1 Provider Relaons Newsleer August 2020 Inside This Issue: 1 Community Health Direct website link 1 ePower Provider Portal 1 New Provider Credentialing 1 New Providers, effective 8/1/2020 1 Termed Providers 2 Naming Conventions 2 Beacon Health Options 3 Imagine Health 4 Metformin ER Recall 5 Genetic Testing PA Updates 6 Provider Relations Staff Directory Credentialing of NEW Providers: ***PLEASE NOTE*** Credentialing through Community Health Direct for ALL new providers can take anywhere from 90-120 days from notification to completion. Community Health Direct Provider Relations Dept. [email protected]ePower Provider Portal: Look up member claims, eligibility and more on Community Health Direct’s Provider Portal (ePower) at: https://www.ecommunity.com/community-health-direct/ providers/community-gold-and-silver-plans Credentialing Corner: NEW Providers joining Community Health Direct - Click HERE TERMED Community Health Direct Providers - Click HERE JUST IN: Effective 7/1/2020, Community Health Direct has a NEW and improved website with valuable info for members & providers! Visit us at: https://www.ecommunity.com/community-health-direct
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August 2020 Provider Relations Newsletter...Newsletter August 2020 Inside This Issue: 1 Community Health Direct website link 1 ePower Provider Portal 1 New Provider Credentialing 1
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P r o v i d e r Re l a ti o n s N ew s l e tte r
August 2020
I n s i d e Th i s I s s u e :
1 Community Health Direct
website link
1 ePower Provider Portal
1 New Provider Credentialing
1 New Providers, effective 8/1/2020
1 Termed Providers
2 Naming Conventions
2 Beacon Health Options
3 Imagine Health
4 Metformin ER Recall
5 Genetic Testing PA Updates
6 Provider Relations Staff
Directory
Credentialing of NEW Providers:
***PLEASE NOTE***
Credentialing through Community Health Direct for ALL
In a review of the types of appeals received by the Community Health Direct in 2019, over 30% of them were for genetic testing. Half of the genetic tests were initially denied as ex-perimental and the other half for lack of obtaining a prior authorization. The genetic ser-vices that were not prior authorized were later reviewed for medical necessity as part of the appeal process; only one of these genetic services met medical necessity criteria re-sulting in continued denial of health plan coverage for the rest of these cases.
Prior authorization is required for ALL genetic test requests for Community Health Direct Gold, Silver and Bronze members to receive health plan coverage with two exceptions. The first exception to prior authorization for genetic testing is for prenatal testing that follows the American College of Obstetrician/Gynecologists (ACOG) guidelines. The second excep-tion is complicated and involves surgical tissue sent for genetic testing. Surgical tissue sent for testing of a specific gene or gene set, such as Lynch syndrome, does not require a prior authorization. Whole genome sequencing also called whole exome sequencing or molecu-lar profiling can be performed on both surgical tissue and on blood samples. The majority of the whole genome sequencing/molecular profiling tests are still considered experi-mental regardless of the sample submitted and therefore require a prior authorization. The specific indication where whole genome sequencing/molecular profiling may meet medical necessity is for stage IV or recurrent non-small cell lung cancer. Examples of ge-netic tests that involve whole genome sequencing/molecular profiling are FoundationOne, Target Now, Molecular Intelligence, MSK-IMPACT, GeneKey, and several more.
Prior authorization is necessary for genetic tests, as many of them are considered experi-mental or are only appropriate for patients with very specific symptoms or family histories. Please be aware of whether the tests you order for your patients include genetic tests. There are some test panels that include more routine labs along with genetic tests. Ge-netic testing is a rapidly expanding technology, you are always welcome to contact Medical Management at 317-621-7505 to determine whether a test panel includes a genetic test component or whether a whole genome sequencing/molecular profiling test is covered under the health plan.