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Telephone
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9900 Corporate Campus Dr.
Ste. 1000
Louisville, Ky. 40223
FAX
To:
Fax:
From:
CoventryCares of Kentucky Provider
Relations
Date:
10/19/2012
Re:
Important Reminders & Updates
Pages:
11
CC:
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Notes:
We appreciate your participation in the CoventryCares of Kentucky provider network and hope you find the
enclosed information helpful.
IMPORTANT WARNING: This message is intended for the use of the person or entity to which it is addressed
and may contain information that is privileged and confidential, the disclosure of which is governed by
applicable law. If the reader of this message is not the intended recipient, or the employee or agent
responsible to deliver it to the intended recipient, you are hereby notified that any dissemination, distribution,
or copying of this information is STRICTLY PROHIBITED. If you have received this message by error, please
notify us immediately and destroy the related message.
To:
From:
Date:
RE:
CoventryCares of Kentucky Providers
CoventryCares of Kentucky Provider Relations
October 19, 2012
Important Updates & Reminders
1.
Specialty Pharmacy Billing Guidelines (High Cost Infusion Medications)
Billing for High Cost Infusions:
Authorization is required prior to the date of service.
If unable to obtain authorization during regular business hours or due to a holiday, Prior Authorization must be
submitted the next business day.
An authorization form must be completed before authorization will be given. Please fax the form to the
attention of the Infusion Specialist at 1- 855-367-4261. The form is available at www.coventrycaresky.com
under the provider tab in the document library.
After services have been rendered, submit paper claims to:
CoventryCares of Kentucky
P. O. Box 7812
London, KY 40742-7812
You may also submit an electronic claim.
Billed dates included on the claim should match the authorized dates. Claims must be billed with a date span:
(example July 1 thru July 31). Do not use Dispense Date.
For IVIG that is given monthly or Remicade given every 8 weeks, claims should only be submitted for a single
date of service.
o Use the infusion date for billing.
When infusion dosing is based on the member’s weight, claims must include the member’s current weight. Enter
current weight on line 19 of the CMS-1500 form.
Claims for services provided in the home should be billed on CMS-1500 (HCFA), service provided in hospital bill
on UB-04:
o
Place of treatment
o
12 (Home)
o
11 (Office)
o
22 (OP Hospital)
Billing to CoventryCares of Kentucky requires using J code, NDC # and HCPC units.
o For example: Medication: Aralast J0256, NDC00944-2802-01
o A dosage of 1200 mg is 120 billable units
CoventryCares of Kentucky
Specialty Pharmacy Vendor Participation Requirements
Applies to vendors* who supply the following high cost medication(s)
Specialty Pharmacy Medication, J-Codes and HCPC Codes/Units
Alpha 1 Antitrypsin Deficiency Medications
Medication
J-Code
HCPC Code
Immune Deficiency Medications
Medication
J-Code
Gammaplex
J1557
HCPC Code
500mg =
1un
Prolastin-C
J0256
10mg=1un
Aralast
J0256
10mg=1un
Gammaplex is the exclusive medication for IVIG. The Medical
Director must approve non-formulary IVIG.
Glassia
Zemaira
J0257
J0256
10mg=1un
10mg=1un
Various Medications
Aldurazyme (laronidase)
J1931
.1mg=1un
Avastin (bevacizumab)
J9035
10mg=1un
VPRIV (velaglucerase)
Elelyso (taliglucerase)
Cerezyme (imiglucerase)
Elaprase (idursulfase)
Erbitux (cetuximab)
Fabrazyme (agalsidase)
Flolan
(epoprostenol/veletri)
Herceptin (trastuzymab)
Myozyme (aglucosidase)
Naglazyme (galsulfase)
Remicade (infliximeb)
Remodulin (treprostinil)
Tysabri (natalizumab)
J3385
J3490
J1786
J1743
J9055
J0180
100un=1un
J1325
.5mg=1un
J9355
J0220
J1458
J1745
J3285
J2323
10mg=1un
10mg=1un
1mg=1un
10mg=1un
1mg=1un
1mg=1un
up to
20mcg=1un
100mg= 1un
Hemophilia Medications
Proplex T
Feiba
Novoseven
Bebulin
Profilnine
Alphanine
J7194
J7198
J7189
J7194
J7194
J7193
1u=1un
1u=1un
1mcg=1un
1u=1un
1u=1un
1u=1un
Mononine
J7193
Benefix
Corifact
Alphanate
Humate-P
Koate:C
Wilate
J7195
J7180
J7186
J7187
J7190
J7183
1u=1un
1u=1un
1u=1un
1u=1un
1u=1un
1u=1un
1u=1un
Hemofil-M
J7190
1u=1un
Ventavis (iloprost)
Q4074
Monoclate
Advate
Helixate
Kogenate
Recombinate
Xyntha
Refacto
J7190
J7192
J7192
J7192
J7192
J7185
J7192
1u=1un
1u=1un
1u=1un
1u=1un
1u=1un
1u=1un
1u=1un
Hizentra
J1559
10un=1un
1mg=1un
10mg=1un
1mg=1un
Vendors who wish to enter into a participation agreement with CoventryCares of Kentucky must apply for
general specialty, bleeding disorders, or IVIG status.
2.
HEDIS Contact Information
A short while ago we contacted your office, via fax, about our upcoming Healthcare Effectiveness Data and
Information Set (HEDIS®) project in which we will gather data from providers related to the services provided to
CoventryCares of Kentucky members in 2012. HEDIS® is the standardized set of criteria by which heath
management organizations and associated providers are measured, benefitting members’ quality of care. The
individual criteria are based on “best practice” and “standard of care” for disease process, age and/or genderbased healthcare needs. Although some information can be gathered from claims data, you may receive
requests for information from us. This year’s HEDIS® project will continue through May 2013.
Please take this opportunity to identify a primary contact person for your office / facility. Typically this is a
medical records person, or office manager. Please complete the requested information and return via fax or
email to the HEDIS team as noted below.
You may have questions about the process. If you do, our contact information is:
CoventryCares of Kentucky
HEDIS® TEAM
FAX: 1-855-415-1215
E-Mail: [email protected]
Once again, thank you for your continued assistance in this process.
Provider Name: ______________________________________________ Fax #:___________________________
Practice / Group:_____________________________________________________________________________
Contact Person for Records Request: _____________________________________________________________
Phone: ___________________________Ext:____________E-mail:______________________________________
Do you use Electronic Medical Records:___________________________________________________________
Name of the EMR software used _________________________________________________________________
3.
New Member Co-Pay/Co-Insurance Program
Effective November 1, 2012, CoventryCares of Kentucky will implement copays and co-insurance for
certain services provided to members. Co-pay and co-insurance amounts are determined by the
benefit plan to which a member is assigned. Members are assigned to either the Global Choices or
Family Choices benefit plan by the Commonwealth of Kentucky.
As a provider, you will be able to view the member’s benefit schedule on the CoventryCares of
Kentucky website (www.coventrycaresky.com). Please click on the Provider tab and select the
“Document Library”. You may also go to the provider portal at www.DirectProvider.com. The
member’s benefit plan is also available on DirectProvider.com under the Member Eligibility tab, and
then view Benefit Plan to verify “plan type”.
Attached is a listing of the benefits with co-pay amounts which will be applicable to members.
CoventryCares of Kentucky will apply one co-pay per provider per date of service.
Members are responsible to pay any required co-pay and co-insurance. Kentucky law states that a
provider may not waive a member’s cost-share amount; however, the provider may determine if they
collect at the time the service is provided or at a later date.
Co-pays are not required to be paid by the following groups:
 Members with no income confirmed by the Commonwealth
 Non-KCHIP members under the age of 19
 Foster Children
 Members who are pregnant
 Members in hospice care
Dual eligible members (Medicare/Medicaid) will be assigned to co-pay plans if they are eligible. However, if
CoventryCares is secondary no co-pay would be applied. If the benefit is covered by Medicare, there is no
CoventryCares cost-share. Only when there is no coverage by Medicare, is a dual eligible responsible to pay a
CoventryCares cost-share amount.
There is no cost sharing for emergency services.
Should you have any questions or concerns about this benefit plan, please do not hesitate to contact your
Provider Relations Representative by dialing (855) 454-0061 and following the prompts to reach your assigned
representative by region.
CoventryCares of Kentucky Family Choices
Benefit/Service
Co-Pay
Acute Inpatient Hospital
$0 per admission
Laboratory, Diagnostic and Radiology
Services
$0 per visit
Outpatient Hospital / Ambulatory
Surgical Centers
$0 per visit
Physician Office Services
$0 per visit
Behavioral Health Services
$0 per visit
Allergy Services
$2 co-pay for office
visit and testing
Preventive Services
$0 per visit
Emergency Ambulance
$0 per visit
Dental Services
$0 per visit
Service Limits
Shots and allergy treatments
limited to children under 21
Children under 21, to include:
2 cleanings and 2 exams per 12month period
Extractions and fillings
1 set of x-rays per
12-month period.
Other dental services are
available.
Occupational Therapy
$0 per visit
At an approved setting
Physical Therapy
$0 per visit
At an approved setting
Speech Therapy
$0 per visit
At an approved setting
Hospice (non-institutional)
$0 per service
Chiropractic Services
$0 per service
Limited to 26 visits per
12-month period for children and
adults
Prescription Drugs (for members who do
NOT have Medicare Part D)
$1 Co-pay for
Preferred Generic
prescription drug or an
atypical anti-psychotic
drug if no generic
equivalent for the
atypical anti-psychotic
drug exists for a
recipient who does not
have Medicare Part D
Must follow drug list (formulary)
Some drugs and all exception
requests require prior
authorization
CoventryCares of Kentucky Family Choices
Benefit/Service
Co-Pay
Service Limits
drug coverage
$2 Co-pay for
Preferred brand name
drug for a recipient
who does not have
Medicare Part D drug
coverage
$3 Co-Pay for Nonpreferred brand name
or generic drug for a
recipient who does not
have Medicare Part D
drug coverage
Emergency Room (only applies to visits
determined to be non-emergency visits)
5% co-insurance for
non-emergency visits
not to exceed $6 per
visit
Hearing Aids
$0 per piece of
equipment
Audiometric Services
$0 per visit
Vision Services (per visit/day, not per
service)
$0 co-pay for
ophthalmologic or
optometric office visit
Limited to children under 21
Not to exceed $800 per ear
every 36 months
One audiologist visit per
calendar year
Eyewear limited to children under
21
$400 limit per calendar year
Children limited to 1 eye exam
per calendar year
Prosthetic Devices
$0 per device
Home Health Services
$0 per visit
Durable Medical Equipment (DME)
$0 per
service/equipment
piece/device
Early and Periodic Screening, Diagnosis,
and Treatment (EPSDT)
$0 per visit
Limited to children under 21.
KCHIP children who pay a monthly
premium are not eligible for EPSDT
Special Services
Substance Abuse
$0 per visit
EPSDT and pregnant women only.
Some KCHIP children are not eligible
for substance abuse services.
CoventryCares of Kentucky Family Choices
Benefit/Service
Co-Pay
Maternity Services
Nurse mid-wife services
Pregnancy-related services
Services for other conditions that
might complicate pregnancy
60 days postpartum pregnancyrelated services
$0 per visit
Family Planning
$0 per visit
Podiatry Services
$0 per visit
End Stage Renal Disease and Transplants
$0 per visit
Tobacco Cessation Assessment
No co-pay for the
actual assessment
$0 co-pay for the office
visit
No co-pay for the
smoking cessation
drugs
All drugs, if prescribed
and covered and DO
NOT require a
preauthorization for
the initial refill.
Refills of the
prescribed smoking
cessation drugs
require prior
authorization
Service Limits
Limited to 2 tobacco cessation
assessments per recipient per
calendar year.
The assessment must be
performed over a period of at least
30 minutes.
Be performed face-to-face with
the member.
Must be performed by a
CoventryCares of Kentucky
network:
Physician; or
Physician Assistant working
under the supervision of a
supervising physician; or
Advanced Practice Registered
Nurse (APRN)
*If the member is a dual eligible and Medicare pays for the service, there is no Medicaid co-pay
No Cost Extra Benefits and Services
KidsHealth® online library
Doc Bear Club for kids
Baby crib program
Diabetic cookbooks
Periodontal care for pregnant women
CoventryCares of Kentucky Global Choices
Benefit/Service
Co-pay
Acute Inpatient Hospital
$50 per admission
Laboratory, Diagnostic and Radiology
Services
$3 per visit
Outpatient Hospital / Ambulatory
Surgical Centers
$3 per visit
Physician Office Services
$2 per visit
Behavioral Health Services
$0 per visit
Allergy Services
$0 per visit
Preventive Services
$0 per visit
Emergency Ambulance
$0 per visit
Dental Services (per visit, not per
service)
$2 per visit
Service Limits
Shots and allergy treatments
limited to children under 21
Children under 21, to include:
2 cleanings and 2 exams per 12month period
Extractions and fillings
1 set of x-rays per 12-month
period
Other dental services are
available
Adults 21 and over:
1 cleaning and 1 exam per 12month period
Limited to 1 emergency dental
visit per month
Extractions and fillings
1 set of x-rays per
12-month period
Occupational Therapy
$0 per visit
At an approved setting:
No limit for children under 21
Adults 21 and over are limited
to 15 visits per calendar year
Physical Therapy
$2 per visit
At an approved setting:
No limit for children under 21
Adults 21 and over are limited
to 15 visits per calendar year
CoventryCares of Kentucky Global Choices
Benefit/Service
Speech Therapy
Co-pay
$1 per visit
Service Limits
At an approved setting:
No limit for children under 21
Adults 21 and over are limited
to 10 visits per calendar year
Hospice (non-institutional)
$0 per service
Chiropractic Services
$2 per visit
Prescription Drugs (for members who
do NOT have Medicare Part D)
Note: Dual eligible members will be
subject to appropriate co-pays for
those drugs CoventryCares covers as
primary payor (i.e. over-the-counter
drugs, benzodiazepines, etc.)
$1 Co-pay for Preferred Must follow drug list (formulary)
Generic prescription
Some drugs and all exception
drug or an atypical
requests require prior
anti-psychotic drug if
authorization
no generic equivalent
for the atypical antipsychotic drug exists
for a recipient who
does not have
Medicare Part D drug
coverage
$2 Co-pay for Preferred
brand name drug for a
recipient who does not
have Medicare Part D
drug coverage
Limited to 26 visits per 12-month
period for children and adults
5% coinsurance (up to
a max of $20) for Nonpreferred brand name
or generic drug for a
recipient who does not
have Medicare Part D
drug coverage
Emergency Room (only applies to visits
determined to be non-emergency)
5% co-insurance for
non-emergency visits
not to exceed $6 per
visit
Hearing Aids
$0 per device
Limited to children under 21
Not to exceed $800 per ear
every 36 months
Audiometric Services
$0 per visit
One audiologist visit per calendar
year
Vision Services (per visit/day, not per
service)
$2 for ophthalmologic
or optometric office
visit
Eyewear limited to children under
21
Adults and children limited to 1
CoventryCares of Kentucky Global Choices
Benefit/Service
Co-pay
Service Limits
eye exam per calendar year
$200 limit per calendar year.
Prosthetic Devices
$0 per device
Home Health Services
$0 per visit
Durable Medical Equipment (DME)
3% coinsurance up to a
maximum of $15 per
month
Early and Periodic Screening, Diagnosis,
and Treatment (EPSDT)
$0 per visit
Limited to children under 21
Substance Abuse
$0 per visit
EPSDT and pregnant women only
Maternity Services
$0 per service
Nurse mid-wife services
Pregnancy-related services
Services for other conditions that
might complicate pregnancy
60 days postpartum pregnancyrelated services
Family Planning
$0 per service
Podiatry Services
$2 per visit
End Stage Renal Disease and
Transplants
$0 per visit
Tobacco Cessation Assessment
No co-pay for the
actual assessment
$2 co-pay for the office
visit
No co-pay for the
smoking cessation
drugs
All drugs, if prescribed
and covered and DO
NOT require a
preauthorization for
the initial refill.
Refills of the prescribed
smoking cessation
drugs require prior
authorization
Limited to 2 tobacco cessation
assessments per recipient per
calendar year.
The assessment must be
performed over a period of at least
30 minutes.
Be performed face-to-face with the
member.
Must be performed by a
CoventryCares of Kentucky
network:
Physician; or
Physician Assistant working
under the supervision of a
supervising physician; or
Advanced Practice Registered
Nurse (APRN)
*If the memberis a dual eligible and Medicare pays for the service, there is no Medicaid co-pay
No Cost Extra Benefits and Services
KidsHealth® online library
Baby crib program
Periodontal care for pregnant women
Doc Bear Club for Kids
Diabetic cookbooks