance as a standard for minimal initiation and engagement of treatment.

  • The IET measure looks at adolescent or adult members ages 13 and older with a new episode of alcohol or other drug dependence.
  • Treatment may be provided in one of these settings:
    • Inpatient
    • Outpatient
    • Telehealth
    • Partial hospitalization
    • Medication treatment
  • First initiation of treatment should occur within 14 days of the initial diagnosis.
  • Engagement of treatment should occur in two or more visits within 34 days from the initial visit.

Exclusions:

  • Members receiving hospice services.
  • Members who die any time during the measurement period.

Follow-Up Care for Children Prescribed ADHD Medication (ADD-E)

HEDIS® description

Members ages 6 to 12 with a new diagnosis of ADHD who have not been prescribed an ADHD medication in the previous four months.

Documentation tips

What members are included in the measure?

Members who were newly treated with ADHD medication and remained on medication for at least 210 days. Intake starts March 1 of the previous measurement year and ending February of the current measurement year.

How many visits are counted?

Three follow-up visits are counted:

  • The first visit is scheduled within 30 days of prescribing the medication (initiation phase).
  • Two more follow-up visits are scheduled within the next nine months, or a total of three follow-ups in a 10-month period (maintenance phase).

What types of visits count for the follow-up visits?

  • First follow-up (initiation phase):
    • Outpatient visit
    • Intensive outpatient encounter or partial hospitalization
    • A community health center visit
    • A telehealth or telephone visit
  • Two maintenance visits (maintenance phase):
    • Outpatient visit
    • Intensive outpatient encounter or partial hospitalization
    • A community health center visit
    • A telehealth or telephone visit
    • An e-visit or virtual check-in

Required exclusions

  • Members receiving hospice services
  • Members with an acute inpatient encounter with a principal diagnosis of mental, behavioral, or neurodevelopmental disorders
  • Member with a diagnosis of narcolepsy at any time during the member’s history through the end of the measurement period
  • Members who die any time during the measurement period

Record your efforts

  • Be sure to schedule a follow-up visit right away within 30 days of ADHD medication initially prescribed or restarted after a 120-day break.
  • Schedule follow-up visits while members are still in the office.
  • Have your office staff call members at least three days before appointments.
  • After the initial follow-up visits, schedule at least two more office visits in the next nine months to monitor the patient’s progress:
    • Be sure that follow-up visits include the diagnosis of ADHD.

Description

CPT/HCPCS

BH outpatient

CPT: 98960-98962, 99078, 99202-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411, 99412, 99483, 99492, 99493, 99494, 99510

HCPCS: G0155, G0176, G0177, G0409, G0463, G0512, H0002, H0004, H0031, H0034, H0036, H0037, H0039, H0040, H2000, H2010, H2011, H2013-H2020, T1015

Online assessments

CPT: 98970, 98971, 98972, 99421, 99422, 99423, 99457, 99458

HCPCS: G0071, G2010, G2012, G2250, G2251, G2252

Telephone visits

CPT: 98966, 98967, 98968, 99441, 99442, 99443

The codes listed are for informational purposes only and are not intended to suggest or guide reimbursement. If applicable, refer to your provider contract or health plan contact for reimbursement information. For a complete list of CPT codes, visit the American Medical Association website.

Health equity

Health equity is when everyone has a fair and just opportunity to attain optimal health regardless of race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, preferred language, or other factors that affect access to care and health outcomes.

We are committed to ongoing and evolving equity in healthcare by intentionally assessing and listening to the voices of underserved communities by listening to our members and identifying ways for eliminating disparities and propelling healthcare toward true equity for everyone.

NCQA Health Equity Accreditation replaced the previous multicultural health distinction. The focus is on creating a culture that supports Wellpoint external health equity work, such as collecting data to advance language services, thereby effectively communicating with members, as well as understanding their cultural needs. Care providers can take advantage of web-based training at My Diverse Patients regarding identifying opportunities for reducing health inequities and improving care.

How NCQA Health Equity Accreditation can help

Health systems

NCQA frameworks and programs help health systems identify disparities in care and close gaps in populations while supporting the priorities of contracting partners.

Health plans

NCQA programs and measures help health plans implement an actionable framework to provide high-quality care for all members, determine how health inequities influence HEDIS measures and outcomes, and meet contracting and regulatory requirements.

State and Federal government

NCQA helps state and federal governments identify high-performing organizations and improve health equity in the community through accountability programs, quality reporting systems, and custom research and analytic services.

Employers

Use NCQA programs to identify health plan and provider partners that excel in providing equitable healthcare with measurable outcomes, supporting equitable treatment to all employees.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Coverage provided by Wellpoint Washington, Inc.

WAWP-CD-050345-24

Quality ManagementMedicaidMay 1, 2024

Take action to improve adolescent immunizations rates

Estimates suggest that around 35 million American adolescents fail to receive at least one recommended vaccine.* The CDC and the American Academy of Pediatrics advise pre-teens between 10 and 12 years old receive three vaccines: (1) one dose for meningococcal; (2) one dose for tetanus, diphtheria, and pertussis (Tdap); and (3) two doses of human papillomavirus (HPV) given five months apart.

Encourage pre-teen immunizations

Take action to provide clear and specific guidance to your patients’ parents to get the recommended vaccines on time. Convey the importance by administering vaccines as part of routine visits and by offering vaccine clinics during non-traditional times when your patients and their parents might be more available. It is helpful to remind patients of their upcoming appointments, follow up to reschedule any missed appointments, and address any concerns or barriers. Although you should check your patients’ benefits, immunizations are generally a covered benefit.

Reporting and documenting for HEDIS

Take action to make sure that all vaccine doses given, including those administered in a pharmacy and an urgent care, are clearly documented in your electronic medical system, your patient’s medical record, and state Immunization Registry. Doses should be clearly reported on claim forms with the assistance of CPT® codes to maximize data collection and to reduce the burden of HEDIS® medical record review, especially since NCQA strongly encourages the electronic collection of Immunizations for Adolescents (IMA) HEDIS data. Contact your provider relationship management representative for additional information and assistance with establishing electronic data exchange.

Opportunities to learn more:

  • An on-demand webinar about the importance of the HPV vaccine and starting the conversation early with parents of 9-year-olds can be found on the Clinical Quality Webinars Hub. One continuing education unit is provided upon completion.
  • Mydiversepatients.com includes free resources and courses that might help you with your diverse patient population.
  • Letsvaccinate.org provides ready-to-use resources and strategies to help your care team increase vaccination rates.

Through our shared health vision, we can affect real change.

* Das, Jai K., et al. Systematic Review and Meta-Analysis of Interventions to Improve Access and Coverage of Adolescent Immunizations. Journal of Adolescent Health. 2016 Oct; 59 (4 Suppl): S40-S48. ncbi.nlm.nih.gov/pmc/articles/PMC5026683.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Coverage provided by Wellpoint Washington, Inc.

MULTI-WP-CD-051198-24-CPN50907

Quality ManagementMedicaidMarch 26, 2024

HEDIS spotlight

As providers and managed care organizations (MCOs), we are in a critical position to keep our fingers on the pulse of our members. This month, we want to emphasize HEDIS® measures that apply to the mental health of our members. Careful assessment of depressive symptoms can help determine possible treatment options, and periodic assessment throughout care can also guide treatment and gauge progress.

Antidepressant Medication Management (AMM) — Acute & Continuation Phase Treatment

HEDIS definition:

Members 18 years of age and older as of April 30 of the measurement year, who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication treatment

Documentation tips:

Measurement period

The 12-month window starting on May 1 of the prior year to the measurement year and ending on April 30 of the measurement year

What two treatments are reported?

  • Effective acute phase treatment: the percentage of members who remained on an antidepressant medication for at least 84 days (12 weeks)
  • Effective continuation phase treatment: the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

Treatment days

The actual number of calendar days covered with prescriptions within the specified measurement interval; for Effective Continuation Phase Treatment, a prescription of 90 days (3 months) supply dispensed on the 151st day will have 82 days counted in the 232-day interval

Record your efforts

  • Identify all acute and nonacute inpatient stays
  • Identify the admission and discharge dates for the stay; either an admission or discharge during the time frame meets criteria

Helpful tips

  • Educate your members and their spouses, caregivers, and/or guardians about the importance of:
    • Complying with long-term medications.
    • Not abruptly stopping medications without consulting you.
    • Contacting you immediately if they experience any unwanted or adverse reactions so that their treatment can be re-evaluated.
    • Calling your office if they cannot get their medications refilled.
    • Scheduling and attending follow-up appointments to review the effectiveness of their medications.
  • Ask your members who have a behavioral health diagnosis to provide you access to their behavioral health records if you are their primary care provider.
  • If utilizing an EMR system, consider electronic data sharing with your health plan to capture all coded elements. Contact your Provider Solutions representative for additional details and questions.
  • Discuss the benefits of participating in a behavioral health case management program.

Required exclusions

  • Members using hospice anytime during the measurement year
  • Members who did not have an encounter with a diagnosis of major depression during the 121-day period from 60 days prior to the IPSD, through the IPSD and the 60 days after the IPSD
  • Members who died during the measurement year

Description

CPT/HCPCS/ICD-10

Major depression

ICD-10: F32.0-F32.4, F32.9, F33.0-F33.3, F33.41, F33.9

BH outpatient

CPT: 98960-98962, 99078, 99202-99205, 99211-99215, 99242-99245,
99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411, 99412, 99483, 99492-99494, 99510

HCPCS: G0155, G0176, G0177, G0409, G0463, G0512, H0002, H0004, H0031, H0034, H0036, H0037, H0039, H0040, H2000, H2010, H2011, H2013-H2020, T1015

Electroconvulsive therapy

CPT: 90870

ICD-10-PCS: GZB0ZZZ, GZB1ZZZ, GZB2ZZZ, GZB3ZZZ, GZB4ZZZ

Online assessments

CPT: 98970, 98971, 98972, 98980, 98981, 99421-99423, 99457, 99458

HCPCS: G0071, G2010, G2012, G2250-G2252

Telephone visits

CPT: 98966, 98967, 98968, 99441, 99442, 99443

Transcranial Magnetic Stimulation

CPT: 98067-90869

Visit Setting Unspecified

CPT: 90791, 90792, 90832-90834, 90836-90840, 90845, 90847, 90849, 90853, 90875, 90876, 99221-99223, 99231-99233, 99238, 99239, 99252-99255

Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS-E)

HEDIS definition:

This measure looks at the percentage of members 12 years of age and older with a diagnosis of major depression or dysthymia who had an outpatient encounter with a Patient Health Questionnaire-9 (PHQ-9) score present in their record in the same assessment period as the encounter during the measurement year (January 1 to December 31).

Documentation tips:

Record your efforts

The measure allows the use of two PHQ-9 assessments. The PHQ-9 assessment does not need to occur during a face-to-face encounter; it may be completed over the telephone or through a web-based portal. Selection of the appropriate assessment should be based on the member’s age:

  • PHQ-9: 12 years of age and older
  • PHQ-9 Modified for Teens: 12 to 17 years of age

Clinical recommendation statement

Standardized instruments are useful in identifying meaningful change in clinical outcomes over time. Guidelines for adults recommend that providers establish and maintain regular follow-up with patients diagnosed with depression and use a standardized tool to track symptoms. Guidelines for adolescents recommend systematic and regular tracking of treatment goals and outcomes, including assessing depressing symptoms.

The PHQ-9 tool assesses the nine DSM, Fourth Edition, Text Revision
(DSM-IV-TR)
criteria symptoms and effects on functioning, and as shown to be highly accurate in discriminating between patients with persistent major depression, partial remission, and full remission.

Service

  • Outpatient visit
  • Telephone or telehealth visit
  • E-visit or virtual check-in
  • Online assessment

Exclusions

  • Members who use hospice services or elect to use a hospice benefit any time during the measurement period
  • Members who die any time during the measurement year
  • Members with any of the following at any time during the member’s history through the end of the measurement period:
    • Bipolar disorder
    • Personality disorder
    • Psychotic disorder
    • Pervasive developmental disorder

The table below shows the required types of standardized instruments that apply to this measure. You will notice that the table indicates which instrument to choose based on age grouping. It also indicates what represents a positive score. There is also an indication of which instruments are brief as opposed to full-length instruments.

Instruments for depression screening by age grouping

Instrument

Positive finding

Adolescents (12 to 17 years)

Adults (18+ years)

LOINC codes

Patient Health Questionnaire (PHQ-9)®

Total score ≥ 10

X

X

44261-6

Patient Health Questionnaire Modified for Teens (PHQ-9M)®

Total score ≥ 10

X

89204-2

Depression Remission or Response for Adolescents and Adults (DRR-E)

HEDIS definition:

This measure looks at the percentage of members 12 years of age and older with a diagnosis of depression and an elevated PHQ-9 score, who had evidence of response or remission within 120 to 240 days (4 to 8 months) of the elevated score during the measurement year:

  • Follow-Up PHQ-9: the percentage of members who have a follow-up PHQ-9 score documented within 120 to 240 days (4 to 8 months) after the initial elevated PHQ-9 score
  • Depression Remission: the percentage of members who achieved remission within 120 to 240 days (4 to 8 months) after the initial elevated PHQ-9 score
  • Depression Response: the percentage of members who showed response within 120 to 240 days (4 to 8 months) after the initial elevated PHQ-9 score

Documentation tips:

Record your efforts

The measure allows the use of two PHQ-9 assessments. The PHQ-9 assessment does not need to occur during a face-to-face encounter; it may be completed over the telephone or through a web-based portal. Selection of the appropriate assessment should be based on the member’s age:

  • PHQ-9: 12 years of age and older
  • PHQ-9 Modified for Teens: 12 to 17 years of age

Exclusions

  • Members who use hospice services or elect to use a hospice benefit any time during the measurement period
  • Members who die any time during the measurement year
  • Members with any of the following at any time during the member’s history through the end of the measurement period:
    • Bipolar disorder
    • Personality disorder
    • Psychotic disorder
    • Pervasive developmental disorder

The table below shows the required types of standardized instruments that apply to this measure. You will notice that the table indicates which instrument to choose based on age grouping. It also indicates what represents a positive score. There is also an indication of which instruments are brief as opposed to full-length instruments.

Important: You must provide the Logical Observation Identifiers, Names and Codes (LOINC) and scores by a standard supplemental data flat file from your EHR to the MCO to capture compliance for this measure.

Instruments for depression screening by age grouping

Instrument

Positive finding

Adolescents (12 to 17 years)

Adults (18+ years)

LOINC codes

Patient Health Questionnaire (PHQ-9)®

Total score ≥ 10

X

X

44261-6

Patient Health Questionnaire Modified for Teens (PHQ-9M)®

Total score ≥ 10

X

89204-2

Depression Screening and Follow-Up for Adolescents and Adults (DSF-E)

HEDIS definition:

The percentage of members 12 years of age and older, as of December 31 of the measurement year, who were screened for clinical depression using a standardized instrument and, if screened positive, received follow-up care

Documentation tips:

What two rates are reported?

  • The member was screened for clinical depression using a standardized instrument.
  • If the screen was positive, the member received follow-up care within the next 30 days.

What counts for a follow-up visit within 30 days?

A follow-up visit within 30 days of a positive test can be counted through:

  • Outpatient visit
  • Telehealth or telephone visit
  • An e-visit or virtual check-in
  • A depression case management encounter
  • A behavioral health encounter
  • A depression medication dispensing event
  • Additional depression screening on a full-length instrument indicating either no depression or no symptoms that require
    follow-up on the same day as a positive screen on a brief instrument

Helpful tips

  • The measure requires the use of an age-appropriate screening instrument. The member’s age is used to select the appropriate depression screening instrument.

Exclusions

  • Members with a history of bipolar any time during the member’s history through the end of the year prior to the measurement period
  • Members with depression that starts during the year prior to the measurement period
  • Members using hospice anytime during the measurement year
  • Members who died during the measurement year

The table below shows the required types of standardized instruments that apply to this measure. You will notice that the table indicates which instrument to choose based on age grouping. It also indicates what represents a positive score. There is also an indication of which instruments are brief as opposed to full-length instruments.

Important: You must provide the Logical Observation Identifiers, Names and Codes (LOINC) and scores by a standard supplemental data flat file from your EHR to the MCO to capture compliance for this measure.

Instruments for depression screening by age grouping

Instrument

Positive finding

Adolescents (12 to 17 years)

Adults (18+ years)

LOINC codes

Patient Health Questionnaire (PHQ-9)®

Total score ≥ 10

X

X

44261-6

Patient Health Questionnaire Modified for Teens (PHQ-9M)®

Total score ≥ 10

X

89204-2

Patient Health Questionnaire-2 (PHQ-2)®,2

Total score ≥ 3

X

X

55758-7

Beck Depression Inventory Fast Screen (BDI-FS)®,1,2

Total score ≥ 8

X

X

89208-3

Beck Depression Inventory (BDI-II)

Total score ≥ 20

X

89209-1

Center for Epidemiologic Studies Depression Scale- Revised (CESD-R)

Total score ≥ 17

X

X

89205-9

Duke Anxiety-Depression Scale (DADS)®,1

Total score ≥ 30

X

90853-3

Edinburgh Postnatal Depression Scale (EPDS)

Total score ≥ 10

X

X

71354-5

My Mood Monitor (M-3)®

Total score ≥ 5

X

71777-7

PROMIS Depression

Total score ≥ 60

X

X

71965-8

Clinically Useful Depression Outcome Scale (CUDOS)

Total score ≥ 31

X

90221-3

1 Proprietary; may be cost or licensing requirement associated with use.
2 Brief screening instrument. All other instruments are full-length.

The codes and measure tips listed are informational only, not clinical guidelines or standards of medical care, and do not guarantee reimbursement. All member care and related decisions of treatment are the sole responsibility of the provider. This information does not dictate or control your clinical decisions regarding the appropriate care of members. Your state/provider contract(s), Medicaid, member benefits, and several other guidelines determine reimbursement for the applicable codes. Proper coding and providing appropriate care decrease the need for high volume of medical record review requests and provider audits. It also helps us review your performance on the quality of care that is provided to our members and meet the HEDIS measure for quality reporting based on the care you provide our members.

Note: The information provided is based on HEDIS MY2024 technical specifications and is subject to change based on guidance given by the National Committee for Quality Assurance (NCQA), the Centers for Medicare & Medicaid Services (CMS), and state recommendations. Please refer to the appropriate agency for additional guidance.

For a complete list of CPT codes, go to the American Medical Association website at ama-assn.org.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Coverage provided by Wellpoint Washington, Inc.

WAWP-CD-052500-24