 Provider News FloridaFebruary 1, 2024 February 2024 Provider Newsletter Featured Articles Quality Management | Simply Healthcare Plans, Inc. - Medicaid Managed Care / Simply Healthcare Plans, Inc. - Florida Healthy Kids / Clear Health Alliance - Medicaid Managed Care | January 17, 2024 Quality Management | Simply Healthcare Plans, Inc. - Medicare Advantage | January 12, 2024
Policy UpdatesPolicy Updates | Simply Healthcare Plans, Inc. - Medicaid Managed Care / Simply Healthcare Plans, Inc. - Florida Healthy Kids / Clear Health Alliance - Medicaid Managed Care | January 12, 2024 Lab testing reminderQuality ManagementQuality Management | Simply Healthcare Plans, Inc. - Medicaid Managed Care / Simply Healthcare Plans, Inc. - Florida Healthy Kids / Clear Health Alliance - Medicaid Managed Care | January 17, 2024 New year, new opportunities for clinic days
FLSMPLY-CDCR-048978-24 HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). Digital Solutions | Simply Healthcare Plans, Inc. - Medicare Advantage / Simply Healthcare Plans, Inc. - Medicaid Managed Care | February 1, 2024 Update: Your requests for additional information will be sent digitally in FebruaryBeginning in February 2024, we will notify you through your Attachments Dashboard when we need medical records, itemized bills, or other documents required to process our member’s claims. When your organization registered to use the Medical Attachments application through Availity Essentials, you also registered to receive digital notifications through that application. This makes it possible for us to notify you digitally when we need documents to process your claim. Digital Request for Additional Information (Digital RFAI) is 50% faster than returning documentation and itemized bills any other way — making it the most efficient way to receive and return information.* Digital RFAI also eliminates the guess work associated with claim documentation by sending you a notification that tells you exactly what is needed. Notifications arrive daily on your Attachments Dashboard on Availity.com so there is no need to key-in claims information to attach documents. Be ready — Take an on-demand or live learning sessionIn collaboration with Availity, we’ve developed a precheck program for your organization’s Availity administrators to ensure your Medical Attachment registration is complete and that you are prepared for Digital RFAI. It is very important that your Availity administrators use this link to register to view the live training on-demand. For associates who are responsible for sending attachments, we’ve developed an enhanced training session that walks through the Attachments Dashboard and many of the unique features that make it most efficient. Availity users with the Medical Attachments and Claims Status role assignment should use this link to register to view the live training on-demand. Resources available For additional resources, contact your provider relationship management representative. * Internal post-launch phase one survey. June 2022. Simply Healthcare Plans, Inc. is a Managed Care Plan with a Florida Medicaid contract.
Simply Healthcare Plans, Inc. is a Medicare contracted coordinated care plan that has a Medicaid contract with the State of Florida Agency for Health Care Administration to provide benefits or arrange for benefits to be provided to enrollees. Enrollment in Simply Healthcare Plans, Inc. depends on contract renewal. FLSMPLY-CDCR-049410-23-CPN48759 Policy Updates | Simply Healthcare Plans, Inc. - Medicaid Managed Care / Clear Health Alliance - Medicaid Managed Care | January 24, 2024 Clinical Criteria updates — September 2023On September 21, 2023, and October 4, 2023, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Simply and CHA. These policies were developed, revised, or reviewed to support clinical coding edits. Visit Clinical Criteria to search for specific policies. For questions or additional information, use this email. Please see the explanation/definition for each category of Clinical Criteria below: - New: Newly published criteria
- Revised: Addition or removal of medical necessity requirements, new document number
- Updates Marked with an asterisk (*) notate that the criteria may be perceived as more restrictive
Please share this notice with other providers in your practice and office staff. Please note:- The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
- This notice is meant to inform the provider of new or revised criteria that has been adopted by Simply and CHA only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.
Effective date | Clinical Criteria number | Clinical Criteria title | New or revised | March 1, 2024 | *CC-0248 | Elrexfio (elranatamab-bcmm) | New | March 1, 2024 | *CC-0249 | Talvey (talquetamab-tgvs) | New | March 1, 2024 | *CC-0250 | Veopoz (pozelimab-bbfg) | New | March 1, 2024 | *CC-0251 | Ycanth (cantharidin) | New | March 1, 2024 | *CC-0021 | Fabrazyme (agalsidase beta) | Revised | March 1, 2024 | *CC-0046 | Zinplava (bezlotoxumab) | Revised | March 1, 2024 | *CC-0233 | Rebyota (fecal microbiota, live – jslm) | Revised | March 1, 2024 | *CC-0020 | Natalizumab Agents (Tysabri, Tyruko) | Revised | March 1, 2024 | *CC-0247 | Beyfortus (nirsevimab) | Revised |
Simply Healthcare Plans, Inc. is a Managed Care Plan with a Florida Medicaid contract. Simply Healthcare Plans, Inc. dba Clear Health Alliance is a Managed Care Plan with a Florida Medicaid contract. FLSMPLY-CD-048725-23-CPN48226 SummaryOn September 21, 2023, and October 4, 2023, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Simply Healthcare Plans, Inc. (Simply). These policies were developed, revised, or reviewed to support clinical coding edits. Visit Clinical Criteria to search for specific policies. For questions or additional information, use this email. Please see the explanation/definition for each category of Clinical Criteria below: - New: newly published criteria
- Revised: addition or removal of medical necessity requirements, new document number
- Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive
Please share this notice with other providers in your practice and office staff. Please note: - The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
- This notice is meant to inform the provider of new or revised criteria that has been adopted by Simply. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.
Effective date | Clinical Criteria number | Clinical Criteria title | New or revised | February 19, 2024 | *CC-0248 | Elrexfio (elranatamab-bcmm) | New | February 19, 2024 | *CC-0249 | Talvey (talquetamab-tgvs) | New | February 19, 2024 | *CC-0250 | Veopoz (pozelimab-bbfg) | New | February 19, 2024 | *CC-0251 | Pompe Disease | New | February 19, 2024 | *CC-0018 | Pompe Disease | Revised | February 19, 2024 | *CC-0021 | Fabrazyme (agalsidase beta) | Revised | February 19, 2024 | *CC-0046 | Zinplava (bezlotoxumab) | Revised | February 19, 2024 | CC-0182 | Iron Agents | Revised | February 19, 2024 | *CC-0068 | Growth Hormones | Revised | February 19, 2024 | CC-0156 | Reblozyl (luspatercept) | Revised | February 19, 2024 | *CC-0233 | Rebyota (fecal microbiota, live – jslm) | Revised | February 19, 2024 | *CC-0020 | Natalizumab Agents (Tysabri, Tyruko) | Revised | February 19, 2024 | CC-0064 | Interleukin-1 Inhibitors | Revised | February 19, 2024 | CC-0026 | Testosterone Injectable | Revised | February 19, 2024 | *CC-0247 | Beyfortus (nirsevimab) | Revised |
Simply Healthcare Plans, Inc. is a Medicare contracted coordinated care plan that has a Medicaid contract with the State of Florida Agency for Health Care Administration to provide benefits or arrange for benefits to be provided to enrollees. Enrollment in Simply Healthcare Plans, Inc. depends on contract renewal. FLSMPLY-CR-047337-23-CPN47070 Summary: On September 21, 2023, and October 4, 2023, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Simply Healthcare Plans, Inc. (Simply). These policies were developed, revised, or reviewed to support clinical coding edits. Visit Clinical Criteria to search for specific policies. For questions or additional information, use this email. Please see the explanation/definition for each category of Clinical Criteria below: - New: Newly published criteria
- Revised: Addition or removal of medical necessity requirements, new document number
- Updates Marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.
Please share this notice with other providers in your practice and office staff. Please note: - The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
- This notice is meant to inform the provider of new or revised criteria that has been adopted by Simply only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.
Effective date | Clinical Criteria number | Clinical Criteria title | New or revised | February 25, 2024 | *CC-0248 | Elrexfio (elranatamab-bcmm) | New | February 25, 2024 | *CC-0249 | Talvey (talquetamab-tgvs) | New | February 25, 2024 | *CC-0250 | Veopoz (pozelimab-bbfg) | New | February 25, 2024 | *CC-0251 | Ycanth (cantharidin) | New | February 25, 2024 | *CC-0018 | Pompe Disease | Revised | February 25, 2024 | *CC-0021 | Fabrazyme (agalsidase beta) | Revised | February 25, 2024 | *CC-0046 | Zinplava (bezlotoxumab) | Revised | February 25, 2024 | CC-0182 | Iron Agents | Revised | February 25, 2024 | *CC-0068 | Growth Hormones | Revised | February 25, 2024 | CC-0156 | Reblozyl (luspatercept) | Revised | February 25, 2024 | *CC-0233 | Rebyota (fecal microbiota, live – jslm) | Revised | February 25, 2024 | *CC-0020 | Natalizumab Agents (Tysabri, Tyruko) | Revised | February 25, 2024 | CC-0064 | Interleukin-1 Inhibitors | Revised | February 25, 2024 | *CC-0247 | Beyfortus (nirsevimab) | Revised |
Simply Healthcare Plans, Inc. is a Managed Care Plan with a Florida Medicaid contract. Simply Healthcare Plans, Inc. is a Managed Care Plan with a Florida Healthy Kids contract. FLSMPLY-CD-048726-23-CPN48226 Policy Updates | Simply Healthcare Plans, Inc. - Medicaid Managed Care / Simply Healthcare Plans, Inc. - Florida Healthy Kids / Clear Health Alliance - Medicaid Managed Care | January 12, 2024 Lab testing reminderBackgroundIn February 2022, updates to Clinical Utilization Management (UM) Guidelines were published with an August 1, 2022, effective date. These updates included changes to clinical coding edits for the lab test indicated below. UpdateThe updated guidelines state that only medically necessary lab testing will be covered. Effective March 1, 2024, coverage for these labs will be denied unless medically necessary: Clinical UM Guideline number/title | Clinical indications for medical necessity | MCD ENT — CG-Lab-29: Gamma Glutamyl Transferase Testing | GGT testing using blood is considered medically necessary for any of the following indications: - To differentiate between sources of elevated alkaline phosphatase activity; or
- To evaluate liver function, injury, or disease in individuals with at least one of the following:
- Known or suspected hepatobiliary disease; or
- Alcohol use disorder; or
- Substance use disorder; or
- Therapy with medication that has potentially toxic effects on the liver; or
- Exposure to hepatotoxins; or
- Infections that may cause liver injury (for example, viral hepatitis, amoebiasis, tuberculosis, and similar infections); or
- Pancreatic disease; or
- Gastrointestinal disease; or
- Liver transplantation; or
- Primary or secondary malignant neoplasms; or
- Diseases or conditions known to have liver involvement (for example, diabetes mellitus, sarcoidosis, amyloidosis, disorders of iron and mineral metabolism, lupus, hypertension, heart failure).
|
Clinical UM Guideline number/title | Clinical indications for medical necessity | MCD ENT-CG — Lab-30: Outpatient Laboratory-based Blood Glucose Testing | Blood glucose testing is considered medically necessary for individuals who meet any of the following criteria (A through Q): - Signs or symptoms of either of the following:
- Hypoglycemia; or
- Hyperglycemia; or
- Overweight or obesity* of any age; or
- From a population with a high prevalence of diabetes mellitus**; or
- Impaired fasting glucose has been found on other testing; or
- Pregnant and considered to be at high risk for type 2 diabetes mellitus; or
- Prior testing at least 3 months previously showed abnormal blood glucose results; or
- Insulin resistance syndrome; or
- Carbohydrate intolerance; or
- Hypoglycemia disorders, such as nesidioblastosis or insulinoma; or
- Catabolic or malnutrition states; or
- Tuberculosis; or
- Unexplained chronic or recurrent infection; or
- Alcohol use disorder; or
- Coronary artery disease; or
- Unexplained skin conditions (including pruritis, local skin infections, ulceration, and gangrene without an established cause); or
- Chronic glucocorticoid therapy; or
- To evaluate glycemic status for individuals with established diabetes mellitus, prediabetes, or a history of gestational diabetes when done no more often than the following test frequencies:
- Up to once yearly for individuals with prediabetes; or
- Up to two times per year for individuals with diabetes mellitus who are meeting treatment goals; or
- Within the first year postpartum and then up to once yearly for individuals who have had gestational diabetes.
Notes: * ADA, ACOG, and USPSTF recommendations about individuals who have overweight or obesity and ** Populations with high prevalence of diabetes mellitus |
What if I have questions?Availity Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity Essentials, go to Availity.com and select the appropriate payer space tile from the drop-down. Then, select Chat with Payer and complete the pre-chat form to start your chat. For additional support, visit the Contact Us section at the bottom of our provider's website for the appropriate contact. Simply Healthcare Plans, Inc. is a Managed Care Plan with a Florida Medicaid contract. Simply Healthcare Plans, Inc. is a Managed Care Plan with a Florida Healthy Kids contract. FLSMPLY-CD-047594-23-CPN47422 Policy Updates | Simply Healthcare Plans, Inc. - Medicaid Managed Care / Clear Health Alliance - Medicaid Managed Care | January 17, 2024 Carelon Medical Benefits Management, Inc. updatesEffective April 1, 2024, Simply and CHA will transition to the following Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines for medical necessity/clinical appropriateness reviews for requested interventions: - Cardiology Guidelines:
- Cardiac Resynchronization Therapy
- Endovascular Revascularization
- Implantable Cardioverter Defibrillators
- Permanent Implantable Pacemakers
Existing precertification requirements have not changed. Please share this notice with other members of your practice and office staff. Simply Healthcare Plans, Inc. is a Managed Care Plan with a Florida Medicaid contract. Simply Healthcare Plans, Inc. dba Clear Health Alliance is a Managed Care Plan with a Florida Medicaid contract. FLSMPLY-CD-048098-23 Medical Policy & Clinical Guidelines | Simply Healthcare Plans, Inc. - Medicare Advantage | January 1, 2024 Carelon Medical Benefits Management, Inc. updatesThe Carelon Medical Benefits Management Clinical Appropriateness Guidelines below have been updated. Existing precertification requirements have not changed. Please share this notice with other members of your practice and office staff. Effective for dates of service on and after April 14, 2024, the following updates will apply to the Carelon Medical Benefits Management Clinical Appropriateness Guidelines for medical necessity review for Simply Healthcare Plans, Inc.: - Musculoskeletal:
- Interventional Pain Management
- Sacroiliac Joint Fusion
- Radiology:
- Imaging of the Chest
- Imaging of the Head and Neck
- Imaging of the Brain
- Oncologic Imaging
- Imaging of the Abdomen and Pelvis
- Imaging of the Heart
- Radiation Oncology:
- Proton Beam Therapy
- Perirectal Hydrogel Spacer for Prostate Radiotherapy
- Rehabilitation:
- Physical, Occupational, and Speech Therapies
Simply Healthcare Plans, Inc. is a Medicare contracted coordinated care plan that has a Medicaid contract with the State of Florida Agency for Health Care Administration to provide benefits or arrange for benefits to be provided to enrollees. Enrollment in Simply Healthcare Plans, Inc. depends on contract renewal. FLSMPLY-CR-047229-23-CPN46504 Medical Policy & Clinical Guidelines | Simply Healthcare Plans, Inc. - Florida Healthy Kids | January 3, 2024 Carelon Medical Benefits Management, Inc. updatesThe Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines below have been updated. Existing precertification requirements have not changed. Please share this notice with other members of your practice and office staff. Effective for dates of service on and after April 14, 2024, the following updates will apply to the Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines for medical necessity review for Simply Healthcare Plans, Inc.: - Musculoskeletal Guidelines:
- Interventional Pain Management
- Sacroiliac Joint Fusion
- Radiation Oncology:
- Proton Beam Therapy
- Perirectal Hydrogel Spacer for Prostate Radiotherapy
- Rehabilitation:
- Physical, Occupational, and Speech Therapies
Simply Healthcare Plans, Inc. is a Managed Care Plan with a Florida Medicaid contract. Simply Healthcare Plans, Inc. is a Managed Care Plan with a Florida Healthy Kids contract. FLSMPLY-CD-047285-23-CPN46505 Medical Policy & Clinical Guidelines | Simply Healthcare Plans, Inc. - Medicaid Managed Care / Clear Health Alliance - Medicaid Managed Care | January 23, 2024 Medical Policies and Clinical Utilization Management GuidelinesThe Medical Policies, Clinical Utilization Management (UM) Guidelines, and Third-Party Criteria below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. Please share this notice with other providers in your practice and office staff. To view a guideline, visit: Notes/updatesUpdates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive: - MED.00004 – Noninvasive Imaging Technologies for the Evaluation of Skin Lesions; Previously Titled: Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy and Ultrasonography)
- Revised title
- Added additional technologies to Investigational & Not Medically Necessary section
- CG-ANC-06 – Ambulance Services: Ground; Non-Emergent
- Revised Medically Necessary and Not Medically Necessary statements regarding mileage
- Revised Not Medically Necessary statement to remove list of non-covered indications
- CG-SURG-95 – Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention; Previously Titled: Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence, Urinary Retention
- Revised title
- Added Medically Necessary criteria for temporary SNS for urinary and fecal conditions
- Reformatted Medically Necessary criteria for permanent SNS for urinary and fecal conditions
- Revised the Clinical Indications section IV for percutaneous or implantable tibial nerve stimulation (PTNS) to include implantable devices
Medical PoliciesOn May 11, 2023, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Simply and CHA. These medical policies take effect March 1, 2024. Publish date | Medical Policy number | Medical Policy title | New or revised | 6/28/2023 | *MED.00004 | Noninvasive Imaging Technologies for the Evaluation of Skin Lesions Previously Titled: Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy and Ultrasonography) | Revised | 7/18/2023 | MED.00135 | Gene Therapy for Hemophilia | Revised | 5/25/2023 | SURG.00121 | Transcatheter Heart Valve Procedures | Revised | 6/28/2023 | TRANS.00025 | Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection | Revised |
Clinical UM GuidelinesOn May 11, 2023, the MPTAC approved the following Clinical UM Guidelines applicable to Simply and CHA. These guidelines were adopted by the medical operations committee for Medicaid members on June 22, 2023. These guidelines take effect March 1, 2024. Publish date | Clinical UM Guideline number | Clinical UM Guideline title | New or revised | 6/28/2023 | *CG-ANC-06 | Ambulance Services: Ground; Non-Emergent | Revised | 6/28/2023 | CG-DME-31 | Powered Wheeled Mobility Devices | Revised | 6/28/2023 | CG-DME-36 | Pediatric Gait Trainers | Revised | 6/28/2023 | CG-DME-42 | Continuous Glucose Monitoring Devices and External Insulin Infusion Pumps | Revised | 6/28/2023 | CG-GENE-16 | BRCA Genetic Testing | Revised | 6/28/2023 | CG-GENE-22 | Gene Expression Profiling for Managing Breast Cancer Treatment | Revised | 5/25/2023 | CG-LAB-22 | Nucleic Acid Amplification Tests Using Algorithmic Analysis for the Diagnosis of Vaginitis Previously Titled: Nucleic Acid Amplification Tests Using Algorithmic Analysis for the Diagnosis of Bacterial Vaginosis | Revised | 6/28/2023 | CG-LAB-25 | Outpatient Glycated Hemoglobin and Protein Testing | Revised | 6/28/2023 | CG-MED-59 | Upper Gastrointestinal Endoscopy in Adults | Revised | 6/28/2023 | CG-MED-66 | Cryopreservation of Oocytes or Ovarian Tissue | Revised | 6/28/2023 | CG-SURG-101 | Ablative Techniques as a Treatment for Barrett's Esophagus | Revised | 6/28/2023 | CG-SURG-61 | Cryosurgical, Radiofrequency or Laser Ablation to Treat Solid Tumors Outside the Liver | Revised | 6/28/2023 | *CG-SURG-95 | Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention Previously Titled: Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence, Urinary Retention | Revised |
Simply Healthcare Plans, Inc. is a Managed Care Plan with a Florida Medicaid contract. Simply Healthcare Plans, Inc. dba Clear Health Alliance is a Managed Care Plan with a Florida Medicaid contract. FLSMPLY-CD-046936-23-CPN43701 UPDATE: This article was originally published as being effective March 1, 2024. The effective date has been delayed to May 1, 2024. Effective May 1, 2024, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA for Simply Healthcare Plans, Inc. members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions take precedence over these precertification rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims. Prior authorization requirements will be added for the following code(s): Code | Description | E0761 | Non-Thermal Pulsed High Frequency Radiowaves, High Peak Power Electrom |
Not all PA requirements are listed here. Detailed PA requirements are available to providers on provider.simplyhealthcareplans.com on the Resources tab or for contracted providers by accessing Availity.com. Providers may also call Provider Services at 844-405-4297 for assistance with PA requirements. UM AROW #: A2023M0415 Simply Healthcare Plans, Inc. is a Medicare contracted coordinated care plan that has a Medicaid contract with the State of Florida Agency for Health Care Administration to provide benefits or arrange for benefits to be provided to enrollees. Enrollment in Simply Healthcare Plans, Inc. depends on contract renewal. FLSMPLY-CR-044190-23-CPN43845, CPN-CRMMP-049296-24 UPDATE: This article was originally published as being effective March 1, 2024. The effective date has been delayed to May 1, 2024. Effective May 1, 2024, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Simply Healthcare Plans, Inc. for Medicare members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions take precedence over these precertification rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims. Prior authorization requirements will be added for the following code(s): Code | Description | 0738T | Treatment planning for magnetic field induction ablation of malignant prostate tissue, using data from previously performed magnetic resonance imaging (MRI) examination | 0739T | Ablation of malignant prostate tissue by magnetic field induction, including all intraprocedural, transperineal needle/catheter placement for nanoparticle installation and int |
Not all PA requirements are listed here. Detailed PA requirements are available to providers on provider.simplyhealthcareplans.com on the Resources tab or for contracted providers by accessing Availity.com. Providers may also call Provider Services at 844-405-4297 for assistance with PA requirements. UM AROW #: A2023M0443 Simply Healthcare Plans, Inc. is a Medicare contracted coordinated care plan that has a Medicaid contract with the State of Florida Agency for Health Care Administration to provide benefits or arrange for benefits to be provided to enrollees. Enrollment in Simply Healthcare Plans, Inc. depends on contract renewal. FLSMPLY-CR-044242-23-CPN43832, CPN-CRMMP-049296-24 UPDATE: This article was originally published as being effective March 1, 2024. The effective date has been delayed to May 1, 2024. Effective May 1, 2024, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Simply Healthcare Plans, Inc. for Medicare members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions take precedence over these precertification rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims. Prior authorization requirements will be added for the following code(s): Code | Description | Q4272 | Esano a, per square centimeter | Q4273 | Esano aaa, per square centimeter | Q4274 | Esano ac, per square centimeter | Q4275 | Esano aca, per square centimeter | Q4276 | Orion, per square centimeter | Q4277 | Woundplus membrane or e-graft, per square centimeter | Q4278 | Epieffect, per square centimeter | Q4280 | Xcell amnio matrix, per square centimeter | Q4281 | Barrera sl or barrera dl, per square centimeter | Q4282 | Cygnus dual, per square centimeter | Q4283 | Biovance tri-layer or biovance 3l, per square centimeter | Q4284 | Dermabind sl, per square centimeter |
Not all PA requirements are listed here. Detailed PA requirements are available to providers on provider.simplyhealthcareplans.com on the Resources tab or for contracted providers by accessing Availity.com. Providers may also call Provider Services at 844-405-4297 for assistance with PA requirements. UM AROW #: A2023M0417 Simply Healthcare Plans, Inc. is a Medicare contracted coordinated care plan that has a Medicaid contract with the State of Florida Agency for Health Care Administration to provide benefits or arrange for benefits to be provided to enrollees. Enrollment in Simply Healthcare Plans, Inc. depends on contract renewal. FLSMPLY-CR-044204-23-CPN43849, CPN-CRMMP-049296-24 Effective March 1, 2024, the following medication codes will require prior authorization. Please note, inclusion of a National Drug Code (NDC) on your medical claim is necessary for claims processing. Visit the Clinical Criteria website to search for the specific Clinical Criteria listed below. Clinical Criteria | HCPCS or CPT® code(s) | Drug name | CC-0241 | J3490, J3590 | Elfabrio (pegunigalsidase alfa-iwxj) | CC-0242 | C9399, J3490, J3590, J9999 | Epkinly (epcoritamab-bysp) | CC-0237 | J3490, J3590 | Qalsody (tofersen) | CC-0243 | J3490, J3590 | Vyjuvek (beremagene geperpavec) | CC-0240 | J9999 | Zynyz (retifanlimab-dlwr) |
What if I need assistance?If you have questions about this communication or need assistance with any other item, contact your local Provider Relations representative or call Provider Services at 844-405-4296. Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity. Simply Healthcare Plans, Inc. is a Managed Care Plan with a Florida Medicaid contract. Simply Healthcare Plans, Inc. is a Managed Care Plan with a Florida Healthy Kids contract. FLSMPLY-CD-047754-23-CPN47364 This article was published in error and retracted on February 23, 2024. Please access the updated version here. Effective for dates of service on and after May 1, 2024, the specialty Medicare Part B drugs listed in the table below will be included in our precertification review process.
Federal and state law, as well as state contract language and CMS guidelines (including definitions and specific contract provisions/exclusions), take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.
HCPCS or CPT® codes
| Medicare Part B drugs
| J3490, J3590, J9999, C9399
| Elrexfio (elranatamab-bcmm)
| J3490, J3590
| Eylea HD (aflibercept)
| J3490, J3590
| Pombiliti (cipaglucosidase alfa-atga)
| J3490, J3590, J9999, C9399
| Talvey (talquetamab-tgvs)
| J3490, J3590
| Tyruko (natalizumab-sztn)
| J3590, C9399
| Veopoz (pozelimab-bbfg)
| J3490
| Ycanth (cantharidin)
|
Simply Healthcare Plans, Inc. is a Medicare contracted coordinated care plan that has a Medicaid contract with the State of Florida Agency for Health Care Administration to provide benefits or arrange for benefits to be provided to enrollees. Enrollment in Simply Healthcare Plans, Inc. depends on contract renewal. FLSMPLY-CR-046708-23-CPN45768 The formulary changes listed in the table were reviewed and approved at our third quarter 2023 Pharmacy and Therapeutics Committee meeting. Effective February 1, 2024, the changes outlined apply to all Florida Healthy Kids members enrolled with Simply Healthcare Plans, Inc. (Simply). Please remember to read the footnotes at the end of the table. Refer
to attachment to view full drug details Simply Healthcare Plans, Inc. is a Managed Care Plan with a Florida Medicaid contract. Simply Healthcare Plans, Inc. is a Managed Care Plan with a Florida Healthy Kids contract. FLSMPLY-CD-048354-23 ATTACHMENTS (available on web): Quarterly pharmacy formulary change notice (pdf - 0.25mb) Quality Management | Simply Healthcare Plans, Inc. - Medicaid Managed Care / Simply Healthcare Plans, Inc. - Florida Healthy Kids / Clear Health Alliance - Medicaid Managed Care | January 17, 2024 New year, new opportunities for clinic daysTake advantage of the Clinic Days program that encourages our members to complete key services while building a relationship with their provider. Keep reading to learn about our current target areas. Hosting a clinic dayA clinic day occurs when a provider agrees to hold open appointments, over the course of one or more days, to provide specific health services for our members. Our Quality Health Promotions team supports you in preparation for this. What are the benefits of hosting a clinic day event?Clinic day events offer an innovative way to encourage members to obtain the health services they need while improving your HEDIS® rates and decreasing no-shows. They also allow for open communication between everyone. Clinic days can also help you: - Identify and manage patient populations in need of care.
- Track and coordinate care.
- Reduce administrative burden on office staff.
- Encourage patient engagement to close care gap(s).
What support will be provided?If you are interested in hosting a clinic day, we will: - Work with your office to coordinate a strategy specific to your office needs and goals.
- Target area(s) of need based on HEDIS measures and/or seasonal activities:
- We currently recommend targeting areas such as the HPV vaccine, cervical cancer screening, eye exams for patients with diabetes, mammograms, and other health observances.
- Distribute member invitations and appointment reminders.
- Work with your office to schedule appointments or provide independent outreach to members.
- Promote member engagement with PCPs.
- Assist members with transportation and/or other needs to meet appointment.
- Provide giveaways and health information.
- Incentivize members to complete their visit and close the care gap(s).
Schedule your clinic day today!To find out more information or to schedule your clinic day, please contact the Quality Health Promotions team at: QualityManagementDept@simplyhealthcareplans.com. HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). Simply Healthcare Plans, Inc. is a Managed Care Plan with a Florida Medicaid contract.
Simply Healthcare Plans, Inc. is a Managed Care Plan with a Florida Healthy Kids contract.
Simply Healthcare Plans, Inc. dba Clear Health Alliance is a Managed Care Plan with a Florida Medicaid contract. FLSMPLY-CD-047616-23 The Healthcare Effectiveness Data and Information Set (HEDIS®) is a tool used by health plans to measure the performance of important dimensions of care and services. HEDIS performance impacts both care providers’ and health plans’ Star performance. By working together, we can improve health outcomes for your patients, our members. HEDIS hybrid data, including administrative data and medical record review, is currently being collected. In an effort to increase HEDIS compliance, members of our HEDIS team may reach out to you requesting medical records regarding services and care for measures such as Transitions of Care (TRC), Breast Cancer Screening (BCS), Colorectal Cancer Screening (COL), Kidney Health Evaluation (KED), Osteoporosis Management in Women (OMW), and Eye Exam for Patients with Diabetes (EED), among others. We strongly encourage our care providers to share any records available once requested. HEDIS records can be faxed to 844-462-5168 or emailed to Simplystars@elevancehealth.com. Any HEDIS-related questions can be emailed to Simplystars@elevancehealth.com. We look forward to a continued partnership in our efforts to provide our members with quality care. HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). Simply Healthcare Plans, Inc. is a Medicare contracted coordinated care plan that has a Medicaid contract with the State of Florida Agency for Health Care Administration to provide benefits or arrange for benefits to be provided to enrollees. Enrollment in Simply Healthcare Plans, Inc. depends on contract renewal. FLSMPLY-CR-048509-23 |