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.
