Fax the Capital District Physicians' Health Plan (CDPHP) Professional Remit Information Sheet to (919) 800-6875. Power 2019 award information, visit jdpower.com/awards, 0202U 0223U 0224U 0225U 0226U 86328 86408 86409 86413 86769 87426 87428 87635 87636 87637 87811 U0001 U0002 U0003 U0004 U0005, CABG Arterial Single, CABG Arterial two, CABG Arterial three, CABG Arterial four or more, Numerous updates due to the release of January 1, 2021 CPT and HCPCS code additions, changes, and deletions. Prescription drugs require a prescription order with appropriate required information. COVID-19 is ruled out, or tests results are inconclusive or unknown. Report signs/symptoms diagnosis code(s) and Z20.822. Here are some common forms and documents used by provider offices. Please note that the current policy list is not exhaustive, but rather a collection of policies that providers have expressed an interest in viewing. on a fully completed Provider Review Form with additional supporting documents attached to CDPHP, Provider Services Department, 500 Patroon Creek Blvd., Albany, NY 12206-1057. . All Rights Reserved | Capital District Physicians' Health Plan, Inc. | 500 Patroon Creek Blvd. Use the portal to pay your premium, CDPHP is your partner in assuring that members have access to quality care. Yes. Patient has no signs/symptoms and has actual or suspected exposure to COVID-19. CMS updates to the allowable list of procedures that can be reported with modifier CS. **For J.D. There you can find information regarding code auditing logic. Quarterly, Capital District Physicians' Health Plan, Inc. (CDPHP) implements appropriate code auditing changes to remain current with industry standard coding updates. Blue Cross, Blue Shield and the Blue Cross and Blue Shield symbols are registered marks of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield companies. Dial ( 518) 641-3500 or1-800-926-7526. The Provider Office Administrative Manual (POAM) is a helpful reference guide to assist you with the day-to-day delivery of CDPHP medical benefits. Highmark Blue Cross Blue Shield serves the 29 counties of western Pennsylvania and 13 counties of northeastern Pennsylvania. Quarterly, Capital District Physicians Health Plan, Inc. (CDPHP) implements appropriate code auditing changes to remain current with industry standard coding updates. For more information on star ratings, visit www.medicare.gov. Each reimbursement policy includes information pertaining to all Highmark markets as indicated in the header, with state specific variations indicated within the policy bulletin. Were looking for well-qualified, talented individuals who can complement our growing CDPHP family and reflect our core values. A collection of Hewlett Packard (HP) Calculator Manuals since 1970s. CDPHP ensures your health insurance needs are covered with our health plans. Dear Network Provider: As a Capital District Physicians' Health Plan (CDPHP) network provider, you may find yourself in a position to provide services for a new group of Medicaid Managed Care (MMC) enrollees who require trauma-informed care: children/youth in direct placement foster care and in the care of Voluntary Foster Care Agencies (VFCA). Each reimbursement policy includes information pertaining to all Highmark markets as indicated in the header, with state specific variations indicated within the policy bulletin. If a denial is issued for the coding scenario, the rationale for the denial isprovided. Report diagnosis code for multisystem inflammatory diagnosis and Z20.822. Members are still responsible for their cost share if they received services unrelated to COVID-19, even if a COVID-19 diagnosis was present on the claim. Doctors can call the provider services department at (518) 641-3500, Monday through Friday, 7:30 a.m. to 5 p.m. to find out if a service requires prior authorization. Copyright 2023 Carelon. Press Enter or Space to expand a menu item, and Tab to navigate through the items. Is there someone available to go over behavioral health codes. Copyright CareSource 2023. This claims editing tool allows providers to enter a specific coding scenario and view the editing results in place on the date of the inquiry (not on the actual claim date of service). Fax the Group/Provider Access Information for 835 Transaction Set to (919) 800-6875. . This article provides coding tips, based on the current official 2021 ICD-10 guidelines, for using the new ICD-10 diagnosis code Z20.822. Cdphp Provider Manual, Esp Workstation 5.5 Manual, 1982 Yamaha Moped Manual, Janus 2020 Manual, Motorola D211 Manual, 1994 Yamaha Virago 250 Manual, Beolab 6000 Service Manual . Once a decision is made, regardless of the outcome, CDPHP will notify the provider and the member in writing and over the phone. You may also contact us at [email protected] or (518) 486-3209 for Medicaid pharmacy policy related questions. A clean claim is a claim received by Carelon with all required data present and valid that was adjudicated without having to obtain information from an external source. Updates to Change Healthcare Technologies, LLC ClaimsXten, our code auditing software, are based on recommendations from a variety of sources, including the American Medical Association (AMA), Centers for Medicare and . Ordering, Referring and Prescribing (ORP). Click the "View History" link on the first page of the policy to view previous versions. At CDPHP, our prior authorization process involves decision-making by medical professionals who base their determinations on two factors: the appropriateness of the service and the contractual relationship between our members and CDPHP. Highmark Blue Cross Blue Shield West Virginia serves the state of West Virginia plus Washington County. Press Space or Escape to collapse the expanded menu item. For a list of services that require prior authorization from CDPHP, members can log in and click Medical Guidelines in the My Resources section on the right-hand side, followed by Explore Prior Authorization Guidelines, also on the right-hand side at the top of the page. Search members and eligibility. We are dedicated to making administrative work as painless as possible because we know you have more important things to care about. All physician claims are to be submitted on either a CMS 1500 formor via a HIPAA compliant 837 transaction. Instructions & Manuals 1500 Medical Assert Training Quick; UB-04 Facility Claim Instruction Manual; . Members should check their plan to determine whether it includes out-of-network benefits. **For J.D. Report U07.1 only for confirmed cases, as documented by the provider or when there is documentation of a positive COVID-19 test. Find general guidelines on our policies and procedures, as well as links to detailed information and frequently used forms. UB-04 Device Claim Art. 837 Transaction Companion Guide. Highmark Blue Shield serves the 21 counties of central Pennsylvania and also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Purpose of this Manual This manual outlines the claiming requirements necessary to ensure proper claim submission for services affected by the Children's Health and Behavioral Health System Transformation (CFTSS and HCBS). Close. Suzanne is senior editor for the corporate communications department at CDPHP. Established in 1984, CDPHP is a physician-founded, member-focused and community-based not-for-profit health plan that offers high-quality affordable health insurance plans to members in 29 . Provider Enrollment & Maintenance Are you interested in Enrolling in the NYS Medicaid Program? Find out More billed with E&M consultation codes 99242 thru 99245. Only primary obstetrical providers are to bill codes Z1032 and Z1034. Billing NPI Number: Tax ID or SSN: Please sign in using the NPI number under which your office is enrolled and under which you submit claims. The Provider Office Administrative Manual (POAM) consists of two volumes and is updated annually at a minimum. Capital District Physicians Health Plan SX065_12X03 141641028 Other ID's: 12X03, 95491 Need to submit transactions to this insurance carrier? This diagnosis code can be reported for dates of service on or after January 1, 2021. For more information on star ratings, visit www.medicare.gov. Not already Contracted to Sell for CareSource? Members can also keep track of and check the status of their prior authorizations by clicking Medical Approvals in the right-hand column on their account home page. Once a decision is made, regardless of the outcome, CDPHP will notify the provider and the member in writing and over the phone. Non-prescription drugs, often referred to as Over-the-Counter or OTC drugs, require a fiscal order (a fiscal order contains all the same information contained on a prescription). Risk coding is the comprehensive capturing of all diagnosis codes through best practice documentation and billing protocols. Have a patient coming back to your office time and time again for reoccurring conditions or old injuries? As a result, you may notice differences in how your claim processes related to changes in code pairs in CCI, which includes modifier override changes; daily frequency limits; incidental, mutually exclusive and unbundled code edits; assistant surgeon eligibility; modifier to procedure compatibility; evaluation of incomplete diagnosis; global surgery pre-operative and post-operative periods as defined by CMS; and other standard coding code edits. When youre sick, injured, or are in need of a procedure, more than likely, the last thing on your mind is whether your health insurance company will pay for it. Network in the Know - Register Sign up for your e-newsletter today! Age Three and Up (NDAC 75-04-06) 6 Claims that are not submitted within the 90-day timeframe will not be considered for reimbursement. Check out our available positions. Volume II is a compendium of our policies and procedures available by logging into your account. Use CPT code 36483 to report the second and subsequent veins treated in a single extremity only when treated through separate access sites. Are you a Practitioner who needs to enroll as an Ordering, Prescribing, Referring or Attending (OPRA) non-billing Provider? This is not an all-inclusive list. Find-A-Doc Find a doctor, specialist, pharmacy, urgent care center, or other care facilities. However, we encourage providers to submit claims on a monthly basis. Volume I is designed to give you and your staff a comprehensive overview of CDPHP and its current administrative practices. Learn what to look for and what you can do about it. Pharmacy program and billing policy and other pharmacy related information can be found in the NYS MMIS Pharmacy Provider Manual and the Department's Medicaid Update. Add the Manuals Search extension and never lose a manual again. This plan uses a provider network. Welcome to MagnaCare's Provider Resource Center! The provider manual is a resource for working with our health plan. Updates to Change Healthcare Technologies, LLC ClaimsXten, our code auditing software, are based on recommendations from a variety of sources, including the American Medical Association (AMA), Centers for Medicare and Medicaid Services (CMS) Correct Coding Initiative and Medically Unlikely Edits, input from specialty organizations, the CPT manual, and the HCPCS Level II manual. Highmark Western and Northeastern New York Inc., serves eight counties in Western New York under the trade name Highmark Blue Cross Blue Shield of Western New York and serves 13 counties in Northeastern New York under the trade name Highmark Blue Shield of Northeastern New York. [] Find-A-Doc can help you locate the right one. Capital District Physicians Health Plan, Inc. 500 Patroon Creek Blvd., Albany, New York 12206, *NCQAs Private Health Plan Ratings 2019-2020. Since then, Karen has worn many hats at CDPHP. Birth through Age Two (NDAC 75-04-06-04) 5 B. The provider's request for registration must be verified prior to enrolling their bank account. | Albany, New York 12206, Provider Office Administration Manual (POAM), CDPHP Care Advantage (HMO C-SNP) Provider Education. doctor, request an ID Card and more. COVID-19 COVID-19 Important information for providers participating in MagnaCare and Create Claim submissions Claim submissions Learn how to submit claims to MagnaCare electronically. Karen Faxon is a registered nurse and certified coder who joined the CDPHP workforce in 1996. Find clinical tools and information about working with CareSource. All fields required unless otherwise noted. Please use it as a helpful reference guide to assist you with the day-to-day delivery of CDPHP medical benefits. In some cases, when a service or medication is approved, we will ask the members doctor to inform the member of our decision. Since the COVID-19 public health emergency was declared, diagnosis codes for reporting actual or suspected exposure to COVID-19 have been updated. Were looking for well-qualified, talented individuals who can complement our growing CDPHP family and reflect our core values. Provider Manual(s) Updates . Highmark Blue Cross Blue Shield Delaware serves the state of Delaware. Check out our available positions. This process, called prior authorization, prior approval, or precertification, serves to protect members safety and well-being. After providing services to an eligible CDPHP member, the practitioner/provider's office is required to prepare and submit aclaim form directly to the CDPHP claims department. Help customers save on generic prescriptions. Quarterly, Capital District Physicians' Health Plan, Inc. (CDPHP) implements appropriate code auditing changes to remain current with industry standard coding updates. When reporting endoluminal radiofrequency ablation (ERFA), use CPT code 36475 for the first vein on each extremity. 518-641-3301 For a complete listing of specialty programs and hours of operation, refer to the Medi-Cal Directory in the provider manual. The results of a coding inquiry may differ from the results of an actual claim payment as a claim may be affected by system edits outside of ClaimsXten (e.g., member eligibility, or other claim processing and/or pricing logic). On weekends, you can often find her gardening or walking her two dogs, Tilly and Jazzy. You want to assume that the answer is a resounding yes, and in most cases, it is. If you have any questions regarding these policies, please contact your . 835 Electronic Remittance Advice: CDPHP 835 Electronic Remittance Advice (ERA) Enrollment Request Complete the form as appropriate. For a complete summary of COVID-19 diagnosis coding guidelines in place as of January 1, 2021, please refer to the links provided below: For additional information on CDPHPs COVID-19 testing policy, please refer to COVID-19 Testing, 1550/20.000219, on the CDPHP Secure Provider Portal. Odds are that several of these providers are near you. talented individuals who can complement our growing CDPHP family press mirror our core value. Information on this benefit can be found in the New York State Medicaid State Plan Amendment. For reference to the ClaimsXten rules currently in place and significant customization, please refer to the Code Auditing Rules and Customization, 1550/20.000162 payment policy. They could be doctor shopping. Providers will receive notification of claims payment or denial via check and remittance advice. 2023 CDPHP. For additional information on CDPHP's COVID-19 testing policy, please refer to COVID-19 Testing, 1550/20.000219, on the CDPHP Secure Provider Portal. Many changes will take effect \u003cstrong\u003eJuly 6, 2023\u003c/strong\u003e. In addition, the approval will ensure that the claims are paid on time. Carelons standards for claim turnaround time are to pay clean claims within 30 days of initial receipt. All rights reserved. Providers. Simply fill out the brief form on this page to receive the latest issue and keep that important information flowing your way each month. Welcome to Carelon Health of Pennsylvania,formerly Beacon Health Options of Pennsylvania. The secure provider site offers you convenient, around-the-clock access to data on member eligibility, claims status, practice guidelines, and much more. 2023 CDPHP. By clicking on these links, you will leave the Fidelis Care website. Below is a high level summary of some of the changes. [email protected]. Since then, Karen has worn many hats at CDPHP. Welcome to NYRx, the Medicaid Pharmacy Program, Health & Safety in the Home, Workplace & Outdoors, Clinical Guidelines, Standards & Quality of Care, All Health Care Professionals & Patient Safety, James V. McDonald, M.D., M.P.H., Commissioner, The Latest on New York's Response to COVID-19, Multisystem Inflammatory Syndrome in Children (MIS-C), Health Care and Mental Hygiene Worker Bonus Program, Lyme Disease & Other Diseases Carried By Ticks, Maternal Mortality & Disparate Racial Outcomes, NY State of Health (Health Plan Marketplace), Help Increasing the Text Size in Your Web Browser. If we end up leaving a voicemail message for the doctor, we will also call the member. Should you have any questions, please call the CDPHP provider services department at (518) 641-3500 or 1-800-926-7526. Highmark adheres to the Centers for Medicare and Medicaid Services (CMS) coverage determinations for Medicare Advantage (MA) membership. Provider Office Admin Manual Section 01 - Introduction, Provider Office Admin Manual Section 02 - Members, Provider Office Admin Manual Section 03 - Government Programs, Provider Office Admin Manual Section 04 - Practitioners, Provider Office Admin Manual Section 05 - Referral & Authorization Process, Provider Office Admin Manual Section 06 - Waivers, Provider Office Admin Manual Section 07 - Services, Provider Office Admin Manual Section 08 - Coordination of Benefits, Provider Office Admin Manual Section 09 - Claim Submission, Provider Office Admin Manual Section 10 - Claim Payment & Provider Appeals, Provider Office Admin Manual Section 11 - Participating Providers, Provider Office Admin Manual Section 12 - Quality Enhancement, Provider Office Admin Manual Section 13 - OB/GYN Standards STD/HIV Screening, Provider Office Admin Manual Section 14 - Utilization Management Program, Provider Office Admin Manual Section 15 - Disease Management & Wellness Programs, Provider Office Admin Manual Section 16 - Case Management, Provider Office Admin Manual Section 17 - Advance Care Planning, Provider Office Admin Manual Section 18 - Behavioral Health, Provider Office Admin Manual Section 19 - Participating Facilities, Provider Office Admin Manual Section 20 - Dental, Provider Office Admin Manual Section 21 - Enhanced Primary Care, Provider Office Admin Manual Section 22 - Forms & Literature. See www.cdphp.com or call 1-800-777-2273 for a list of network providers . Quickly locate and download any forms you need to get your job done. The Provider Office Administrative Manual (POAM) is a helpful reference guide to assist you with the day-to-day delivery of CDPHP medical benefits. Providers should not bill separately for the chemical adhesive. The provider's request for registration must be verified prior to enrolling their bank account. . | Albany, New York 12206, CORE Service Initiation Notification Form, X12 HIPAA Standard Transaction Enrollment Request Form, Registration Form for Trading Partner Testing, Instructions for Electronic Claim and Trading Partner Testing, Instructions for Paper Claim and Trading Partner Testing, Appointment of Representative Form Instructions, Adult Behavioral Health HCBS: Authorization Request, Pharmacy/Medication Prior Authorization Request Form, Individualized Service Recommendation: PROS Admission Request, Psychological and Neuropsychological Testing Request, Preauthorization for Medical Services Request Form (Utilization Review), Student Out-of-Area Prior Authorization Form, Synagis Seasonal Respiratory Syncytial Virus Enrollment Form, Utilization Review Prior Authorization/Medical Exception Form Continuous Glucose Monitors, Medicare Vaccine Coverage Guide Part B Versus Part D. Create Your CDPHP Provider Account. \u003ca href=\"https://content.highmarkprc.com/Files/NewsletterNotices/SpecialBulletins/sb-post-phe-provider-communication.pdf\" target=\"_blank\" rel=\"noopener noreferrer\"\u003e\u003cstrong\u003eCLICK HERE\u003c/strong\u003e \u003c/a\u003efor the details.\u003c/p\u003e","longDescription":null,"visible":false,"archive":false,"liveStatus":2}], Effective: {{:: bull.dateVal(item.date)}}, Policy End: {{:: bull.dateVal(item.endDate)}}, Revised: {{:: bull.dateVal(item.additionalDate)}}. Doctors can call the provider services department at (518) 641-3500, Monday through Friday, 7:30 a.m. to 5 p.m. to find out if a service requires prior authorization. While CDPHP members are always encouraged to use network providers, at times they may need a procedure or to see a specialist whos out of network. All rights reserved. As a reminder, Clear Claim Connection is available on the CDPHP Secure Provider Portal. Power 2019 award information, visit jdpower.com/awards. Prior, she worked as a national campaign coordinator at the National Association of Broadcasters in Washington, DC, and as a copy editor and special sections editor at The Tampa Tribune. Should you have any questions, please call the CDPHP provider services department at (518) 641-3500 or 1-800-929-7526. Each of these companies is an independent licensee of the Blue Cross Blue Shield Association. Please use the Tax ID or Social Security Number under which you receive IRS reporting information (1099s). Press Enter on an item's link to navigate to that page. However, before certain services, medications, and procedures are received or performed, health insurers require that these services, medications, and procedures are deemed medically necessary and delivered at the proper location. Affordable high-quality coverage with commercial and government-sponsored plans to serve our members in New York state. 835 Transaction Companion Guide. For additional information, refer to the Provider Office Administrative Manual, Section 9: Claim Submission and Section 10: Claim Payment and Provider Appeals. When shes not fine-tuning others writing and her own, Suzanne enjoys running, traveling, scuba diving, and hanging out with her dogs and husband. **For J.D. Currently, she is a Senior Clinical Configuration analysis ensuring integrity of clinical codes and code auditing software. Press Tab or Shift+Tab to navigate through menu. While our members can certainly contact us to have a service or medication approved, we encourage them to leave this task to their doctors, who will already have the necessary documentation our medical directors need to make a decision. All Rights Reserved | Capital District Physicians' Health Plan, Inc. | 500 Patroon Creek Blvd. Mailing Address: California MMIS Fiscal Intermediary PO Box 13029 Sacramento, CA 95813-4029. Search Now. Karen Faxon is a registered nurse and certified coder who joined the CDPHP workforce in 1996. If the member's eligibility cannot be identified, the provider will receive notification via voucher designated "PAUNK." The member's name will be included on this voucher so that the provider can research and resubmit if necessary. Get all the details Important COVID-19 Changes The federal public health emergency has ended. Pharmacy program and billing policy and other pharmacy related information can be found in the NYS MMIS Pharmacy Provider Manual and the Department's Medicaid Update. Credentialing Submit Completed Document: Email or Fax to CDPHP. States are required to provide dental benefits to children covered by Medicaid and the Children's Health Insurance Program (CHIP), but states choose whether to provide dental benefits for adults. Every year, Medicare evaluates plans based on a 5-star rating system. Here you will find helpful information on MagnaCare programs and procedures for providers. Many more are available. . The chart is organized according to plan type and service. All claims must be submitted within ninety (90) days of the discharge date or date of service. Volume I is designed to give you and your staff a comprehensive overview of CDPHP and its current administrative practices. . Electronic funds transfer (EFT) payments are automatically transferred from CDPHP to your bank account, minimizing the risk of a delayed payment that could potentially happen with a paper check. Check out our available positions. Traditional IID/DD HCBS Waiver 4 B. Medicaid State Plan Services 4 C. General Fund Services 4 SECTION II - CLIENT ELIGIBILITY & ENROLLMENT 5 A. Report the reason for surgery as the primary diagnosis code and Z20.822 as an additional diagnosis code. Amendments, modifications, supplements to these posted policies and/or additional policies may be posted in the near future. Report signs/symptoms diagnosis code(s) and Z20.822. FIDELIS and FIDELIS CARE are trademarks of Centene Corporation, Clinical and Preventive Health Guidelines, Durable Medical Equipment (DME), Orthotics & Prosthetics, Fetal Surgery in Utero for Prenatally Diagnosed Malformations, Home Health Criteria for Prenatal and Postpartum Nursing Visits & Home Health Aide Services, Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea, Intradiscal Steroid Injections for Pain Management, Posterior Tibial Nerve Stimulation for-Voiding Dysfunction, Reduction Mammoplasty and Gynecomastia Surgery, Selective Dorsal Rhizotomy for Spasticity, Sickle Cell Anemia and -Thalassemia Cell Transplant, Transplant Service Documentation Requirements, Urinary Incontinence Devices and Treatments, 25-hydroxyvitamin D Testing in Children and Adolescents, Emergency Department Evaluation and Management Claim Adjustment, Evaluation and Management Claim Adjustment, Gastrointestinal Pathogen Nucleic Acid Detection Panel, Low-Frequency Ultrasound and Noncontact Normothermic Wound Therapy, National Diabetes Prevention Program (NDPP), Non-obstetrical and Obstetrical Transabdominal & Transvaginal Ultrasounds, Pre-Payment and Post-Payment Review (Non-Medicare), Pre-Payment and Post-Payment Review (Medicare), Spinal Muscular Atrophy (SMA) Carrier Screening in Pregnancy, Testing for Select Genitourinary Conditions, Transgender Services Billing Requirements, Transparency in Coverage Machine Readable Files.
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