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School of Medicine
Johns Hopkins Advantage MD Pre-Authorization Guidelines Update
Based on your feedback, we have updated the pre-authorization guidelines for the Johns Hopkins Advantage MD programs. The updates are in alignment with industry standard and will be effective April 15.
Summary of updates:
Effective April 15, the following procedures no longer need pre-authorization:
- Carpal Tunnel Surgical Decompression
- Routine Outpatient Mental Health Services
- Sleep Studies
- Sacroiliac Joint Injections
- Transformaminal Epidurals
- Wound Clinic
Effective April 15, the following procedures have revised pre-authorization requirements:
- CT – CTA of Heart only
- MRI – Breast only
- Outpatient Surgery* (Ambulatory Surgical Center or Hospital-based)
*Specified surgeries continue to have pre-authorization requirements.
Emergency Room Facility Update
Effective March 23, 2017, EHP will follow the ER sudden and serious auto pay list for facility emergency services for members covered under the EHP medical plans for Johns Hopkins Hospital, Johns Hopkins Bayview and Johns Hopkins Health System with group numbers: E00090, E00091, E00092, E00093, E00190, E00192, E00194, E00198, E00006, E00007.
The ER sudden and serious list includes the ICD-10 codes designating an emergency room visit requiring immediate medical attention. The ER sudden and serious list will automatically adjudicate the hospital claims.
Diagnoses listed on the ER sudden and serious list will automatically adjudicate based on the principal diagnosis submitted and billed. This applies for hospitals billing with revenue codes 451/452.
Emergency services claims in which the principal diagnosis is not on the ER sudden and serious list will be subject to medical record review and possible denial of payment for services by EHP
Please refer to the Emergency Department Review Process, Policy: APL.009 for additional information.
If you have questions or need assistance with any other item, please contact Provider Relations at (888)-895-4998.
Johns Hopkins Advantage MD Influenza "Flu" Vaccinations
People 65 years and older are at greater risk of serious influenza (flu) disease. Immunosenescence (decline in immune function) is a normal part of aging, increasing the susceptibility of flu-related hospitalizations and deaths among people in this age group. We strongly encourage our seniors and their caregivers to get their flu vaccinations during this season.
According to the Centers for Disease Control and Prevention, there are two vaccines designed specifically for people 65 and older:
- The “high-dose vaccine” is designed specifically for people 65 and older and contains four times the amount of antigen as the regular flu shot. It is associated with a stronger immune response following vaccination (higher antibody production). Results from a clinical trial of more than 30,000 participants showed that adults 65 years and older who received the high dose vaccine had 24% fewer influenza infections as compared to those who received the standard dose flu vaccine. The high dose vaccine has been approved for use in the United States since 2009.
- The adjuvanted flu vaccine, Fluad, is made with MF59 adjuvant, which is designed to help create a stronger immune response to vaccination. In a Canadian observational study of 282 persons aged 65 years and older conducted during the 2011-12 season, Fluad was 63% more effective than regular-dose unadjuvanted flu shots. There are no randomized studies comparing Fluad with Fluzone High-Dose. This vaccine will be available for the first time in the United States during the 2016-2017 season.
The high-dose and adjuvanted flu vaccines may result in more of the mild side effects that can occur with standard-dose seasonal shots. Mild side effects can include pain, redness or swelling at the injection site, headache, muscle ache, and malaise.
In addition, it is important that people 65 years and older are up to date with pneumococcal vaccination to protect against pneumococcal disease, such as pneumonia, meningitis, and bloodstream infections. The annual focus on influenza vaccination is an ideal time to ensure that your patients are also up to date on their pneumococcal vaccination.
Johns Hopkins HealthCare (JHHC) will reimburse providers who administer pneumococcal and flu vaccinations for Advantage MD members.
- Pneumococcal and influenza (flu) virus vaccines are covered by Medicare Part B
- Member may receive the vaccine at a participating network pharmacy or at the provider’s office
- Member’s responsibility is $0
The provider must bill the appropriate CPT code, which includes the vaccine and administration of the vaccine, to be reimbursed for this service.
If an Evaluation and Management code (E&M code) is billed with the flu vaccine, it implies an examination has been completed and the applicable copay will be applied.
If you have questions, please contact the JHHC Provider Relations department at 888-895-4998.
Consistent with current standards of practice in mental health and addiction medicine, these changes will reduce administrative barriers and improve access for mental health and substance use disorder treatment.
The following services no longer have quantitative limits, however all other requirements remain unchanged:
- Partial hospitalization and intensice outpatient programs (must still be pre-authorized and reviewed for medical necessity)
- Substance use disorder rehabilitation facility (must still be pre-authorized and reviewed for medical necessity)
- Outpatient individual, family, and group psychotherapy (8 yearly unmanaged visits before submission of a treatment plan is required; outpatient services performed in a hospital or facility setting require referral)
- Psychological testing (must still be pre-authorized and reviewed for medical necessity)
- Smoking cessation quit attempts
- Smoking cessation counseling sessions per attempt
As a result of these changes, mental health and substance use disorder services, regardless of the length or quantity, may be covered as long as the care is authorized and considered medically or psychologically necessary and appropriate. The current benefit of not requiring a referral or authorization for the first eight outpatient mental health visits in a fiscal year remains unchanged.
Also effective October 3, 2016, copays for mental health and substance abuse services will be changed as follows:
|Prior to 10/3/16||On and after 10/3/16|
|Individual Outpatient Psychotherapy||$25||$12/visit|
|Inpatient Mental Health||$40/day||$11/day ($25 minimum per visit)|
Download the Uniform Treatment Plan form to be submitted for purposes of treatment authorization.
Please contact the customer service department at 410-424-4528 or 800-808-7347 with questions.
Did you know that NCQA rates the Johns Hopkins Health Plans each year? All of the John’s Hopkins health plans rated as high performance plans in 2016. NCQA’s Health Insurance Plan Ratings are based on quality measures (HEDIS), member satisfaction (CAHPS) and NCQA Accreditation standards scores. NCQA’s uses a rating methodology which classifies plans into scores from 1-5 in 0.5 increments–-a system similar to CMS’ Five-Star Quality Rating System. You can view each plan’s report card on the NCQA website.
The 2016 NCQA ratings are as follows:
- EHP – High performance (4.0) with Accredited Accreditation
- PPMCO – High performance (4.0) with Commendable Accreditation
- USFHP – High Performance (5.0) with Excellent Accreditation
The Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT) features many required health care services for children on Medicaid. To help you stay informed about the requirements of EPSDT, we have created a webpage with helpful information and links to periodicity schedules, immunization recommendations, and additional resources. Visit the EPSDT webpage for more information.
Thank you for providing great health care to our Priority Partners child members, and we hope this information helps you to continue this great care.
Johns Hopkins HealthCare has begun sending the 277CA EDI transaction to providers for EDI claims errors for Employer Health Programs (EHP) and Priority Partners members.
What is the 277CA?
A 277CA is an acknowledgement back from the Payer to the provider indicating that a claim was received by Payer, but was unable to be accepted for processing. A common example of a claim unable to be accepted is a claim with an invalid member ID number.
The 277CA will be sent to the various EDI claim trading partners who submit claims to Johns Hopkins HealthCare on behalf of providers. The EDI trading partners will in turn send those transactions to the provider or their EDI contractor or vendor.
Providers who use outside contractors or vendors for their EDI claims transactions will need to contact their EDI vendor to setup the receipt of the 277CA from Johns Hopkins HealthCare.
The 277CA will use both the CARC’s and RARC’s to explain what needs to be corrected on the claim and then resubmit them back to Johns Hopkins HealthCare for processing as a new claim.
The purpose of the 277CA is to better serve our provider network and reduce the need for providers to make a phone call to check on a claim status.
This follow-up to Seminar I presents additional tools and tactics to close gaps in care and optimize Medicare Advantage Hierarchical Conditional Coding and is designed for practice administrators, office managers and appropriate clinical staff.
Seminar II is offered:
Thursday, September 15, 1 p.m. – 4 p.m.
Thursday, December 8, 9 a.m. – 12 p.m. or 1 p.m. – 4 p.m.
Johns Hopkins HealthCare
Suite D Conference Room
6701 Baymeadow Drive
Glen Burnie, MD 21060
Please RSVP to one of the offerings to firstname.lastname@example.org or 888-895-4998.
If a representative from the provider entity attends two seminars, the provider entity will receive a $100 incentive.
Please note that CME and CEU credit is not offered. Please call Provider Relations with questions about the seminar at 888-895-4998.
Per the Provider Notice letter you should have received, the 2016 Outpatient Referral & Pre-Authorization Guidelines for EHP, Priority Partners, and USFHP are now up on the JHHC website. To view these guidelines, please click the links below:
The Alternative Drug Guide for EHP Members is a tool that displays drug brands by category and offers less expensive, generic alternatives to consider for each brand. Please do your part and save your patients money by prescribing cost-effective medications.
The state is now prepared to process redetermination forms. They will begin contacting everyone who was up to re-enroll since last October. Priority Partners will be contacting members who are up for redetermination giving them information on where they can get a redetermination form, what they need to complete the form, and where to send the forms. Be sure to EVS patients to ensure eligibility.
Under your Participating Provider Agreement with JHHC, you are entitled to notices regarding the policies and procedures and the Provider Manual, and modifications thereto, applicable under your agreement. Moving forward, notice of policies and procedures and the Provider Manual, together with medications thereto, will be posted on the JHHC website so that you can remain up-to-date on policies and procedures applicable under the Agreement. We will also send a notification of updates via email and fax 30 days prior to policy effective dates. You should have received a letter in the mail as your official notification of this change.