What's new

We have made the decision to not implement changes to our Modifier 25; Significant, Separately Identifiable Service (Modifier #103) and Global Days (Administrative #101) reimbursement policies at this time.

We had previously announced in the December 2024 issues of The Bulletin and The Connection that we would update these policies effective March 1, 2025.

We will announce any future policy changes according to our notification requirements.

View the current policies in our Reimbursement Policy Manual.

2/18/2025

We have identified an edit that is incorrectly denying commercial claims for CPT 98000-98015 when billed with a telehealth place of service and modifier. We added these codes to our Virtual Care (Administrative #132) commercial reimbursement policy effective January 1, 2025.

We have paused the edit that is causing these denials, and we are reprocessing these claims. Providers do not need to resubmit the claims.

2/13/2025

September updates to standard reimbursement schedules are available on Availity Essentials’ Fee Schedule Tool. However, we continue to experience issues with producing Q4 2024 and Q1 2025 updates. In the interim, our Provider Contact Center can provide reimbursement schedule updates.

We apologize for this inconvenience and appreciate your patience as we work to resolve this issue.

2/11/2025

For joint surgeries performed March 1, 2025, or later, the Asuris clinical team will perform site-of-care reviews when the service does not require medical necessity review. eviCore healthcare (eviCore) will continue joint site-of-care reviews when the service is also reviewed for medical necessity.

This change affects services for commercial members only. Affected codes are listed in the Surgical Site of Care—Hospital Outpatient section of our commercial pre-authorization list alongside the Surgical Site of Care Additional Information Form for faxed requests.

You can begin submitting pre-authorization requests for affected services now. To check requirements and receive the fastest review, submit requests through Availity Essentials’ Electronic Authorization application.

Learn more about these reviews in our Surgical Site of Care – Hospital Outpatient (Utilization Management #19) medical policy.

2/5/2025

Industry-wide supply constraints have led Walgreens to limit the amount of GLP-1 medications they'll dispense. They will only dispense one-month supplies of GLP-1 medications in most cases.

Please inform your patients of these restrictions or guide them to alternative in-network pharmacies when needed.

What’s happening with the GLP-1 shortage?

The FDA announced that the GLP-1 medication tirzepatide injection, used to treat type 2 diabetes, is no longer in shortage. But several other GLP-1 products remain in short supply. GLP-1 manufacturers Novo Nordisk and Eli Lilly have invested heavily in expanding their manufacturing capabilities to ease shortages in the coming months.

Express Scripts (ESI) home delivery pharmacy suspended dispensing GLP-1 drugs for members who are new to therapy (NTT) in December 2024. As of February 1, 2025, they have resumed dispensing these medications for NTT members.

2/11/2025

As we continue to prioritize our members' health and well-being, we want to highlight the various care options available to them for quickly and effectively addressing urinary tract infections (UTIs). Leveraging these convenient alternatives can reduce unnecessary emergency room visits and ensure the right care at the right time.

Understanding UTIs

Urinary tract infections are a common condition affecting millions of people each year. Symptoms can range from mild to severe and may include burning during urination, frequent urination and abdominal pain. If left untreated, UTIs can lead to more serious complications, such as kidney damage or sepsis.

Care options for our members
To provide our members with easy access to UTI care, we offer the following options:

• Virtual care: Our members can schedule virtual consultations with board-certified physicians, allowing them to receive a diagnosis and treatment plan from the comfort of their own homes. This convenient option is ideal for those with mild to moderate symptoms.
• In-home visits: DispatchHealth offers urgent medical services, including treating UTIs, in the comfort of patients' own homes. They are available in the Spokane area.
• PCP visits: For members with more severe symptoms or underlying medical conditions, a visit to their PCP is recommended. PCPs can provide comprehensive care, including diagnostic testing and treatment, as well as coordinate follow-up appointments as needed.
• Urgent care centers: For members who require in-person care, urgent care centers offer extended hours and minimal wait times. These centers are equipped to provide diagnostic testing, including urinalyses and cultures, and can prescribe antibiotics as needed.
• Retail clinics: Many retail clinics, such as those found in pharmacies, offer walk-in UTI treatment services. Their providers can evaluate symptoms, perform diagnostic tests and prescribe medication.

Learn more in our Care Options Toolkit. Easily find in-network providers using the Find a Doctor tool on our provider website.

What you can do

As a provider, you play a vital role in educating our members about these care options and encouraging them to seek timely treatment. Here are some ways you can support these efforts:

• Review the Agency for Healthcare Research and Quality’s Best Practices in the Diagnosis and Treatment of Asymptomatic Bacteriuria and Urinary Tract Infections
• Inform your patients about the available care options and their benefits
• Emphasize the importance of seeking medical attention if symptoms persist or worsen
• Coordinate care with our network of urgent care centers and retail clinics as needed
• Encourage members to schedule follow-up appointments to ensure successful treatment and prevent future UTIs

By working together, we can ensure our members receive the best possible care for UTIs while reducing unnecessary emergency room visits.

1/24/2025

The CDC recommends expediting subtyping of influenza A virus-positive specimens from severely ill hospitalized patients. This is crucial for ensuring timely and effective infection prevention and control measures, as well as early identification of potential avian influenza A(H5N1) cases.

Why expedited subtyping is essential

Early subtyping is vital to distinguish between seasonal influenza A(H1) and A(H3) and novel influenza A virus infections, such as avian influenza A(H5N1). The CDC has emphasized the importance of subtyping influenza A virus-positive specimens as soon as possible, ideally within 24 hours. This recommendation is consistent with current guidelines but underscores the need for prompt action to facilitate rapid public health response.

Current risk assessment

While the CDC still considers the risk from avian influenza A(H5N1) viruses to the public to be low, they are closely monitoring this dynamic situation. Currently, with seasonal influenza levels high nationally, nearly all people who are currently hospitalized with influenza A virus infections probably have seasonal influenza.

Key CDC recommendations

To ensure timely and effective infection prevention and control measures, follow these key CDC recommendations:

1. Send specimens from hospitalized patients that are influenza A virus-positive for subtyping within 24 hours.
2. If on-site subtyping is negative for H1 and H3, send specimens to local public health laboratory within 24 hours.
3. If on-site subtyping is not possible, send specimens to a commercial laboratory or local/state public health laboratory within 24 hours.

The goal of these recommendations is to ensure that subtyping results are available while patients are still hospitalized, enabling more expedited infection prevention and control measures and case investigations should the patient have influenza A(H5) virus infection.

1/24/2025