2024 was a year of reinvestment, growth, and impactful partnerships for UHIN. We dedicated 100% of our net income to enhancing the products and services on which our clients rely, achieving a remarkable 95% customer satisfaction rate. Our Clearinghouse solution processed 329 million transactions, while the CHIE supported 33 of 36 short-term acute care hospitals in Utah, and delivered over 18 million ADT alerts. Key milestones included our affiliation with Comagine Health to drive actionable health insights and the launch of a modernized CHIE portal built on the HL7 FHIR standard for improved data sharing (Learn more about the CHIE portal experience here).
As we reflect on 2024’s successes, we are energized to take on 2025, poised for even greater growth and impact in healthcare.
Top Questions and Answers from the Virtual Payer Panel with Korey Marsh and Lisa Varley (both of DMBA)
In our final virtual payer panel in 2024, DMBA representatives Korey Marsh, Manager of Network Strategy and Provider Relations, and Lisa Varley, Director of Configuration, shared key updates for providers. Highlights included an overview of DMBA’s provider portal, which offers tools for pre-authorizations, claims searches, and remittance tracking, with plans for expanded functionality. DMBA also announced the rollout of four new medical plans, including PPO and HSA options, set to replace their existing plans in 2025. Additionally, DMBA addressed questions on coding and coverage, emphasizing their commitment to clarity and support for the provider community.
In this post, let’s dive into three of the top questions, insights, and announcements shared during the session, offering clarity on new health plans, coding, coverage, and other important topics.
1. DMBA’s Provider Portal Enhancements
DMBA has introduced a provider portal with functionalities like pre-authorizations, claim searches, and remittance features. The portal has been live for a year, and additional features will be rolled out over time. Providers can register through DMBA’s website or contact customer service for assistance.
DMBA is retiring its existing four commercial medical plans and introducing four new ones (two PPO and two HSA plans). Providers are advised to review participants’ new ID cards starting next year for updated plan details, including coinsurance and copay structures. The two HSA plans do not have co pays and have certain nuances.
DMBA clarified coverage details for various medical services and billing codes, such as ABA therapy (requires pre-authorization), transitional care management (covered), and select telehealth codes (accepted if recognized by AMA/CPT). Prolonged visit codes, such as 99417, require additional review.
Top Questions and Answers from the Virtual Payer Panel with Lori Weber (Noridian Healthcare Solutions) and Melissa Shoemaker (Select Health)
In the ever-evolving landscape of healthcare billing, staying up-to-date is essential for providers and billing services. In our Virtual Payer Panel, attendees asked questions for two longtime UHIN customers and health plan representatives: Lori Weber, Education Representative for Part B Provider Education at Noridian Healthcare Solutions, and Melissa Shoemaker, Senior Network Engagement Representative at Select Health. Over the course of the webinar, both Lori and Melissa addressed key updates and fielded questions from caregivers of all types.
In this post, let’s dive into five of the top questions and insights shared during the session, offering clarity on telehealth billing, claims processing, EDI recertification preparation and other essential topics.
1. Key Updates on Telehealth Billing
Q: What are the latest updates on POS codes and modifiers for telehealth services? Are there anticipated changes for 2025?
For 2024, providers should use POS 2 for telehealth services provided outside the home and POS 10 for those conducted in the home, eliminating the need for telehealth-specific modifiers. Updates for 2025 will be available after the final rule is released. Providers are encouraged to monitor payer websites for the latest resources, including telehealth pages and webinar archives.
Claims processed with POS 10 will now be reimbursed at the same rate as in-office visits. Adjustments for previously underpaid claims will appear in remittances within 45-60 days.
Q: Can you provide guidance on POS 02, POS 10, and exceptions?
For telehealth services:
POS 10 is used when the patient is at home, while POS 02 applies when the patient is outside their home.
Modifiers are generally not required, but if included, they won’t cause claim denials. However, they may affect reimbursement rates.
Exceptions:
Outpatient therapy services (e.g., physical, occupational, or speech therapy): Use the specific POS 11 (office) as if the patient were seen onsite, and append modifier 95.
Outpatient hospital clinicians: When services are provided to patients at home, use POS 22 (on-campus) or POS 19 (off-campus) with modifier 95.
These guidelines will be detailed in the final documentation.
2. Coverage and Claims Processing for Vaccines and Shots
Q: Is the 90611 JYNNEOS vaccine covered by Medicare Part B?
Yes, Medicare covers the JYNNEOS vaccine for smallpox and MPOX. Billing guidance is available through on-demand webinars that detail the appropriate processes.
Q: What actions are being taken to address flu shot claim denials for certain age groups?
Select Health has identified and is correcting a system error causing flu shot claim denials. Affected claims are being reprocessed automatically. To avoid similar issues, ensure the use of age-appropriate codes and confirm the patient’s Medicare beneficiary status when applicable.
Q: Should 90471 and 90472 still be used for non payable immunizations?
These codes apply to non payable immunizations like tetanus given after an injury. However, for flu and other vaccines, Medicare requires specific G codes for administration. Upcoming webinars will provide further clarification on these requirements.
Q: What steps are involved in the annual EDI recertification process?
Starting in November, providers will be required to verify their trading partner IDs, NPIs, and address consistency across key systems. Email notifications will be sent when recertification is due, ensuring a smooth process for those with up-to-date records.
Q: Is there anywhere online that we can check when the patient had their last preventative visit?
Payers typically allow one preventative billed each year at either 365 days from the previous visit or one in a calendar year.
Lori recommended using the Noridian Medicare portal to track patient preventative visits, ensuring services are billed within covered timelines. Lori emphasized that not all preventative services are annual, with intervals depending on risk levels (e.g., colonoscopies every 5-10 years).
For pediatric visits, Melissa suggested leveraging Select Health’s portal to check service histories beyond the clinic’s records. If more detailed data is needed, she offered to connect attendees with specialized reps for further assistance.
This Virtual Payer Panel highlighted significant updates in healthcare billing, including telehealth billing adjustments, coverage and claims processing for vaccines and shots, the EDI recertification process, and preventative services and eligibility checks. Caregivers are encouraged to leverage available resources from health plans, such as webinars and support services, to stay informed and adapt to these changes effectively.
UHIN will continue to host virtual payer panels with representatives from different health plans throughout the year. Subscribe to the UHIN newsletter and follow us on LinkedIn to stay informed of upcoming virtual payer panels.
The CHIE continues to add important data sources, providing healthcare professionals with vital medical information when it is needed most. Recently, we’ have’ve onboarded CommonSpirit Health as a data source.
These include:
Holy Cross Hospital – Davis (formerly known as Davis Hospital and Medical Center) in Layton
Holy Cross Hospital – Jordan Valley (formerly known as Jordan Valley Medical Center) in West Jordan
Holy Cross Hospital – Jordan Valley West (formerly known as Jordan Valley Medical Center-West Valley Campus) in West Valley City
Holy Cross Hospital – Mountain Point (formerly known as Mountain Point Medical Center) in Lehi
Holy Cross Hospital – Salt Lake (formerly known as Salt Lake Regional Medical Center) in Salt Lake City
And their clinics
CommonSpirit Health is a nonprofit, Catholic health system dedicated to advancing health for all people.
Comagine Health, a national nonprofit health care consulting firm, and the Utah Health Information Network (UHIN), a leading health care information technology organization, recently announced they are affiliating. The two organizations have a long history of working together over the last decade on federal and state initiatives to advance electronic health record (EHR) adoption, cost transparency reporting, capacity and functionality of all-payer claims databases (APCDs) and interoperability and surveillance activities. Through this new affiliation, they will be able to become even more powerful drivers for health care improvement.
An affiliation between the two organizations allows UHIN and Comagine Health to each leverage their deep expertise and success in different areas. The affiliation will help both organizations better meet their missions, respond to a changing economic landscape and create greater value for their respective customers.
Comagine Health is a national leader in health care consulting for federal, state and local government agencies as well as privately funded groups. The company is widely recognized for its expertise in quality improvement, care management, data solutions and research and evaluation. Additionally, Comagine Health has a long-standing history with the Centers for Medicare & Medicaid Services (CMS) serving as the Quality Innovation Network-Quality Improvement Organization (QIN-QIO) and is preparing to bid as a prime contractor for the 13th statement of work to serve as the QIN-QIO in Region 6, covering 14 states from the Pacific Northwest through the Midwest.
“I’m excited about this affiliation. Our two organizations are well-suited to partner together. We have a shared vision of improving health and health care and each organization brings unique talents to the partnership.”
Marc Bennett, Comagine Health’s president and chief executive officer
As a national leader in interoperability, UHIN provides technological solutions and services that simplify data sharing across health plans, providers and other health care parties. UHIN manages Utah’s only health information exchange (HIE), the CHIE, and shares data nationwide through the Patient Centered Data Home® (PCDH). UHIN’s clearinghouse and claims management solutions ensure seamless, secure claims data management and delivery for a national network of health plans, providers and trading partners.
“Aligning our health care knowledge and expertise through affiliation is a profound opportunity to advance our parallel missions, while delivering greater success to our customers and partners. We have collaborated successfully for more than a decade. As affiliates, UHIN and Comagine Health can serve as a unified force for change in health care for the foreseeable future.”
Brian Chin, UHIN’s chief executive officer
The combined strengths of each organization will create opportunities to improve services for current customers and provides a framework for developing new services and products that bring together UHIN’s technology solutions and Comagine Health’s analytic services, enabling more actionable health insights and more sustainable, transformational improvements for communities.
About UHIN
UHIN is dedicated to healthcare interoperability for all. When UHIN sees the barriers and complexities in healthcare, we know we need to act and be a force for change. Our healthcare technology solutions and services empower payers, providers, ACOs, government entities, billing services, and other healthcare partners to collaborate, share information and data, and provide better affordable care for patients. To learn more about UHIN, visit www.uhin.org.
About Comagine Health
Comagine Health works collaboratively with patients, providers, payers and other stakeholders to reimagine, redesign and implement sustainable improvements in the health care system. As a trusted, neutral party, we work in our communities to address key, complex health and health care delivery problems. In all our engagements and initiatives, we draw upon our expertise in quality improvement, care management, health information technology, analytics and research. We invite our partners and communities to work with us to improve health and redesign the health care delivery system. For more information, please visit comagine.org.
UHIN is dedicated to maintaining interoperability for all payers, providers and partners. When an event as large as the Change Healthcare cyberattack impacts our community, we know we need to serve as a bridge to stable ground.
In response to the incident, UHIN immediately disconnected from Change Healthcare’s platform to prevent potential harm. We also conducted a detailed review of our internal systems, confirming no impact on our network. UHIN continues to communicate with Change Healthcare and United Health Group to receive the latest updates and guidance.
UHIN is currently retaining any claims submitted after February 21, 2024, that are intended to be delivered to Change. These retained claims will be processed through our system and sent to Change once it is safe to re-establish those connections. The restoration timeline is being updated by UnitedHealth Group here.
For providers, you need to get your claims flowing again. We are working with payers to expedite your enrollment with them. You can then create and send professional and institutional claims, submit via SFTP, file tool or online hand-entry, check claims status, manage denials and rejections, and search, view, and download payment information. Most electronic health records systems have configuration capabilities to securely connect with UHIN’s systems. Sign up to fast-track your enrollment with many payers today, and manage your claims and revenue with assurance.
For health plans, you can receive claims from your providers through a direct connection to UHIN. We support enrollment for your providers, just as we’re currently supporting fast-track enrollment for the payer list below. Empower your provider network by elevating your collaboration efforts, securely sharing information and data, and providing better affordable care for your members.
The annual Health Information Technology Conference (HIT) will return to Salt Lake on Wednesday, October 18 at the Conference Center at Gail Miller Campus, SLCC. The conference, hosted by UHIN, will look towards the “future of healthcare interoperability” with speakers, leaders and professionals from across the healthcare and technology continuum.
Join office managers, billers, administrators, CEOs, CTOs, CIOs, Chief Medical Officers, VPs, directors, doctors, nurses, and educators.
Learn from speakers from the State of Utah, the Salt Lake Department of Health, Intermountain Health, University of Utah Health, Sharp Index, Amazon Web Services (AWS), Noridian Healthcare Solutions, BYU, healthKERI, Comagine, Molina, SelectHealth, University of Utah Health Plans, UHIN and more.
Conference topics include: Attendees can expect powerful sessions with experts covering important topics in healthcare, including:
Artificial Intelligence in healthcare
Billing for today and beyond
Cybersecurity
Digital transformation in healthcare
Documentation burden
HL7 and FHIR
Health equity
Health Data Utilities (HDUs)
Medicare updates
Mental health and burn out
Population Health
Welcome KeynoteSpeakers: Dr. Angela Dunn
Executive Director of the Salt Lake County Health Department
Prior to becoming Executive Director of Salt Lake County Health Department, Dr. Angela C. Dunn served as state epidemiologist for the Utah Department of Health and as an epidemic intelligence service officer for the U.S. Centers for Disease Control and Prevention, where she responded to the 2014–2016 Ebola epidemic in West Africa, as well as several infectious disease outbreaks in Utah including measles, hepatitis C, and campylobacter.
Afternoon Keynote: Joy Rios
Founder and CEO of the “HIT Like a Girl” podcast
Joy Rios, MBA is a preeminent Health IT strategist and an established subject matter expert in value-based care payment models. As the founder and CEO of the “HIT Like a Girl” podcast, she amplifies diverse voices, fostering innovation and connection within the healthcare industry. Her groundbreaking “RoadtoHLTH” journey further underscores her commitment to enhancing healthcare interoperability. With an unwavering passion for merging health, technology, and meaningful dialogue, Joy’s insights inspire both industry veterans and newcomers alike. Her visionary leadership and in-depth knowledge position her at the forefront of healthcare’s rapidly evolving landscape.
Question 1: Why are you with your current EDI vendor?
Health plans are often led to believe that healthcare electronic data interchange (EDI) vendors and Clearinghouses are utilities. Just a means to an end. It’s true that utilities – such as water – and EDI vendors both follow regulated protocols and move standardized, secure things.
When you turn on the faucet in your kitchen or bathroom, you expect clean, clear water delivered immediately and at your desired temperature. Often it works perfectly. However, you don’t typically choose where the water comes from or the company who provides water to you. You don’t adjust your settings at an infrastructure level and underlying delivery issues may be well beyond your control.
As a health plan, you can select your EDI vendor, enhance your provider network, adjust settings at an infrastructure level, and get ahead of underlying issues. Beneath the surface, health plans can work with expert EDI partners (not just vendors) to navigate turbulent waters together and deliver seemingly fluid experience and impactful outcomes. This process is understandably daunting despite the increased adoption of automated processes.
For this reason, health plans should ask four key questions to understand the value that their EDI vendor is bringing to the table. Our next four blog posts will cover these four simple, yet critical questions for health plans:
With many options out there, why are you with your current EDI vendor? Are they just a vendor in your tech stack or do they serve you as a partner should?
Can your Clearinghouse validate claims? Can you customize validation to your needs?
Is your provider network frequently contacting you with questions? How does this impact your staff, strategy and budget?
How does your EDI partner alleviate the burden of claims submission and simplify your administrative workflow?
Ready to read all four questions now? Want to know how your EDI partner stacks up? Download our white paper here.
Why Are You With Your Current EDI Vendor or Clearinghouse?
Our first post is introspective. We’ll look at the reasons you may be with your current Clearinghouse or EDI vendor, and how they should serve you to meet the strategic objectives of your department and company as a whole. Keep reading about the way it’s always been, and the futurist approach that health plans should take with a key strategic EDI partner.
The Way Clearinghouses Have Worked
Healthcare EDI networks have been built on vendor relationships that can be daunting and confusing, despite best intentions and the increased adoption of automated processes. Vendors offer “sticky” solutions that can entangle health plans with complicated agreements, abrasive onboarding processes, and technology that may not provide meaningful value.
Today, the essence of a partnership can get lost in the complications of healthcare EDI management. We can shift this paradigm by remembering we’re all in this together – from payers to trading partners, and providers to patients.
So, What Keeps You With Your Current Clearinghouse?
Does your partner simplify administrative burden? Do you have visibility into transactions? Do you receive timely, expert guidance on future X12 standards and HIPAA compliant transactions? An EDI partner should be focused on your holistic operations, and not merely transactions (though they should do those well, too). Perhaps it’s time to rethink the status quo.
If your EDI vendor is not serving you as a partner, you may want to consider what this relationship is costing you.
UHIN is a national EDI network built in 1993 by health plans. We partner with payers and providers across the US. Our approach to EDI and customer service is different. If you’re interest in learning more, please contact us today.
