CoOportunity Health
                     

May 1, 2014
 
Billing for Routine Preventive Care
  

When an in-network physician delivers routine preventive care, services billed as a routine preventive service pay in full without a member cost-share. As a Qualified Health Plan issuer, CoOportunity Health covers these services in full for all members.

 

Routine preventive services do not include those intended to treat an existing illness, injury, or condition, or one discovered during a preventive exam. This does not preclude the patient from having routine preventive exams and services. For example:

  • If during a routine preventive exam, additional services (such as lab work) related to a symptom or condition are provided, identify the services with the appropriate diagnosis code(s). The services will process according to the member's nonpreventive benefits.
  • If the diagnosis and treatment of a condition involves significant, separate additional effort, you may bill an E/M code in addition to the routine preventive exam CPT code. The E/M code would require a 25 modifier (see CPT requirements) and will process as a nonpreventive benefit.

For information about covered services, visit our medical policies:

A Preventive Care Benefits fact sheet is also now available online.

 

How and When to Submit Requests for Claim Review

 

Forms

Request a claim review by completing and faxing one of these Forms with supporting documents, if applicable:

  • Claim Adjustment Request Form - Use when submitting additional or corrected data. Examples: Submitting coordination of benefits information or late charges or credits. See more examples on the request form.
  • Claim Appeal Form - Use when claim is rejected as beyond the timely filing guideline or when originally submitted data was accurate and is not being changed. Examples: Appealing medical necessity determination or benefit application. See more examples on the request form.

Time Frame

You must submit your request within:

  • 60 days of the claim denial if the claim is denied as being submitted beyond the timely filing guideline of 365 days.
  • 18 months of the process date for all other claims if you are an in-network provider.
  • 12 months of the process date for all other claims if you are an out-of-network provider.

 

Receive Claim Payments Faster

 

Receive claim payment more quickly by doing business electronically.

  • Claims: For clearinghouse information and Payer IDs, visit coOportunityhealth.com/eservices. Please confirm this information with your vendor or clearinghouse prior to submission. Even if your clearinghouse is not listed, your vendor can redirect claims through a HealthPartners approved clearinghouse.
  • Payment: To receive access to claims payments sooner, sign up for electronic funds transfer.

 

Medical Policy Updates

 

The following medical policies have been updated or will be updated (dates noted below). To view complete information, visit the Medical Policy Updates posted May 1.

 

EnhancedRx Drug List (Drug Formulary) Updates

 

Quarterly Drug List Updates

We make quarterly drug list updates in January, April, July, and October. The April 2014 updates are available; there are no deletions or negative changes for April of 2014.

 

To identify coverage and requirements of a particular drug, visit coOportunityhealth.com/druglist. Use key at the bottom of each page to correctly interpret information.

 

All CoOportunity Health plans use the same drug list.

 

Additional Information

 

If you have additional questions, contact our Pharmacy Customer Service 24/7:

  • Telephone: 1.800.492.7259
  • Fax: 1.888.883.5434
  • HealthPartners Pharmacy Services, PO Box 1309, Minneapolis, MN 55440

 

Prior Authorization Requirements

 

Diagnostic Imaging: Currently, we do not require prior authorization for diagnostic imaging. We will watch utilization patterns and encourage providers to use the American College of Radiology Appropriateness Criteria to make decisions as to which test is most appropriate for their patient.

 

Prior Authorization of Procedures, Services, and Drugs: Prior authorization is required for a select number of procedures, services, and drugs provided to patients by a healthcare professional. Check our medical policies/coverage criteria for details and forms.

 

Note: For coverage criteria of drugs filled at a pharmacy that patients take themselves, visit our Drug List. 
 

Admission Notification: We require facilities to notify us within 24 hours of a CoOportunity Health member's inpatient admission to or discharge from their facility. This enables us to identify candidates for complex case management or disease management programs. Notification is not required for maternity admissions.

 

Use the hospital/facility notification form under the General tab of our Forms page, or call:

  • 1.888.883.7510 - in-network admission/discharge notification
  • 1.800.316.9807 - out-of-network admission/discharge notification