What's new

We updated our Virtual Care (Administrative #132) reimbursement policy effective January 1, 2025. To learn more about the changes:

• Read the January 2025 issue of The Bulletin

• View our Virtual Care reimbursement policy

1/1/2025

In accordance with health care operating rules mandated by the Affordable Care Act (ACA), beginning January 1, 2025, we will include “1” as the prepended value in the TRN03 field of the Electronic Funds Transfer (EFT) Corporate Credit or Debit Entry Plus Addenda Record (CCD+). For example, TRN10123456789*1999999999~.

You may need to update your system accordingly to prevent a potential discrepancy when you re-associate your EFT with your electronic remittance advice (ERA).

Learn more about reconciling your payments with EFTs and ERAs.

12/23/2024

September updates to standard reimbursement schedules are available on Availity Essentials’ Fee Schedule Tool. We are currently producing October updates. Production and availability of reimbursement schedules will resume their usual cadence in January 2025.

We understand that the delay in the availability of reimbursement schedules may have caused some inconvenience, and we appreciate your patience and understanding during this time.

12/23/2024

Effective January 1, 2025, the following update will be made to the list of preventive care services covered at no cost to members with Affordable Care Act (ACA) preventive benefits:

• Anemia screening: The U.S. Preventive Services Task Force (USPSTF) does not routinely recommend iron screening for pregnant women. Therefore, we are removing “anemia screening” from the Pregnant members section of our preventive care lists. A complete blood count (CBC) test will remain eligible for no cost-share for pregnant members.
• General health panel (CPT 80050): The USPSTF does not routinely recommend this panel’s lab components for the general population. We will cover this general health panel as a preventive benefit only in specific clinical settings, when a component of the lab could be considered preventive (e.g., for newborns for a thyroid stimulating hormone in context of newborn screening or a CBC for pregnant women).

Our preventive care list will be updated in January to reflect these changes.

12/4/2024

Our annual retrospective medical record review starts on December 4, 2024. In the next few months, you may receive medical record requests from Advantmed or Episource to complete this review. We appreciate your prompt response to all requests.

As a reminder, you are required to provide medical records for this review free of charge as part of your agreement with us. Learn more about our risk adjustment program, including best practices, tips and education resources.

12/4/2024