Exceptions:
- Claims that deny because they are received after the timely filing requirement may be appealed up to 60 days from the claim's denial.
- Claims that deny to provider liability when a prior authorization was not requested may be appealed up to 30 days from the claim's denial.
To request a claims appeal or adjustment, select the appropriate form.
TOP
Review January 1 Drug List Changes
On January 1, we are changing from the EnhancedRx Drug List to the CoOportunity Health Drug List. In addition, we will be making a few general updates and the changes outlined below.
Prior Authorization Requirements
We are adding prior authorization requirements to a number of nonpreferred (tier 3) drugs. Affected drugs fall into these categories:
- Asthma & COPD
- Behavioral Health
- Diabetes (oral drugs and insulin)
- Heart Health (blood pressure & cholesterol lowering statins)
- Topical Acne
- Ulcers, Heartburn, or GERD
If you have prescribed one of these drugs, you will receive a letter about the change. Affected members will receive a similar letter.
High-Cost Drugs
We are moving some high-cost drugs to the tier 4 benefit level. Starting in January, tier 4 will include:
- Specialty Drugs
- All specialty drugs continue to be purchased through CVS Caremark Specialty Pharmacy.
- High-Cost Drugs
- If the high-cost drug is also a specialty drug, it must be purchased through CVS Caremark Specialty Pharmacy.
- If the drug is not a specialty drug, it can continue to be purchased at a retail or mail-order pharmacy.
The member still has coverage for these drugs, but may have a higher cost share. Keep in mind that a member's cost share (copayment, deductible, or coinsurance) is counted toward his or her out-of-pocket limit each calendar year.
Specialty Drugs
Several drugs that are self-administered and/or professionally administered will be added to the Specialty Pharmacy Drug List effective January 1, 2015.
- Infusion centers, outpatient centers, or home health agencies that provide and professionally administer a specialty drug to our member may procure the drug and bill the health plan for the infusion services and the drug.
- Members who self-administer a specialty drug must obtain the drug from our designated Specialty Pharmacy, CVS Caremark Specialty Pharmacy.
A few of the drugs are moving to the Specialty Drug List on January 1:
- Hereditary Angioedema: Cinryze, Berinert, Kalbitor
- Alpha-1 Antitrypsin: Glassia, Aralast, Prolastin, Zemaira
- Pulmonary HTM: Remodulin, Veletri
Members currently taking one of these drugs will receive notification of these changes.
Read More
Review more information about changes that become effective on January 1:
- January 2015 Drug List Changes - Includes list of drugs that will be changing tiers and/or requiring prior authorizations
- 2015 CoOportunity Health Drug List - Includes requirements that begin January 1; the 2014 drug list to be used for current fills is also available from this page until January
- High-Cost Drug List - Identifies tier 4 high-cost drugs that can be purchased at a retail or mail-order pharmacy
- Specialty Drug List - Identifies tier 4 specialty drugs that must be purchased through CVS Caremark Specialty Pharmacy
Additional Assistance
You may access Pharmacy Customer Service 24 hours per day, every day:
- Fax - 1.888.883.5434
- Telephone - 1.800.492.7259
- Mail - HealthPartners Pharmacy Services, PO Box 1309, Minneapolis, MN 55440
TOP
New Provider Directories Reflect Changes for 2015
Effective January 1, 2015, some providers' network status will change for some of our products. To make members and your staff aware of the changes, both our 2014 and 2015 Provider Directories will be available for your use and review the week of November 3.
In October, we mailed letters notifying providers whose status was changing to Tier 1 or to Tier 2 for CoOportunity Choice,* and either in- or out-of-network for CoOportunity Preferred in 2015. Our new 2015 product, CoOportunity CorePlus, will use the same network as Tier 1 Choice and Preferred.**
Your organization, current members, and shoppers should use the:
- 2014 directories for care in 2014.
- 2015 directories when selecting an insurance product and for care in 2015.
The 2014 directory will be removed in January 2015.
Note: All Midlands Choice providers will continue to be in-network for CoOportunity Premier members.
*Although our Choice product is not available for 2015 sales, employer groups may continue to have Choice until their 2015 renewal.
**Pending Centers for Medicare & Medicaid Services (CMS) and state approval.
TOP
New Modifiers to Be Added January 1
Effective January 1, 2015, the Medical Claims Policies will incorporate existing and new modifiers. The HQ modifier (group setting) will be updated, and new modifiers XE, XS, XP and XU will be added. Changes are available in our Claims Manual.
TOP
New and Updated Medical Policies
To review several new policies and updated criteria for medical and pharmacy services, check our Medical Policy Update dated November 1, 2014. Unless otherwise noted below, policies and revisions are effective January 1, 2015.
Medical Services
- Low-Dose Computed Tomography (CT for Screening for Lung Cancer) - New
- Mesenchymal Stem Cell Therapy for Orthopedic Indications - New
- Preventive Services - Children and Adolescents - New
- Selective Nerve Root Block (SNRB) for Diagnosis of Chronic Low Back Pain with Radiculopathy - New
Pharmacy Services
- Belinostat (Beleodaq) - New
- Blood Factor Products - New
- Growth Deficiency Therapy - Revised
- Medication for Risk Reduction of Primary Breast Cancer in Women - New eff. October 1, 2014
- Mucopolysaccharidoses (MPS) Drug Therapy - Revised eff. immediately
- Pralatrexate (Folotyn) - Revised eff. immediately
- Ramucirumab (Cyramza) - New
- Recent FDA-Approved Medications Coverage Policy - Reminder of prior approval requirement for new drugs
- Siltuximab (Sylvant) - New
- Vedolizumab (Entyvio) - New
TOP
Prior Authorizations and Notifications Web Page Available
Before providing services, please review CoOportunity Health's preservice coverage information, accessible from our new Prior Authorization and Notifications website page. You'll find a link to this page at coOportunityhealth.com/ProviderPolicyManual.
TOP
Access to Utilization Management Criteria
CoOportunity Health contracts with HealthPartners Administrators, Inc. to provide claims processing, medical management and certain other administrative services. You have access to staff who make utilization management decisions for CoOportunity Health.
- To receive information on medical utilization management criteria and its application to a specific case, call 1.888.467.0774.
- To receive information on pharmacy utilization management, call 1.800.492.7259.
The following administrative policies provide additional details:
TOP
Need to Add TINs/NPIs to Your Secure Website Account?
Your organization's delegate can now use a check/EFT number to instantly add Tax Identification Numbers (TINs)/National Provider Identifiers (NPIs) to your secure Provider website account. The new feature also enables delegates to view your organization's current access.
If you need TINs/NPIs added to your access, please contact your delegate.
TOP
Register Now for Fall 2015 Webinars
Want to learn more about 2015 product changes? Register for one of two webinars:
TOP
Tools for New Providers and Staff Members
For access to our secure Provider website tools, contact your organization's site delegate or register today.
TOP
