This past month, the managed care plans have published updates on events and policy changes impacting their organizations.

CareSource Updates: 

•  New Policy – Special Needs Car Seats: Recommendations by the AAP specify that car seats should be placed in the rear seat of the vehicle. However, they do note that a special needs child requiring frequent monitoring may need to be placed in the front seat when no adult is available to sit in the rear seat with the child. If the child is placed in the front seat, the automatic air bag should be disabled. Due to this CareSource has developed a new policy on special needs care seats. Click here to view the policy and what CareSource will cover.
• Coding and Billing Updates: Over the past several years, CareSource has implemented payment policies that reflect guidelines set forth by industry authorities. Starting on December 15, 2023, CareSource will begin implementing additional enhancements to their claims editing programs that promote correct coding and billing practices for all provider types and specialties. The enhancements take into consideration CareSource’s historical claims experience as well as policy guidelines from a variety of medical policy categories including: CMS National Coverage Determinations (NCD), Drug and Biologicals, Evaluation and Management Services,  National Correct Cording Initiative (NCCI), Psychiatry-Psychology, State Medicaid policies. After the implementation, your practice may receive claim denials or payment changes based on these enhanced claim editing concepts of your Explanation of Benefits or electronic remittances. Click here to read more about this update.

Molina Update: 

• EOP and 835 Files Refund Reporting Enhancement: On July 24, 2023, Molina made new enhancements to the reporting of refunds received that are displayed on the Explanation of Payment (EOP) and 835 files. Refund amounts were previously combined as a bulk total for the payment with a reference ID of the payment check history ID (CHKHST ID) on an EOP and 835. These sections will be updated to utilize a reference ID of the claim itself, allowing for more precise reporting of these transactions. Note: The setup of using WO/72 code types will remain. Updates include: EOP: Reference ID on the EOP adjustment section will reflect the claim ID or the transactions related to each refund posting and no longer use the check history ID & Provider Level Balance (PLB) segment on the 835: Items labeled as Provider Return/Refund credit reflect on the 835 as adjustment code type 72 with a reference ID of the claim ID for each refund. Items labeled Overpayment Recovery reflect on the 835 as adjustment code type WO with a reference ID of the claim ID for each refund. This is Molina’s method of recording refunds received and will result in a net total of $0.00 on the payment. Click here and scroll to the middle of page two to learn more about the update.