When a patient presents with more than one diagnosis or comorbidity, such as diabetes and hypertension, it is important to include all diagnoses on your claim.

Appropriate coding drives appropriate benefit administration and payment. It also identifies the health of our members and our potential financial risk.

Three provisions in the Affordable Care Act - the 3 Rs - are designed to help protect CoOportunity Health's financial exposure: 

• The Reinsurance program provides us with limited exposure to high-dollar claims.
• The Risk Adjustment and Risk Corridor programs provide us with additional funds if we have attracted a disproportionately unhealthy population in total.

To learn more about the 3 Rs, see Explaining Health Care Reform: Risk Adjustment, Reinsurance, and Risk Corridors.  

Prior Authorization Responsibilities

Depending on the situation, claims for services requiring a prior authorization are processed one of three ways:

• Prior Authorization Approved: Claim is processed according to member benefits.

• Prior Authorization Request is Not Submitted: Claim is denied as provider liability.

• Prior Authorization Request is Denied: Claim is denied as member responsibility if the patient signs a waiver indicating that he or she understands that the specific service is not covered and accepts financial responsibility for the services, and the claim is submitted with a GA modifier. For specific information about waiver and claims filing requirements, review our administrative policy Use of a GA Modifier on Claim Submissions.

Appeals/Reviews 

• To request a review of a denied claim when prior authorization is not submitted, complete and fax a Medical Appeal Request form.
• To discuss a denied prior authorization, contact us at 1.888.467.0774 within 30 days of the denial.

Medical Policies and Updates

To locate a medical policy, visit coOportunityhealth.com/medicalpolicies. The medical policy page includes an icon that links you to our Medical Policy Updates.

Changes are announced on our News page and in our Provider Alert newsletters, which are also posted on Midlands Choice Provider News page.

Physical and Occupational Therapy - Rehabilitation

Medical Policy Update

Effective immediately, we have removed the 60-day time frame requirements for plan of care reviews and revisions in the physical and occupational therapy - rehabilitation medical policy [see #3 under Indications that are covered].

Prior authorization continues to be required for more than 20 visits in a calendar year.

The date of the update posting is April 2014.

Help for Members With Complex Drug Therapy Needs

CoOportunity Health, in partnership with HealthPartners, is recruiting Iowa and Nebraska phamacists for a medication therapy management [MTM] network. When a member is identified with a complex drug therapy need, an MTM network pharmacist consults with the patient privately to:

• Assess the entire medication regimen for indications, effectiveness, safety, and adherence.
• Assess the patient's understanding, expectations, and concerns about his or her medications.
• Assist with the timing of medications.
• Suggest ways to reduce medication side effects.
• Provide recommendations to potentially reduce the patient's medication costs.

If an issue is identified during the process, the pharmacist will contact the patient's physican[s] to address the concern.

If one of your patients could benefit from a pharmacist's services, please call Clinical Support Services - HealthPartners' MTM vendor - at 1.877.296.9670. Pharmacists interested in enrolling in our network or learning more about the program should also call Clinical Support Services or visit our Medication Therapy Management website page. 

Administrative Policy: Affirmation Statement Regarding Incentives

It is the policy of CoOportunity Health that utilization review decisions are made based only on appropriateness of care, service and existence of coverage. Financial incentives, if any, that are offered by CoOportunity Health [or any entity that contracts with CoOportunity Health to provide utilization management services] to individuals or entities involved in making utilization management decisions will not encourage decisions that result in underutilization or inappropriate restrictions of care.

This means that practitioners or other individuals conducting utilization review will not be specifically rewarded, hired, promoted, or terminated for issuing denials of coverage or services. Rather, financial incentives will be designed to encourage appropriate utilization and discourage underutilization.

Locate our complete list of Administrative Policies at coOportunityhealth.com/adminpolicies.  

Secure Provider Website Tools

To register for access to our secure Provider website, visit our registration page. With access, you can:

• Locate your claim payment details/remittance with option to print.
• Sign up to receive an email notification when a remittance is posted.
• Locate a patient ID number using his or her name and birth date.
• Print or save a time- and date-stamped PDF of a member's benefits.
• Check claim status.

Where to Find Posted News