Providers must follow the claims submission instructions listed on the back of the member ID card. If the instructions require you to submit the claim directly to Mayo Clinic Health Solutions, you will only have one claim form to submit. If you have any questions about these new requirements or the crossover process, please contact Customer Service at the phone number listed on the back of the member ID card.

When filling out your clinical documentation:

• Please be as comprehensive as possible.
• Include both pharmacological and non-pharmacological failures.

If you have any questions about the information that is needed in your clinical documentation, please contact Sharon Chambers, Director of Health Services.

 

If your provider name and a confidentiality statement are not included, we will not be able to leave detailed messages and we will usually require you to return our call to obtain any information that includes PHI.

The subcategories in the table, below, should be used to further specify private room and board codes.

Subcategory	Standard Abbreviations
0 - General Classification	ROOM-BOARD/PVT
1- Medical/Surgical/Gyn	MED-SUR-GY/PVT
2 - OB	OB/PVT
3 - Pediatric	PEDS/PVT
4 - Psychiatric	PSYCH/PVT
5 - Hospice	HOSPICE/PVT
6 - Detoxification	DETOX/PVT
7 - Oncology	ONCOLOGY/PVT
8 - Rehabilitation	REHAB/PVT
9 - Other	OTHER/PVT

 

Members participating in the ICM program receive support from a Mayo Clinic-trained Registered Nurse who will reach out to the member and their family by phone to: 

• Help the member understand how to make the best use of their health plan benefits.
• Facilitate communication between the member and their health care provider.  
• Provide additional information about their medical condition and treatment options to help them make health care decisions.
• Coordinate services, such as appointments, mental health and substance abuse services, and home health care.
• Link them to community resources to help them stay as healthy, active, and connected as possible.

When one of your patients begins participating in ICM, Mayo Clinic Health Solutions will also notify you by mail or email.  If you have questions about the patient’s plan of care or would like to provide input, please contact the patient’s case manager at the direct phone number provided in the letter or email.  

If you have any questions about the ICM program, please call 1-800-645-6296 to speak to one of our case managers.

This electronic solution also fulfills the requirements of a recent Minnesota state mandate: “drug prior authorization requests must be accessible and submitted by health care providers, and accepted by group purchasers (PBMs), electronically through secure electronic transmissions.”

Effective immediately, you can start using CoverMyMeds®, to begin submitting medication prior authorization requests to Mayo Clinic Health Solutions.  

1. Go to www.covermymeds.com and sign in to your account. You will need to register on your first visit.  
2. Start a prior authorization request, making sure to fill in the “BIN/PCN/RxGroup or Plan or PBM” box with the corresponding information shown on the member’s ID card.
3. Fill in all the required medical details. When finished, submit the request. 

For the next few months, our CoverMyMeds® prior authorization determinations will be delivered by fax. However, starting in June 2016, these determinations will be delivered online via your account on the CoverMyMeds® website.

In the future, we plan to discontinue use of many of the medication prior authorization forms currently posted on the Provider Forms page at www.MayoClinicHealthSolutions.com.  In addition, we will be posting a link to CoverMyMeds® on this page, for your convenience. We will announce any important changes on our website and in this provider newsletter.

If you submit a claim for summer camp services without attaching supporting medical records, the claim will deny with the following message: “member responsibility PR 96,” indicating that the service was a non-covered charge.  If this occurs, please resubmit the claim along with the required medical records.

Please note: This guideline applies to non-government plans only. Government plans allow diagnosis code Z02.89 to be used for billing child and teen checkups. 

Significant Changes to MinnesotaCare Copays for 2016

New legislation passed in 2015 that requires MinnesotaCare members to pay a greater share of the cost of their benefits. This means the adult benefit set for MinnesotaCare will have copay increases for some services in 2016. There are also new copays for some services that previously had none. Members must pay their copay directly to the provider. 

MinnesotaCare members under the age of 21 or who are American Indians in a federally recognized tribe will still have no copays for health care services.

MinnesotaCare services requiring a copay include the following:

• Non-Preventative Visits
• Ambulatory Surgery
• Emergency Room Visits
• Inpatient Hospital Visits
• Outpatient Hospital Visits
• Eyeglasses
• Generic Prescription Drugs
• Brand Name Prescription Drugs
• Radiology

Rural Health Clinic and Federally Qualified Health Center Payment Changes for Medicare Part B Crossover Claims

Effective January 1, 2016 South Country Health Alliance began reimbursing the full Medicare Part B cost sharing for all Medicare dual claims as it applies to Rural Health Clinics and Federally Qualified Health Centers.  Minnesota Statutes 2014, section 256B.0625, subdivision 57, has been amended to read:

• Effective for services provided on or after January 1, 2012, medical assistance payment for an enrollee’s cost-sharing associated with Medicare Part B is limited to an amount up to the medical assistance total allowed, when the medical assistance rate exceeds the amount paid by Medicare.
• Excluded from this limitation are payments for mental health services and payments for dialysis services provided to end-stage renal disease patients. The exclusion for mental health services does not apply to payments for physician services provided by psychiatrists and advanced practice nurses with a specialty in mental health.
• Excluded from this limitation are payments to federally qualified health centers and rural health clinics (effective January 1, 2016).

Child & Teen Checkup Screning with an Evaluation & Management Service

If a significant, separately identifiable Evaluation & Management service is provided at the time of the Child & Teen Checkup screening, that Evaluation & Management code must be billed with the modifier 25. Documentation in the health record must support key components of billed Evaluation & Management services. Follow CPT instructions for appropriate coding. 

The National Correct Coding Initiative rules state that a vaccine administration and Evaluation & Management code cannot be billed on the same day, by the same provider, unless a “significant, separately identifiable service by the same physician was provided on the same day.” 
For additional information, view the Minnesota Department of Human Services Child & Teen Checkup guidelines. 

Attention All Prescribers: Provider Enrollment Requirements for Writing Medicare Prescriptions

The Centers for Medicare & Medicaid Services (CMS) recently updated a new rule that was originally finalized in 2014. This rule requires any physician or other eligible professional who prescribes Part D drugs to enroll in the Medicare program or opt out of receiving Medicare reimbursement in order to prescribe drugs to patients with Part D prescription drug benefit plans. 
The new policy became effective January 1, 2016, but CMS has delayed enforcement until June 1, 2016. 

Prescribers who are not currently enrolled in Medicare are advised to submit an enrollment application to their Part B Medicare Administrative Contractor (MACS) by June 1, 2016. Applications should be submitted as soon as possible to allow CMS enough time to process enrollment paperwork. If prescribing providers are not enrolled in Medicare by June 1, 2016, patients’ Part D prescription drug claims may be denied. 

For more information about this requirement, review the related Medicare Learning Network (MLN) Matters bulletin and the CMS Prescriber outreach communication.

Elderly Waiver Updates

Effective January 1, 2016, all UCare Elderly Waiver services require an authorization from the assigned Minnesota Senior Health Options/Minnesota Senior Care Plus case manager for claims payment purposes. If you do not have documented written approval, please contact the member’s case manager or UCare Clinical Services at 612-676-6705 for assistance.

UCare Weekly Payment Cycle

UCare returned to conducting one payment cycle each week for all lines of business on March 1, 2016. This means that UCare Minnesota will remit payments each Friday for claims processed in the prior calendar week. 

UCare is returning to this payment frequency because of decreases in membership and claim volume in Prepaid Medical Assistance Program and MinnesotaCare this year. Until UCare’s claim volumes become more aligned with their new membership numbers, providers may experience delays in receiving remittance advices. UCare sends remits up to three business days after payment is made on a claim. UCare claim status and remits can be accessed via UCare’s Provider Portal.

UCare Behavioral Health Retroactive Authorization Process

Effective April 15, 2016, UCare will only accept the Adjustment/Recoupment Request Form for retroactive authorization requests. The request form must be used when providers are seeking to receive payment on services that have already been rendered and billed to UCare and were denied by UCare for no notification and/or authorization being on file. 

If a claim is denied because a notification or authorization was not obtained prior to services being rendered or the number of available units were insufficient, providers will be required to follow the claim adjustment process. The Adjustment/Recoupment Request Form must be submitted along with clinical information to support the medical necessity of the provided services. All information should be faxed to the number on the form. 

The goal of requiring the standard Adjustment/Recoupment Request Form is to streamline the review and processing of these claims for providers and UCare. Requests submitted on this form are reviewed by UCare’s Behavioral Health clinicians and Claims department in one request. These requests are typically completed within 30 days. The current retro authorization process requires multiple steps between UCare and the provider. The new process and form will allow UCare to more quickly review and re-process denied claims so providers can receive more timely payments.  For more information, please review the UCare Provider Bulletin.