Provider Alert Archives Now Available
Now you can locate past Provider Alerts from our News Archive page. We'll continue to post articles by topic (see tabs).
New Medical Policy Updates
New
- Genetic Testing for Hereditary Colorectal Cancer Susceptibility
- Golimumab (Simponi ARIA)
- Obinutuzumab (Gazyva)
Revised
- Abatacept (Orencia)
- Advanced Drug Therapy for Pulmonary Hypertension
- Omalizumab (Xolair)
- Tocilizumab (Actemra)
Coverage of New OTC Nexium 24HR
Nexium 24HR, a new over-the-counter (OTC) drug, will be added to our drug list as a covered non-formulary drug on July 15, 2014. Other forms of Nexium will no longer be covered by CoOportunity Health beginning July 15.
Even though Nexium 24HR is an OTC drug, it will not be covered by CoOportunity Health without a prescription. If a member presents a prescription for a noncovered form of Nexium, a pharmacist will receive instructions to fill the prescription with Nexium 24HR. The member will pay lesser of charge or the plan's cost share.
We are sending communications to pharmacies and letters to affected members in early July. More information about this drug is available at
nexium24hr.com.
Drug List Update Reminder
Drug List changes were posted in June and made to the EnhancedRx Drug List on July 1.
To talk with a representative about the drug list or updates, contact Pharmacy Services at 1.800.492.7259.
Credentialing Arrangement
CoOportunity Health utilizes Midlands Choice for provider network contracting and credentialing services. All providers in our networks are credentialed by Midlands Choice through a delegate arrangement.
Iowa Marketplace Choice Plan Network
If you are a Midlands Choice provider, you are in-network for Iowa Marketplace Choice Pan (IMCP) members. In Iowa and Nebraska, 100 percent of hospitals and 97 percent of practitioners are Midlands Choice providers.
For more information about IMCP, visit Plan Resources and select the IMCP tab.
Claim Submissions Reminders
Please follow the NUBC coding guidelines regarding the use of Bill Frequencies 1, 7 and 8. Replacement claims submitted with Bill Frequency 1 could deny as a duplicate.
Bill Frequency 7: Complete Replacement of a Prior Claim - This code is used when a specific bill has been issued for a specific provider, patient, insured and "Statement Covers Period," and the claim needs to be restated in its entirety except for the same identity information. In using this code, the payer is to operate on the principle that the original bill is null and void, and that the information present on this bill represents a complete replacement of the previously issued bill.
Bill Frequency 8: Void/Cancel of an Entire Prior Claim - This code reflects the elimination in its entirety of a previously submitted bill for a specific provider, patient, payer, insured and "Statement Covers Period." Providers may wish to follow a Void Bill with a bill containing the correct information when a payer is unable to process a replacement to a prior claim. The appropriate Frequency Code must be used when submitting the new bill.
Bill Frequency 1: Admit through Discharge Claim - This code is to be used for a bill which is expected to be the only bill to be received for a course of treatment or inpatient confinement. This will include bills representing a total confinement or course of treatment, and bills that represent an entire benefit period of the primary third-party payer.
Member Rights and Responsibilities
A member is entitled to certain rights and services. Members also have the right to participate in their healthcare. A good partnership between the member and the healthcare provider will enhance the provider's ability to provide appropriate services and the member's ability to receive the maximum benefit from these services.
View our complete Member Rights and Responsibilities Statement.
For New Providers and Staff Members
Access these tools to learn more about us at coOportunityhealth.com/Provider.
For access to our secure Provider website tools, contact your organization's site delegate or register today.
