Provider News
April
Prior Authorization Updates Effective 7/1/2025
Date: 04/29/2025
Thank you for your continued partnership with Absolute Total Care and Ambetter from Absolute Total Care. Prior authorization code updates effective 7/1/2025 can be viewed by selecting one of the links below:
- Ambetter from Absolute Total Care Prior Authorization Code Updates - Effective 7/1/2025 (PDF)
- Absolute Total Care (Medicaid) Prior Authorization Code Updates - Effective 7/1/2025 (PDF)
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February
Emergency Department (ED) Outpatient Evaluation and Management (E/M) Coding Policy, Professional Services
Date: 02/26/2025
As part of our continued efforts to improve claims review and payment processes, Absolute Total Care we will begin applying national Current Procedural Terminology (CPT®) billing guidelines for the appropriate coding of professional emergency department Evaluation and Management (E&M) code levels. This policy applies to the following lines of business as of the dates shown below:
- Absolute Total Care Healthy Connections Medicaid, effective April 1, 2025
- Wellcare Prime by Absolute Total Care (Medicare-Medicaid Plan), effective April 1, 2025
- Ambetter from Absolute Total Care (Marketplace), effective April 1, 2025
Both Centers for Medicare & Medicaid Services (CMS) and the Office of Inspector General (OIG) have documented that E&M services are among the most likely services to be incorrectly coded, resulting in improper payments to providers. The OIG has also recommended that payers continue to help to educate practitioners on coding and documentation for E&M services and develop programs to review E&M services billed for by high-coding providers.
Overview of Absolute Total Care’s E&M Program:
- Evaluates and reviews only high-level E&M services based upon diagnostic information that appears on the claim.
- Applies the relevant E&M policy and recoding of the claim line to the corrected E&M level of service.
- Allows reimbursement at the highest E&M service code level for which the criteria are satisfied based on our comparative peer risk adjustment process.
Providers should report E&M service in accordance with American Medical Association’s (AMA) CPT® Manual and the CMS' guidelines for billing E&M service codes; “Documentation Guidelines for Evaluation and Management”. The proper reporting of E&M Services enables Absolute Total Care to more precisely apply reimbursement-coding guidelines and ensure that an accurate record of patient care history is maintained.
Determinations should be made with reference to accepted standards of medical practice and the medical circumstances of the individual case.
Policy Number: SC.CC.PP.066
Policy Name: Leveling of Care: Evaluation and Management
Line of Business Impacted: Medicaid, Marketplace, Medicare-Medicaid (MMP)
Thank you for your continued participation and cooperation in our ongoing efforts to render the highest quality health care to our members. If you need further information, please contact Provider Services or your dedicated Provider Engagement Account Manager.
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November
Ambetter from Absolute Total Care Provider Update
Date: 11/01/2024
Ambetter is grateful for your participation in our provider network and the care you provide our members. Each year, we conduct a comprehensive review of our market operations and footprint to best align our network strategy and improve member experience.
As of Jan. 1, 2025, the following changes will take place:
- The Bronze | Silver | Gold (Core) network will be renamed to the PREMIER network.
- The Ambetter Virtual Access plan will be discontinued. Our other Ambetter offerings will still be available.
We are committed to ensuring you have all the resources available to make this transition as smooth as possible for you and your patients. While our network name and plan offerings are changing, our commitment to delivering quality care and services to our members is unwavering. Members will be notified through various upcoming notifications and will see this change on Ambetter Guide.
If you have questions about this information, call Provider Services at 1-833-270-5443 or contact your dedicated Provider Relations Specialist.
Thank you for continuing to provide our members with high quality and compassionate care.
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October
Ambetter from Absolute Total Care Prior Authorization Update for Opioid Treatment Programs
Date: 10/25/2024
Ambetter from Absolute Total Care is committed to delivering cost effective care to our members. Effective December 15, 2024, prior authorization will be required for Opioid Treatment Programs (OTPs) codes.
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Medicare Prescription Payment Plan (M3P)
Date: 10/02/2024
A new program to make prescription drugs more affordable will be available to all eligible Medicare members, beginning January 1, 2025. The program will help members manage prescription costs by enabling them to spread their monthly payments over time.
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July
Availity Essentials: New Multi-Payer Portal Launches September 24, 2024
Date: 07/24/2024
Centene Corporation has chosen Availity Essentials as its new, secure provider portal. Starting September 24, 2024, you can validate eligibility and benefits, submit claims, check claim status, submit authorizations, and access payer resources via Availity Essentials for Absolute Total Care Healthy Connections Medicaid, Ambetter from Absolute Total Care, Wellcare Prime by Absolute Total Care and Wellcare of South Carolina.
Here's how to get started:
If you are new to Availity Essentials, getting your Essentials account is the first step toward working with the Health Plan on Availity. Your provider organization’s designated Availity administrator is the person responsible for registering your organization in Essentials and managing user accounts. This person should have legal authority to sign agreements for your organization. Visit Register and Get Started with Availity Essentials to enroll for training and access other helpful resources.
If you already work in Essentials, you can log in to your existing Essentials account to enjoy these benefits beginning September 24, 2024:
- Verify member eligibility and benefits, submit claims, check claim status, submit authorizations, and more.
- Look for additional functionality in the Health Plan’s payer space on Essentials and use the heart icon to add apps to My Favorites in the top navigation bar.
- Save provider information in Essentials and auto-populate it to save time and prevent errors.
We encourage you to use Availity Essentials for transactions once the portal is live. With an active Availity Essentials account, providers will have immediate access to new health plans and features as soon as they become available. Our current secure portal will still be available for other functions you may use today, and we will notify you when our current secure portal will be retired.
We're excited to welcome you to Availity Essentials, helping you transform the way you impact patient care. If you need additional assistance with your registration, please call Availity Client Services at 1-800-AVAILITY (282-4548). Assistance is available Monday through Friday, 8 a.m. – 8 p.m. EST. For general questions, please contact Provider Services or reach out to your Provider Engagement Administrator.
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June
Ambetter from Absolute Total Care Claims Processing Change, Effective July 1, 2024
Date: 06/28/2024
Ambetter from Absolute Total Care values the relationships we have with our provider partners. We want to ensure that doing business with us is easy and straightforward. We are pleased to announce that, effective July 1, 2024, Ambetter from Absolute Total Care will be extending the timely filing for initial claims from 120 business day to 180 calendar days from date of service. Days are calculated from the Date of Service (DOS) to the date that claims are received by Ambetter. For observation and inpatient stays, the claim received date is calculated from the date of discharge. Claims received on or after July 1, 2024, will process under the new guideline for 180 calendar days.
The Ambetter from Absolute Total Care Provider Manual and Quick Reference Guide available on Ambetter from Absolute Total Care website will be updated to reflect these changes.
Please contact your Provider Engagement Administrator or call Provider Services at 1-833-270-5443 with any questions you may have.
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May
Absolute Total Care prior authorization updates effective 7/1/2024 for new American Medical Association (AMA) Current Procedural Terminology (CPT®) codes.
Date: 5/31/2024
The new CPT Proprietary Laboratory Analyses (PLA) codes and CPT Category III codes will require prior authorization, unless determined to be a non-covered service, upon their effective date of 7/1/2024.
For other established codes, please use the Pre-Auth Check Tool on our website to confirm if the code(s) requires prior authorization. Prior authorization requirements vary based on the line of business, so please select the applicable Pre-Auth Check Tool by the line of business.
List of Codes - Updates Effective 7/1/2024 (PDF)
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March
Availity to Host Live Training Webinars for Providers
Date: 03/11/2024
As you may be aware, the ability to electronically submit claims to Absolute Total Care through Change Healthcare is currently unavailable due to a cybersecurity incident that impacted its network and operations with no timeline for resolution. Availity, our preferred clearinghouse partner, is ready and available to help providers to enroll and begin submitting claims. They are offering several live training webinars for providers to get started with Availity Essentials.
Webinar registration is easy via the Availity Essentials Provider Portal. Providers must be enrolled with Availity Essentials to access webinars. Step-by-step instructions for Availity Essentials enrollment can be found on the Availity Lifeline website.
Availity to Host Live Training Webinars for Providers (PDF)
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February
Provider Alert: Change Healthcare Cybersecurity Incident and Its Impact to Absolute Total Care Medicaid, Marketplace and Medicare-Medicaid Plans
Date: 02/29/2024
On February 21, Change Healthcare, a software and data analytics subsidiary of UnitedHealth Group’s Optum unit, experienced a cybersecurity incident that has impacted its network and operations. The cybersecurity incident has created a service disruption impacting Absolute Total Care members and provider network in several ways.
As of now, Change Healthcare has not provided a timeline for resolution. To protect our members and providers, Absolute Total Care fully disconnected system access to and from Change Healthcare on Feb. 21. We are working on multiple solutions to restore provider functionality and ensure continuity of care for our members. We will continue to provide updates as this situation evolves.
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Provider Alert: Change Healthcare Cybersecurity Incident and Its Impact to Wellcare Medicare Plans
Date: 02/29/2024
On February 21, Change Healthcare, a software and data analytics subsidiary of UnitedHealth Group’s Optum unit, experienced a cybersecurity incident that has impacted its network and operations. The cybersecurity incident has created a service disruption impacting Wellcare members and provider network in several ways.
As of now, Change Healthcare has not provided a timeline for resolution. To protect our members and providers, Wellcare fully disconnected system access to and from Change Healthcare on Feb. 21. We are working on multiple solutions to restore provider functionality and ensure continuity of care for our members. We will continue to provide updates as this situation evolves.
Change Healthcare Cybersecurity Incident and Its Impact to Wellcare Medicare Plans (PDF)
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January
Important Pharmacy Claims Processing Change, Effective January 1, 2024
Date: 01/19/2024
We are pleased to announce that, effective January 1, 2024, Express Scripts® will begin processing pharmacy claims for our plan members.
Express Scripts is a pharmacy benefit management (PBM) company serving more than 100 million Americans. Express Scripts Pharmacy delivers specialized care that puts patients first through a smarter approach to pharmacy services.
Members have been notified in advance and will receive a new ID card with updated pharmacy information, so that they are prepared to begin having their prescriptions filled at participating network pharmacies when this change occurs.
Providers can direct members to call the Member Services phone number listed on their ID card should they have questions about this change.
Please contact your Provider Relations Representative with any additional questions.
Thank you for the care you provide to our members.
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Provider Notification: Controlling Blood Pressure
Date: 01/05/2024
At Absolute Total Care, we are committed to ensuring our members with chronic conditions receive the care they need to be healthy. Our primary goal is to partner with you in managing these patients with high blood pressure. We hope you find the attached reference guide for controlling blood pressure valuable in your efforts to manage your patients. We appreciate your partnership and thank you for your continuance in excellent patient care.
Controlling Blood Pressure (PDF)
Sincerely,
Absolute Total Care
December
Provider Notification: Ambetter from Absolute Total Care's Top Priority is Helping You Care for Your Patients
Date: 12/15/2023
Strong communication and trust between you and your patients will help ensure they’re satisfied and have good outcomes. You can rely on Ambetter from Absolute Total Care for information and support to help you keep those patient relationships strong.
Read the full provider notification here:
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November
Provider Notification: Absolute Total Care and Wellcare Announce Expanded Partnership with NIA-Evolent
Date: 11/27/2023
Absolute Total Care and Wellcare are committed to continuous improvement of quality services for our members. We are pleased to announce our expanded partnership with National Imaging Associates, Inc. (NIA)* to implement a new Musculoskeletal (MSK) Management program. This program is consistent with industry-wide efforts to ensure clinically appropriate care and to manage the increased utilization of these services.
New Program Starts February 1, 2024
The MSK program includes prior authorization for non-emergent outpatient interventional spine pain management services (IPM), and inpatient and outpatient hip, knee, shoulder, lumbar, and cervical spine surgeries for Absolute Total Care Marketplace and Medicaid members, Wellcare Medicare of South Carolina members, and Wellcare Prime by Absolute Total Care (Medicare-Medicaid Plan) members.
Read the full provider notification here:
- Absolute Total Care and Wellcare Announce Expanded Partnership with NIA-Evolent (effective 2.1.2024)
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Provider Notification: Medicare Part B Step Therapy
Date: 11/22/2023
Step Therapy programs are developed by Wellcare's Pharmacy & Therapeutics (P&T) Committee. They encourage the use of therapeutically equivalent, lower-cost medication alternatives (first-line therapy) before “stepping up” to alternatives that are usually less cost-effective.
Drugs requiring step therapy effective January 1, 2024 can be found in this list:
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October
Provider Notification: Sleep Study Policy Update
Date: 10/30/2023
Absolute Total Care is committed to delivering medically appropriate, cost-effective care to our members leading to increased compliance and improved health outcomes.
The updated sleep study policy taking effect 1/1/2024, will assist providers in:
· Consistent application of clinical guidelines
· Improved compliance and health outcomes for members
· Improved member experience (comfort, convenience)
· Appropriate utilization of home-based and facility-based studies
The complete Clinical Policy: Facility-based Sleep Studies for Obstructive Sleep Apnea can be found here: CP.MP.248 Facility-based Sleep Studies for Obstructive Sleep Apnea (PDF).
For further information, please contact your Provider Engagement Administrator.
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Provider Training Update
Date: 10/23/2023
Absolute Total Care partners with all of our contracted providers to ensure that you have received the necessary training to deliver quality care to our members and your patients and to be compliant with Centers for Medicare & Medicaid Services (CMS) and state requirements. In 2023, all Medicare Advantage Organization (MAO) and Medicare-Medicaid Plan (MMP) contracted providers are required to complete the following trainings within 90 days of contracting and annually thereafter:
- General Compliance (Compliance)
- Fraud, Waste, and Abuse
- Model of Care (MOC)*
- Person-Centered Planning**
For more information, please view the Annual Provider Requirements (PDF).
*MOC training is required for providers who directly or indirectly facilitate and/or provide Medicare Part C or D benefits for any Wellcare HMO SNP Member. Please refer to the MOC Self-Study Program MOC Self-Study Program.
**Person-Centered Planning training is required for providers who directly or indirectly provide services for our Wellcare Prime by Absolute Total Care MMP members
August
Medicare Prior Authorization Change Summary - Effective 10/1/2023
Date: 08/30/2023
Absolute Total Care requires prior authorization (PA) as a condition of payment for many services. This Notice contains information regarding such prior authorization requirements and is applicable to all Medicare products offered by Absolute Total Care.
Absolute Total Care is committed to delivering cost effective quality care to our members. This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice. Prior authorization is a process initiated by the physician in which we verify the medical necessity of a treatment in advance using independent objective medical criteria and/or in network utilization, where applicable.
It is the ordering/prescribing provider’s responsibility to determine which specific codes require prior authorization.
Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered. NON-PAR PROVIDERS & FACILITIES REQUIRE AUTHORIZATION FOR ALL HMO SERVICES EXCEPT WHERE INDICATED.
For complete CPT/HCPCS code listing, please see Online Prior Authorization Tool.
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Medicaid Prior Authorization Updates Effective 11/1/2023
Date: 08/29/2023
Absolute Total Care is committed to delivering cost effective care to our members. This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice. Absolute Total Care accomplishes this goal by utilizing prior authorization and benefit limit guidelines to verify the medical necessity of a treatment.
Effective 11/01/2023 prior authorization will be required for the following procedure codes: 37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230 and 37231.
The preferred and easiest method for submitting authorization requests is through the Secure Web Portal when you visit the Absolute Total Care website. If your request is approved, you will receive verification through the web portal. If you are not currently registered on our secure web portal, you may register through a quick and simple online process. If the provider is not already a registered user on the Secure Web Portal and needs assistance or training on submitting prior authorizations, the provider should contact Provider Relations.
Prior authorization requests may also be submitted by fax using the appropriate prior authorization form found under Provider Manuals and Forms on the Absolute Total Care website.
If you have questions about this update, please contact Provider Services at 1-866-433-6041.
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NCH Oncology Pathway Solutions / Cardiology Management Program
Date: 08/29/2023
Wellcare has partnered with New Century Health (NCH) to implement a new oncology prior authorization program, Oncology Pathway Solutions. Effective October 1, 2023, NCH will manage prior authorization requests for Medical Oncology and Radiation Oncology treatments provided in an outpatient setting. This includes all oncology-related chemotherapeutic drugs and supportive agents and radiation oncology treatments. This requirement applies for your Medicare members 18 years of age and older.
Wellcare has partnered with New Century Health (NCH) to implement a new cardiology prior authorization program, the Cardiology Management Program. This program is intended to help providers easily and effectively deliver quality patient care. Effective October 1, 2023, cardiology services rendered in a physician’s office, in an outpatient hospital ambulatory setting, or in an inpatient setting (planned professional services only) must be submitted to NCH for prior authorization. Approvals issued by Wellcare before October 1, 2023, are effective until the authorization end date, but all prior authorization requests needed after October 1, 2023, must be submitted to NCH. This requirement applies to all your Medicare members ages 18 and older.
Prior authorization can be requested by:
• Visiting NCH’s Web portal at my.newcenturyhealth.com, or
• Calling 1-888-999-7713, Option 1 (Monday–Friday, 8 a.m.–8 p.m. EST)
A provider network specialist will contact you to schedule an introductory meeting and training. If you have any questions prior to the introductory meeting, please contact NCH at 1-888-999-7713, Option 6 or email providertraining@newcenturyhealth.com. You can also self-register online at my.newcenturyhealth.com.
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Optum CPI AMISYS Phase 2
Date: 08/01/2023
Thank you for your continued partnership with Ambetter from Absolute Total Care. We are committed to continuously evaluating and improving overall Payment Integrity solutions as required by State and Federal governing entities. As a reminder, we have partnered with Optum who is supporting us in performing prepayment claim auditing. The purpose of our review is to verify the extent and nature of the services rendered for the patient’s condition and that the claim is coded correctly for the services billed.
For claims received on or after 9/1/2023 providers may receive a written request for medical record submission prior to payment based on the areas outlined below. These requests will come from Optum and will contain instructions for providing the documentation. Should the requested documents not be returned, the claim(s) will be denied. Providers will have the ability to dispute findings through Optum directly in the event of a disagreement.
Editing Area | Description | Lines of Business |
|---|---|---|
ER Surgical Services without Modifier 54 |
Requesting medical records to determine if documentation supports services billed for ER surgical services where the follow up was not performed in the ER setting, and the correct modifier (54) was not included with the claim. |
Marketplace |
Thank you for your continued participation and cooperation in our ongoing efforts to render quality health care to our members. We look forward to helping you provide the highest quality of care for our members.
July
Internal diagnostic-related group (DRG) Reviews for Inpatient Claims
Date: 07/12/2023
Absolute Total Care is committed to continuously evaluating and improving overall payment integrity solutions as required by State and Federal governing entities. We are writing today to inform you of a review process change that will begin taking place on or after 8/15/2023:
- Inpatient claims will be reviewed internally for diagnostic-related group (DRG) validation prior to utilizing external vendors. Medical records will be requested for selected claims and should be sent according to the instructions on the request correspondence.
- This applies to Medicare-Medicaid Plan, Medicaid, Marketplace
Internal DRG Provider Notification (PDF)
June
REVISED PHYSICAL AND SPEECH THERAPY PRIOR AUTHORIZATION REQUIREMENTS
Date: 06/01/2023
Absolute Total Care is committed to delivering cost effective care to our members. This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice. Absolute Total Care accomplishes this goal by utilizing prior authorization and benefit limit guidelines to verify the medical necessity of a treatment.
Physical and Speech Therapy via Telehealth
- Prior authorization for physical and speech telehealth therapy services will be required for dates of service on or after August 1, 2023 and need to be verified by NIA.
- The following physical and speech therapy services, when delivered via telehealth, should be billed with modifier GT in addition to modifiers that are already required per Medicaid billing guidelines:
- Prior authorization for all other therapy services not specifically outlined above remain in effect and need to be verified by NIA.
- Benefit limits apply to all services according to existing SCDHHS and Absolute Total Care policy.
- Services identified above must meet standard requirements for medical necessity.
- Services provided pursuant to the current SCDHHS telemedicine coverage policy should continue to be billed according to those guidelines.
May
Provider Notification: Claims Xten Optimization
Date: 05/26/2023
Dear Provider,
Thank you for your continued partnership with Absolute Total Care. As you know, we continually review and update our payment and utilization policies to ensure that they are designed to comply with industry standards while delivering the best patient experience to our members. We are writing today to inform you of new policies Absolute Total Care will be implementing effective 8/1/2023.
Policy Name | Policy Description | Lines of Business |
|---|---|---|
Claims Xten Optimization – NCD Alignment | Adding prepay reviews for several national coverage determinations (NCDs) to be in accordance with CMS guidelines for correct coding. | Medicare |
Single Chamber and Dual Chamber Permanent Cardiac Pacemakers | Medicare | |
Bone (Mineral) Density Studies | Medicare | |
Percutaneous Image-Guided Breast Biopsy | Medicare | |
Prostate Cancer Screening Tests | Medicare | |
Screening for Sexually Transmitted Infections (STIs) and High-Intensity Behavioral Counseling (HIBC) to Prevent STIs | Medicare | |
Screening for Hepatitis B Virus HBV Infection | Medicare | |
Screening for the Human Immunodeficiency Virus HIV Infection | Medicare | |
Glycated Hemoglobin Glycated Protein | Medicare | |
Implantable Cardiac Defibrillators | Medicare | |
Prostate Screening Cancer | Medicare |
If you have questions about this or any of our other policies, please don’t hesitate to reach out to Provider Services.
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Medicare Prior Authorization Change Summary - Effective 7/1/2023
Date: 05/25/2023
Absolute Total Care requires prior authorization (PA) as a condition of payment for many services. This Notice contains information regarding such prior authorization requirements and is applicable to all Medicare products offered by Absolute Total Care.
Absolute Total Care is committed to delivering cost effective quality care to our members. This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice. Prior authorization is a process initiated by the physician in which we verify the medical necessity of a treatment in advance using independent objective medical criteria and/or in network utilization, where applicable.
If you have any questions regarding this information, you may contact Provider Services at 1-855-766-1497 or contact your dedicated Provider Relations Specialist.
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Hemodialysis Modifier
Date: 05/18/2023
Dear Valued Provider,
Thank you for your continued partnership with Absolute Total Care. As you know, we are committed to continuously evaluating and improving overall Payment Integrity solutions as required by State and Federal governing entities. We are writing today to inform you of new policies Absolute Total Care will be implementing effective on or after July 1, 2023.
| Edit Name | Description | Lines of Business |
|---|---|---|
| Hemodialysis Modifier | Based on CMS guidelines, hemodialysis (CPT 90999) will be denied when the required modifier (G1-G6) is not present. | Medicare Marketplace |
Thank you for your continued participation and cooperation in our ongoing efforts to render quality health care to our members. We look forward to helping you provide the highest quality of care for our members.
Sincerely,
Absolute Total Care
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Emergency Department (ED) Outpatient Facility Evaluation and Management (E/M) Coding Policy
Date: 05/17/2023
As part of our continued efforts to reinforce accurate coding practices, Absolute Total Care will implement the following new Emergency Department (ED) outpatient facility Evaluation and Management (E/M) coding reimbursement policy and procedure. This policy applies to the following lines of business as of the dates shown below:
- Wellcare Prime by Absolute Total Care (Medicare-Medicaid Plan), Effective July 15, 2023
- Ambetter from Absolute Total Care (Marketplace), Effective July 15, 2023
This policy focuses on outpatient facility ED claims that are submitted with level 1 (99281, G0380), level 2 (99282, G0381), level 3 (99283, G0382), level 4 (99284, G0383), or level 5 (99285, G0384) E/M codes. This policy was developed using our national experience to address inconsistencies in coding accuracy and is based on the E/M coding principles created by the Centers for Medicare and Medicaid Services (CMS) that require hospital ED facility E/M coding guidelines to follow the intent of CPT® code descriptions and reasonably relate to hospital resource use.
This policy will apply to all facilities, including freestanding facilities, that submit ED claims with level 1, 2, 3, 4, or 5 E/M codes for members of the affected lines of business, regardless of whether they’re under contract to participate in our network.
As part of the implementation of this policy, we will begin using the Optum Emergency Department Claim (EDC) Analyzer tool, which determines appropriate E/M coding levels based on data from the patient’s claim including the following:
- Patient’s presenting problem
- Diagnostic services performed during the visit
- Any patient complicating conditions
The goal of the Optum Emergency Department Claim (EDC) Analyzer is to achieve fair and consistent E/M coding and reimbursement of facility outpatient emergency department claims. The EDC Analyzer™ systematically evaluates each ED visit level code in the context of other claim data (i.e., diagnosis codes, procedure codes, patient age, and patient gender) to ensure that it reasonably relates to the intensity of hospital resource utilization as required per CMS Guidelines. The methodology used by the EDC Analyzer™ is based on Optum's Lynx™ tool, which is used by 1,500 facilities nationwide to code outpatient emergency department claims. This shared methodology between payers and providers promotes transparency in the coding and reimbursement process.
When a claim is processed through the Analyzer tool, a numbered weighting for each of three factors is assigned.
- Step 1 is Standard Costs, which assigns a standard cost weight to the visit based on evaluation of demographic characteristics and presenting problem.
- Step 2 is Extended Costs, which assigns an extended cost weight according to the intensity of the diagnostic workup based on diagnostic CPT codes.
- Step 3 is Patient Complexity Costs, which assigns a weight based on whether the patient has any conditions or has experienced any circumstances that may increase the complexity of the visit.
The weight numbers from each of these steps are added together to determine the total weight of the claim. The appropriate level of E/M service is then assigned based on this number.
For a more in-depth look at each of the EDC Analyzer Tool steps and to view specific claim examples, please visit EDCAnalyzer.com.
Facilities submitting claims for ED E/M codes may experience adjustments to level 2, 3, 4, or 5 E/M codes to reflect an appropriate level E/M code. Facilities will have the opportunity to submit reconsideration or appeal requests if they believe a higher level E/M code is justified, in accordance with the terms of their contract.
Criteria that may exclude outpatient facility claims from these policies include, but are not limited to:
- Claims for patients who were admitted from the emergency department or transferred to another health care setting (Skilled Nursing Facility, Long Term Care Hospital, etc.)
- Claims for patients who received critical care services (99291, 99292)
- Claims for patients who are under the age of 2 years
- Claims with certain diagnosis codes that when treated in the ED most often necessitate greater than average resource usage, such as significant nursing time
- Claims for patients who expired in the ED
Ultimately, the mutual goal of facility coding is to accurately capture ED resource utilization and align that with the E/M CPT® code description for a patient visit per CMS guidance.
If you need further information, please contact your Network Representative. Thank you for your continued partnership.
April
Provider Notification: Payment Policy Update
Date: 04/18/2023
Dear Provider,
Thank you for your continued partnership with Ambetter from Absolute Total Care. As you know, we continually review and update our payment and utilization policies to ensure that they are designed to comply with industry standards while delivering the best patient experience to our members. We are writing today to inform you of the revision to existing policies Ambetter from Absolute Total Care will be implementing effective 06/01/2023.
| Policy Number | Policy Name | Policy Description | Effective Date | Lines of Business |
|---|---|---|---|---|
| CP.MP.100 | Allergy Testing and Therapy | Policy updated to reflect Current Procedural Terminology (CPT®), Healthcare Common Procedure Coding System (HCPCS) and International Classification of Diseases, Tenth Edition (ICD-10) code guidelines. A comprehensive summary of changes is provided at the bottom of the policy document for reference. | 06/01/2023 | Marketplace and Medicaid |
| CP.MP.97 | Testing for Select Genitourinary Conditions | Policy updated to reflect Current Procedural Terminology (CPT®), Healthcare Common Procedure Coding System (HCPCS) and International Classification of Diseases, Tenth Edition (ICD-10) code guidelines. A comprehensive summary of changes is provided at the bottom of the policy document for reference. | 06/01/2023 | Marketplace and Medicaid |
For detailed information about these policies, please refer to our website at ambetter.absolutetotalcare.com. And for questions about this or any of our payment policies, please don’t hesitate to reach out to our Provider Services team at 1-833-270-5443.
Sincerely,
Ambetter from Absolute Total Care
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Provider Notification: Dialysis Payment Policy
Date: 04/18/2023
Dear Provider,
Thank you for your continued partnership with Ambetter from Absolute Total Care. As you know, we are committed to continuously evaluating and improving overall Payment Integrity solutions as required by State and Federal governing entities. We are writing today to inform you of new policies Ambetter from Absolute Total Care will be implementing effective on or after 06/01/2023.
| Policy Name | Description | Lines of Business |
|---|---|---|
| Dialysis Payment Policy | Based on CMS guidelines, hemodialysis service (90999) hemodialysis (CPT 90999) will be denied when a modifier (G1-G6) is not present on the claim. Interim claim bill type ending in XX2 or XX3 will be denied when discharge status 30 is not present on the claim. Medicare Claims Processing Manual – Chapter 1, Chapter 8 | Marketplace |
If you have any questions about this or any of our payment policies, please don’t hesitate to reach out to our Provider Services team at 1-833-270-5443. Thank you for your continued participation and cooperation in our ongoing efforts to render quality health care to our members. We look forward to helping you provide the highest quality of care for our members.
Sincerely,
Ambetter from Absolute Total Care
March
Provider News Update: Prepayment Claim Reviews
Date: 03/22/2023
Absolute Total Care is committed to continuously improving its overall payment integrity solutions to prevent overpayments due to waste or abuse. This is a notification that we will begin performing additional prepayment claim reviews on 6/1/2023 using Optum’s Comprehensive Payment Integrity (CPI) tool. As a result of these prepayment claim reviews, providers may be asked for medical records and billing documents that support the charges billed.
Absolute Total Care utilizes widely acknowledged national guidelines for billing practices and supports the concept of uniform billing for all payers. These prepayment claim reviews will look for overutilization of services or other practices that directly or indirectly result in unnecessary costs. A provider’s order must be present in the medical record to support all charges, along with clinical documentation to support the diagnosis and services or supplies billed.
The provider will receive detailed instructions about how to submit the requested documentation. Providers who do not submit the requested documentation may receive a technical denial, which will result in the claim being denied until the information required to adjudicate the claim is received.
If it is determined that a coding and/or payment adjustment is applicable, the provider will receive the appropriate claim adjudication. Providers retain their right to dispute results of reviews.
Please contact your Provider Services representative if you have any questions.
Thank you for your partnership.
Sincerely,
Absolute Total Care
December
Medicare Claim Submission Changes Effective for Dates of Service January 1, 2023, and Forward
Date: 12/07/2022
We want to help your billing department process your claim submissions as efficiently as possible. Effective January 1, 2023 and forward, current Wellcare by Allwell Medicare plans, i.e., Wellcare No Premium Medicare (HMO), Wellcare Dual Liberty (HMO D-SNP) and Wellcare Dual Access (HMO D-SNP) will transition to Wellcare Medicare plans administered by Wellcare on the Wellcare claim platform.
August
Medicare Prior Authorization Updates Effective 10/01/2022
Date: 8/19/22
Absolute Total Care requires prior authorization as a condition of payment for many services. This notice contains information regarding such prior authorization requirements and is applicable to all Medicare products offered by Absolute Total Care. Absolute Total Care is committed to delivering cost effective quality care our members. This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice. If you have any questions regarding this information, you may contact Provider Services at 1-855-766-1497 or contact your dedicated Provider Relations Specialist.
__________________________________________________________
National Imaging Associates (NIA) Expansion
Date: 08/30/22
Absolute Total Care is pleased to announce the expansion of its partnership with National Imaging Associates, Inc. (NIA). In addition to the services that currently require prior authorization through NIA, certain cardiac-related procedures will also require prior authorization beginning November 1, 2022. Providers may begin contacting NIA on November 1, 2022, to seek prior authorization for procedures scheduled on or after November 1, 2022. The program expansion is applicable for all Absolute Total Care Medicaid members, Wellcare Prime by Absolute Total Care (Medicare-Medicaid Plan) members and Ambetter from Absolute Total Care (Health Insurance Marketplace) members.
September
Wellcare By Allwell Changing Peer-to-Peer Review Request and Elective Inpatient Prior Authorization Requirements for Medicare Advantage Plans
Date: 09/01/22
To reduce administrative burden on our provider partners, Wellcare By Allwell is making changes to both our peer-to-peer review request requirements and elective medical inpatient authorization process. This will impact peer-to-peer and elective medical inpatient authorization requests received on or after the dates outlined below.
_______________________________________________________________________________
NIA Cardiac Expansion Program - Provider Education Webinars
Date: 09/30/2022
In an effort to continue promotion of quality improvement for services provided to Absolute Total Care, Ambetter from Absolute Total Care, and Wellcare Prime by Absolute Total Care (MMP) members, effective November 1, 2022, the aforementioned health plans are expanding their existing partnership with National Imaging Associates, Inc. (NIA) to provide the management and prior authorization of non-emergent outpatient procedures. This decision is consistent with industry-wide efforts to ensure clinically appropriate quality of care and to manage the increasing utilization of these services.
October
Provider Training Update
Date: 10/06/2022
Absolute Total Care partners with all of our contracted providers to ensure that you have received the necessary training to deliver quality care to our members and your patients and to be compliant with Centers for Medicare & Medicaid Services (CMS) and state requirements. All Medicare Advantage Organization (MAO) and Medicare-Medicaid Plan (MMP) contracted providers are required to complete the following trainings within 90 days of contracting and annually thereafter:
- General Compliance (Compliance)
- Fraud, Waste, and Abuse
- Model of Care (MOC)*
- Person-Centered Planning**
For more information, please view the Annual Provider Requirements (PDF) and visit our Provider Training page.
November
NEW Attestation Process for Special Supplemental Benefits for Chronically Ill (SSBCI)
Date: 11/09/2022
Effective January 1, 2023, fax attestations are no longer accepted.
Special Supplemental Benefits for Chronically Ill (SSBCI) are offered to Wellcare by Allwell’s highest-risk members who meet specific criteria for eligibility based on the Centers for Medicare and Medicaid Services (CMS) guidelines.
Effective January 1, 2023, you can check eligibility requirements and submit attestations on behalf of members online at ssbci.rrd.com
Steps to determine eligibility, submit attestations and activate benefits
Members are required to schedule an office visit with their doctor or participating physician group for evaluation. Once appointment is made follow the steps below:
1 Visit ssbci.rrd.com.
2 Follow the steps on ssbci.rrd.com to evaluate your patient against the eligibility requirements outlined at ssbci.rrd.com.
3 Submit an attestation form through ssbci.rrd.com indicating your patient meets the eligibility requirements.
4 Submit a claim with the appropriate diagnosis codes from this office visit indicating a member has been diagnosed with one or more qualifying chronic conditions listed on ssbci.rrd.com.
5 Upon receipt of all required information, the member will be sent an approval or denial letter within 10 business days. Approval letters include information on steps the member should follow to activate supplemental member benefits.
If you have questions regarding the information contained in this update, contact 1-855-766-1497 (TTY: 711). From October 1 – March 31, you can call us 7 days a week from 8 a.m. to 8 p.m. From April 1 – September 30, you can call us Monday – Friday from 8 a.m. to 8 p.m. A messaging system is used after hours, weekends, and on federal holidays.
______________________________________________________________________________
Medicare Prior Authorization Change Summary - Effective 1/1/2023
Date: 11/28/2022
Absolute Total Care requires prior authorization (PA) as a condition of payment for many services. This Notice contains information regarding such prior authorization requirements and is applicable to all Medicare products offered by Absolute Total Care.
Absolute Total Care is committed to delivering cost effective quality care to our members. This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice. Prior authorization is a process initiated by the physician in which we verify the medical necessity of a treatment in advance using independent objective medical criteria and/or in network utilization, where applicable.
It is the ordering/prescribing provider’s responsibility to determine which specific codes require prior authorization.
Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered. NON-PAR PROVIDERS & FACILITIES REQUIRE AUTHORIZATION FOR ALL HMO SERVICES EXCEPT WHERE INDICATED.
For complete CPT/HCPCS code listing, please see Online Prior Authorization Tool on our website at https://www.absolutetotalcare.com/providers/preauth-check.html.
January
All Together Now
Date: 01/08/21
In South Carolina, WellCare and Absolute Total Care are joining health plans. This means beginning April 1, 2021, your Medicaid coverage will be provided by Absolute Total Care. We are excited about what this means for our members.
For WellCare of South Carolina members, there will be very little change to the benefits and services you currently receive.
You will receive a new member ID card in the mail from Absolute Total Care. Although there will be very little change to your benefits, you will receive a new member welcome packet with information on your new health plan.
If your provider is not in the Absolute Total Care network, you will receive a letter telling you what to do.
You can be aware of any updates by visiting this page. If you have any questions or need help, please call WellCare of South Carolina Member Services at 1-888-588-9842 (TTY: 711).
WellCare of South Carolina and Absolute Total Care are committed to making sure that you keep getting high-quality medical care. We want to make this change as easy as possible for you.
Integration FAQs
I am a WellCare member. Was I enrolled into Absolute Total Care?
No member is automatically enrolled in Absolute Total Care until April 1, 2021, unless you are within your recertification or annual enrollment period. During this time, you could have been automatically assigned to Absolute Total Care if you did not choose a different plan.
What if my provider told me that they do not participate with Absolute Total Care?
Your health is important to us. If you are currently receiving care from a provider that says that they do not participate with Absolute Total Care, please call Absolute Total Care Member Services at 1-866-433-6041 (TTY: 711). Member Services will be happy to assist you with locating another provider if your provider does not participate with Absolute Total Care.
Can I transition to Absolute Total Care now instead of April 1, 2021?
Please contact South Carolina Healthy Connections Choices toll-free at 1-877-552-4642 (TTY: 1-877-552-4670) so an Enrollment Counselor can assist you with enrollment into Absolute Total Care.
Is my WellCare ID card still valid?
Continue to use your WellCare ID card to get prescriptions and access healthcare services through March 31, 2021. You will receive a new member ID card and a welcome packet from Absolute Total Care in March 2021. The new ID card will allow you to get prescriptions and access healthcare services starting April 1, 2021. Please make sure you show your new Absolute Total Care ID card to your doctor and at the pharmacy beginning April 1, 2021 to access your Absolute Total Care benefits.
When can I start using my new benefits?
You can start using your Absolute Total Care benefits on April 1, 2021. Absolute Total Care will mail out new member ID cards and a welcome packet to all new members in March 2021. Please make sure you show your new Absolute Total Care ID card to your doctor and at the pharmacy beginning April 1, 2021 to access your Absolute Total Care benefits.
Do I need to call to request a new ID card from Absolute Total Care?
You do not need to contact Absolute Total Care to request a new ID card. Absolute Total Care will mail out new member ID cards and a welcome packet to all new members in March 2021. Please make sure you show your new Absolute Total Care ID card to your doctor and at the pharmacy beginning April 1, 2021 to access your Absolute Total Care benefits.
When will I receive my new ID card?
Absolute Total Care will mail out new member ID cards and a welcome packet to all new members in March 2021. Please make sure you show your new Absolute Total Care ID card to your doctor and at the pharmacy beginning April 1, 2021 to access your Absolute Total Care benefits.
I received my new Absolute Total Care ID card, and my primary care provider (PCP) information is incorrect.
Please contact Absolute Total Care Member Services at 1-866-433-6041 (TTY: 711) to verify and update your PCP information. If you do not have a PCP, Member Services can help you choose one.
Should I contact my doctor to advise him/her of my plan change?
You do not have to contact your doctor to advise them of your new plan. You will receive an Absolute Total Care member ID card that will allow you to get prescriptions and access healthcare services starting April 1, 2021. Please make sure you show your new Absolute Total Care ID card to your doctor and at the pharmacy beginning April 1, 2021 to access your Absolute Total Care benefits. If you would like to check to see if your doctor is in network with Absolute Total Care, you may use the Find A Provider Tool.
Will there be any changes to my current healthcare appointments or procedures?
This change will not have an impact on your previously scheduled appointments or procedures. We will honor your previous health plan’s authorized services for 90 days after coming onto our plan. After that time, we may require authorization for the service. We will let you stay with an out-of-network doctor until you are able to find a doctor in our network that can provide the services you need. If you do experience any issues, please call Absolute Total Care Member Services at 1-866-433-6041 (TTY: 711) as soon as possible.
Will this change have an impact on my current prescriptions prescribed by my doctor?
This will not cause any immediate change to your current prescriptions. We will honor your previous health plan’s authorized services for 90 days after coming onto our plan. After that time, we may require authorization for the service. It is important to discuss your current prescriptions with your doctor to make sure Absolute Total Care covers them after the 90-day transition of care period. If you do experience any issues, please call Absolute Total Care Member Services at 1-866-433-6041 (TTY: 711) as soon as possible.
What is my new Rx BIN and Group Number?
- RXBIN: 004336
- RXPCN: MCAIDADV
- RXGROUP: RX5433
Can I stay with WellCare?
WellCare will no longer be an independent plan, and all members enrolled with WellCare will be enrolled into Absolute Total Care effective April 1, 2021.
Can I continue to see my current provider?
On April 1, 2021, all WellCare of South Carolina Medicaid members will become Absolute Total Care members. You will receive a welcome packet and new member ID card from Absolute Total Care in March 2021 and will use your Absolute Total Care ID card to get your prescriptions and access health care services starting April 1, 2021. Please make sure you show your new Absolute Total Care ID card to your doctor and at the pharmacy beginning April 1, 2021 to access your Absolute Total Care benefits.
Your health is important to us. If you are currently receiving care from a provider that says that they do not participate with Absolute Total Care, please call Absolute Total Care Member Services at 1-866-433-6041 (TTY: 711). Member Services will be happy to assist you with locating another provider if your provider does not participate with Absolute Total Care.
What happens after April 1, 2021?
Once you transition to Absolute Total Care you will receive your new Absolute Total Care member ID card and will access all medical and pharmacy services through Absolute Total Care providers. Please make sure you show your new Absolute Total Care ID card to your doctor and at the pharmacy beginning April 1, 2021 to access your Absolute Total Care benefits.
Does my provider participate in the Absolute Total Care network?
Absolute Total Care and WellCare utilize 98% of the same networks, so it is possible that your provider is already in the network. If you would like to check to see if your doctor is in network with Absolute Total Care, you may use the Find A Provider Tool. You may also call Absolute Total Care Member Services at 1-866-433-6041 (TTY: 711) for assistance.
Will Absolute Total Care continue to offer Medicare and Marketplace products?
Yes, Absolute Total Care and WellCare will continue to offer Medicare products under their current brands and product names, until further notice. Absolute Total Care will continue to offer Marketplace products under the Ambetter brand.
Will Absolute Total Care change its name to WellCare?
No, Absolute Total Care will continue to operate under the Absolute Total Care name. The current transaction means that WellCare of South Carolina Medicaid members are transitioning to Absolute Total Care and will become Absolute Total Care members, effective April 1, 2021.
Will WellCare continue to offer current products or Medicare only?
As of April 1, 2021, all WellCare South Carolina Medicaid members will transfer to Absolute Total Care. WellCare and Absolute Total Care Medicare plans will continue to operate under current brands, product names, and provider contracts, until further notice.
When I become an Absolute Total Care member will I still have my Healthy Rewards?
The Healthy Rewards benefit with WellCare will end March 31, 2021; however, effective April 1, 2021 you will receive My Health Pays® rewards benefits with Absolute Total Care.
April
Absolute Total Care Payment Policy and Edit Updates Effective 5/1/21
Date: 04/24/21
Thank you for your continued partnership with Absolute Total Care. As you know, we continually review and update our payment and utilization policies to ensure that they are designed to comply with industry standards while delivering the best patient experience to our members. We are writing today to inform you of new policies Absolute Total Care will be implementing effective *5/1/2021*.
Policy Number | Policy Name | Policy Description | Lines of Business |
|---|---|---|---|
CC.PP.070 | 340B Drug Payment Reduction | Ensures that providers participating in the 340B Drug Pricing Program are correctly reporting 340B acquired drugs according to guidelines established by the Centers for Medicare and Medicaid Services (CMS). | Medicare |
CP.MP.208 | Outpatient Testing for Drugs of Abuse: Presumptive Frequency Edits | Medical necessity criteria for presumptive (preliminary) testing for a specific drug and frequency limits for 80305, 80306, and 80307 for chronic opioid therapy. | Medicaid, Medicare, Marketplace |
Policy Number | Policy Name | Policy Description | EX Code | Lines of Business |
|---|---|---|---|---|
Prepay Edit | WCG Integration Value Capture – Correct Coding Batch 2 (Cotiviti 8, WCIVC B2) | The purpose of this policy is to serve as a reference guide for general coding and claims editing information. Cotiviti 8 is a correct coding edit of ICD-10 diagnosis codes. Source: ICD-10 CM Diagnosis Code Manual | EX Code: wd Diagnosis Code Incorrectly Coded Per ICD10 Manual
| Medicaid, Medicare, Marketplace |
For detailed information about these policies, please refer to our website at www.absolutetotalcare.com.
For questions about this or any of our payment policies, please don’t hesitate to reach out to our Provider Services team at 1-866-433-6041.
Notice About a New Payment Integrity Audit Program
Date: 04/27/21
Send requested medical records to help ensure your DRG payment is correct.
A new audit program will begin in July 2021. Selected inpatient claims and their related medical records will be audited as part of the payment integrity program. The audit ensures diagnosis related group (DRG) payments are applied using nationally correct coding rules.
Cotiviti May Contact You
Absolute Total Care has contracted with Cotiviti to help with this effort. If you have an inpatient claim selected for audit, you will receive a letter from Cotiviti listing the claim information and the medical records needed. You may receive the request for medical records before the claim is paid.
- Send in only the requested medical records to the address noted in the letter.
- An inpatient claim selected for prepay audit will be suspended for medical records. Payment is made after the medical records are received and the audit is complete. Claims payment will be denied if requested medical records are not received within the requested timeframe.
Claims Reimbursement
As a reminder, payments to contracted providers for covered services are based on contract provisions supplemented by fee schedules, payment policies and coding methodologies.
Additional Information
Providers are encouraged to access Absolute Total Care’s provider portal online at www.absolutetotalcare.com for real-time information, including eligibility verification, claims status, prior authorization status, and more. If you have questions regarding the information contained in this update, contact Absolute Total Care at 1-866-433-6041. We appreciate your participation in our network and your dedication to the health and welfare of our members and your patients.
June
Medicare Prior Authorization Updates
Date: 06/01/21
Absolute Total Care requires prior authorization as a condition of payment for many services. This notice contains information regarding such prior authorization requirements and is applicable to all Medicare products offered by Absolute Total Care. Absolute Total Care is committed to delivering cost effective quality care our members. This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice. If you have any questions regarding this information, you may contact Provider Services at 1-866-433-6041 or contact your dedicated Provider Relations Specialist.
Effective August 1st, 2021, prior authorization will be required for the services listed on the Bi-Annual Prior Authorization Update (PDF).
Provider Training Update
Date: 06/16/21
Absolute Total Care partners with all of our contracted providers to ensure that you have received the necessary training to deliver quality care to our members and your patients and to be compliant with Centers for Medicare & Medicaid Services (CMS) and state requirements. In 2021, all Medicare Advantage Organization (MAO) and Medicare-Medicaid Plan (MMP) contracted providers are required to complete the following trainings within 90 days of contracting and annually thereafter:
- General Compliance (Compliance)
- Fraud, Waste, and Abuse
- Model of Care (MOC)*
For more information, please view the Annual Provider Requirements (PDF) and the Model of Care Training Quick Reference Guide (PDF).
New Prepayment Audit Review Program
Date: 06/22/21
Thank you for being part of the Absolute Total Care provider network. We pride ourselves on offering our members access to quality care from valued providers. This letter is to inform you that Absolute Total Care will begin a new prepayment audit review program effective September 1, 2021. Selected laboratory, diagnostic, telemedicine, behavioral health therapy and other services will be audited as part of the payment integrity program. The claims review program will require medical records in order to confirm billing accuracy and appropriateness before the claim is paid.
Absolute Total Care, as a health insurance plan, is responsible to promptly pay providers and ensure that claims submitted for payment are accurately billed and appropriately documented. Absolute Total Care satisfies these responsibilities via prospective and retrospective reviews of submitted claims. Absolute Total Care’s Payment Integrity Dept. is one of the units engaged in such reviews. Many issues raised through these reviews involve provider coding errors or some other inadvertent mistakes, which may have resulted in erroneous payments to providers.
Cotiviti May Contact You
Absolute Total Care has contracted with Cotiviti, Inc. (Cotiviti) to conduct its claim reviews. If you receive a letter from Cotiviti requesting medical records, please send in the documentation to support billed services.
- The documentation must be submitted directly to Cotiviti within 60 days of the date of the letter requesting medical records.
- Please only submit records in response to the requests for records.
- If documentation is not submitted in a timely manner directly to Cotiviti, the related claims will be denied.
Additional Information
Providers are encouraged to access Absolute Total Care’s provider portal online at www.absolutetotalcare.com for real-time information, including eligibility verification, claims status, prior authorization status, and more. If you have any questions regarding this information, you may contact Provider Services at 1-866-433-6041 or contact your dedicated Provider Relations Specialist. We appreciate your participation in our network and your dedication to the health and welfare of our members and your patients.
July
Absolute Total Care Payment Policy and Edit Updates Effective 10/1/2021
Date: 07/30/21
Thank you for your continued partnership with Absolute Total Care. As you know, we continually review and update our payment and utilization policies to ensure that they are designed to comply with industry standards while delivering the best patient experience to our members. We are writing today to inform you of new policies Absolute Total Care will be implementing effective *10/1/2021*.
CC.PP.001 PREPAY EDIT | EDIT FUNCTION | EDIT DESCRIPTION | EX CODE | LINES OF BUSINESS |
|---|---|---|---|---|
Procedure Modifier Revenue Necessary (PMRN) | The PMRN edit will deny procedures that require an associated modifier. The edit also identifies situations where a correct modifier and a correct revenue code are required. This edit applies to professional (HCFA) and outpatient facility (UB-04) claims. | According to CMS and AMA, to facilitate claim processing and prevent claim denials, procedures which can be performed on different sides of the body, separate anatomical areas, or separate patient encounters require the use of modifiers whenever appropriate.
Therapy Claims: On professional claims, each code designated as “always therapy” must always be furnished under an SLP, OT, or PT plan of care, regardless of who furnishes them; and, as such, must always be accompanied by one of the therapy modifiers.
Medicare recognizes the services furnished under the OPT services benefit as either “always” or “sometimes” therapy.
“Always therapy” codes require modifier GN, GO, or GP appended to the therapy CPT code.
CMS approved "sometimes therapy" codes require the appropriate modifier and revenue code combination when furnished by a therapist. | EX Code: we -Procedure Modifier Revenue Necessary | Medicare Marketplac |
Ambetter from Absolute Total Care Payment Policy and Edit Updates Effective 10/1/2021
Date: 07/30/21
Thank you for your continued partnership with Absolute Total Care. As you know, we continually review and update our payment and utilization policies to ensure that they are designed to comply with industry standards while delivering the best patient experience to our members. We are writing today to inform you of new policies Absolute Total Care will be implementing effective *10/1/2021*.
CC.PP.001 PREPAY EDIT | EDIT FUNCTION | EDIT DESCRIPTION | EX CODE | LINES OF BUSINESS |
|---|---|---|---|---|
Procedure Modifier Revenue Necessary (PMRN) | The PMRN edit will deny procedures that require an associated modifier. The edit also identifies situations where a correct modifier and a correct revenue code are required. This edit applies to professional (HCFA) and outpatient facility (UB-04) claims. | According to CMS and AMA, to facilitate claim processing and prevent claim denials, procedures which can be performed on different sides of the body, separate anatomical areas, or separate patient encounters require the use of modifiers whenever appropriate.
Therapy Claims: On professional claims, each code designated as “always therapy” must always be furnished under an SLP, OT, or PT plan of care, regardless of who furnishes them; and, as such, must always be accompanied by one of the therapy modifiers.
Medicare recognizes the services furnished under the OPT services benefit as either “always” or “sometimes” therapy.
“Always therapy” codes require modifier GN, GO, or GP appended to the therapy CPT code.
CMS approved "sometimes therapy" codes require the appropriate modifier and revenue code combination when furnished by a therapist. | EX Code: we -Procedure Modifier Revenue Necessary | Marketplace |
POLICY | POLICY NAME | LINES OF BUSINESS |
|---|---|---|
Single Chamber and Dual Chamber Permanent Cardiac Pacemakers | Marketplace | |
Bone (Mineral) Density Studies | Marketplace | |
Percutaneous Image-Guided Breast Biopsy | Marketplace | |
Prostate Cancer Screening Tests | Marketplace | |
Screening for Sexually Transmitted Infections (STIs) and High-Intensity Behavioral Counseling (HIBC) to Prevent STIs | Marketplace | |
Intravenous Immune Globulin for the Treatment of Autoimmune Mucocutaneous Blistering Diseases | Marketplace | |
Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions | Marketplace |
For questions about this or any of our payment policies, please don’t hesitate to reach out to our Provider Services team at 1-833-270-5443.
August
COVID-19 PUBLIC HEALTH EMERGENCY EXTENDED BY FEDERAL GOVERNMENT
Date: 08/13/21
On July 19, 2021, HHS Secretary Xavier Becerra renewed the COVID-19 Public Health Emergency (PHE). This extends flexibilities and funding tied to the PHE to continue for another 90 days, effective July 20, 2021.
With this renewal the various testing, screening, billing, and telehealth coverages that were implemented in response to the COVID-19 PHE will be extended to our members. This extension will continue until the PHE is either terminated or extended again.
If you have any questions about the extension or the covered benefits impacted by it, please contact Member Services at 1-866-433-6041 (TTY: 711).
January
Revised Behavioral Health Prior Authorization Requirement
Date: 01/13/20
Note: This is a revision to the prior authorization requirement notification posted on May 1, 2019.
Absolute Total Care is committed to delivering cost effective care to our members. This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice. Absolute Total Care accomplishes this goal by utilizing prior authorization and benefit limit guidelines to verify the medical necessity of a treatment.
For Licensed Individual Practitioners (LIPS) and Rehabilitative Behavioral Health Services (RBHS) providers, prior authorization will be required starting June 1, 2019 for any combination of the following procedure codes for continued services after the 24th encounter within a calendar year per member: 90832, 90834, 90837, 90846, 90847, 90849, and 90853.
Additionally, for all provider types, Absolute Total Care will reset its benefit limits for all codes identified above to match the benefit limits currently outlined by the South Carolina Department of Health and Human Services (SCDHHS). Details on benefit limits for each code per provider type are outlined in the provider manuals provided on the SCDHHS website.
You may submit the prior authorization requests utilizing our secure web portal at absolutetotalcare.com. If you are not currently registered on our secure web portal, you may register through a quick and simple online process. If your request is approved, you will receive verification through the web portal. You may also submit the prior authorization request by faxing an Outpatient Treatment Request (OTR) Form to 1-866-694-3649. The OTR Form can be found at cenpatico.com under Provider Tools.
If you have questions about this update, please reach out to Provider Services at 1-866-433-6041. For more information, visit our Behavioral Health webpage.
All together now.
Date: 01/24/20
All together now.
In South Carolina, WellCare of South Carolina and Absolute Total Care are bringing our health plans together to better serve our members, providers, partners, and communities.
We’re excited about this opportunity to bring our companies together, what it means for our employees, and most importantly – what it means for YOU.
Right now, nothing is changing.
WellCare of South Carolina and Absolute Total Care members can still depend on the same health plan, network, supports, and services you’ve come to expect. Your current member ID card is still your key to your good health.
WellCare of South Carolina and Absolute Total Care providers should continue to treat members from each health plan as you do under your current contract(s). Your existing provider support channels will remain in place. And your patients’ current member ID cards will remain valid as well. We will communicate any relevant changes in health plan operations to you well in advance.
Over the next few months, WellCare of South Carolina and Absolute Total Care will all come together. This will help us continue delivering the best healthcare options. We’ll keep you updated about any changes and choices that you will have.
You may also call us.
Members:
- Absolute Total Care: 1-866-433-6041 (TTY: 711)
Providers:
- Absolute Total Care: 1-866-433-6041
All together now.
Date: 01/24/20
All together now.
In South Carolina, WellCare of South Carolina and Absolute Total Care are bringing our health plans together to better serve our members, providers, partners, and communities.
We’re excited about what this opportunity means for our combined companies, our employees, and most importantly – YOU.
Right now, nothing is changing. Any relationship you have with either company remains the same. If you have questions, please contact Provider Services at 1-866-433-6041.
Annual Training Requirements
Date: 01/28/20
Absolute Total Care partners with all of our contracted providers to ensure that you have received the necessary training to deliver quality care to our members and your patients and to be compliant with Centers for Medicare & Medicaid Services (CMS) and state requirements. In 2020, all Medicare Advantage Organization (MAO) and Medicare-Medicaid Plan (MMP) contracted providers are required to complete the following trainings within 90 days of contracting and annually thereafter:
- General Compliance (Compliance)
- Fraud, Waste, and Abuse
- Model of Care (MOC)*
For more information, please view the Annual Provider Requirements (PDF) and the Model of Care Training Quick Reference Guide (PDF).
March
Medicare Prior Authorization Updates
Date: 03/12/20
Absolute Total Care requires prior authorization as a condition of payment for many services. This notice contains information regarding such prior authorization requirements and is applicable to all Medicare products offered by Absolute Total Care. Absolute Total Care is committed to delivering cost effective quality care our members. This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice. If you have any questions regarding this information, you may contact Provider Services at 1-866-433-6041 or contact your dedicated Provider Relations Specialist
Effective June 1st, 2020, prior authorization will be required for the services listed on the Bi-Annual Prior Authorization Update (PDF).
What You Need to Know About COVID-19
Date: 03/13/20
Coronavirus disease 2019 (COVID-19) is an emerging illness. Many details about this disease are still unknown, such as treatment options, how the virus works, the total impact of the illness, and many other factors.
What is the coronavirus?
COVID-19 is a respiratory disease that is caused by a new virus called a coronavirus, which has become a public health emergency. The number of cases continue to increase nationally and globally.
What are the symptoms?
The symptoms of coronavirus include mild to severe respiratory symptoms. Symptoms include fever, cough, and shortness of breath, and lower respiratory illness. It may be contagious before a person begins showing symptoms.
What else causes similar symptoms?
Influenza (the flu), a contagious respiratory illness caused by the influenza viruses (Type A and Type B), has high activity in the United States at this time. Everyone 6 months of age and older should get a flu vaccine.
I may have symptoms. What do I do?
If you have been exposed or begin showing symptoms of the virus or flu, contact your healthcare provider or health department immediately.
Protect yourself and your community.
We all have a role to play in protecting our communities and families from the spread of coronavirus. It is similar to other communicable viruses. You can also follow these tips to prevent infection:
- Wash your hands thoroughly and frequently. Use soap and water for at least 20 seconds.
- Use an alcohol-based hand sanitizing rub (must contain at least 60 percent alcohol).
- Cover your mouth when you cough or sneeze by coughing/sneezing into your elbow.
- Promptly dispose of tissues in a wastebasket after use.
- Clean public surfaces thoroughly.
- Stay home when you are sick.
- Avoid shaking hands.
- Avoid close contact with people who are sick.
- Get a flu vaccine.
For more information, including travel advisories, please visit cdc.gov.
- CDC General Information on COVID-19
- WHO General Information on COVID-19
- CDC Information on Travel
- CDC Videos on COVID-19
- CDC Print Resources
Absolute Total Care Taking Additional Steps to Protect Members' Health Amid COVID-19 Outbreak
Date: 03/16/20
As we continue to learn more and address the novel coronavirus and its resulting illness COVID-19, we want to update you on important coverage information around its testing, treatment and care.
Absolute Total Care will be extending coverage for COVID-19. This important step is being taken in partnership with other major insurers and with the support of the White House Coronavirus Task Force.
We intend to cover COVID-19 testing and screening services for Medicaid, Medicare, Medicare-Medicaid Plan (MMP), and Marketplace members and are waiving all associated member cost share amounts for COVID-19 testing and screening. To ensure that our members receive the care they need as quickly as possible, Absolute Total Care will not require prior authorization, prior certification, prior notification or step therapy protocols for these services.
This coverage extension follows the Centers for Medicare & Medicaid Services’ (CMS) guidance that coronavirus tests will be fully covered without cost-sharing for Medicare and Medicaid plans, a decision that Absolute Total Care fully supports for our members covered under these programs. We also support the administration’s guidance to provide more flexibility to Medicare Advantage and Part D plans. The specific guidance includes:
- Waiving cost-sharing for COVID-19 tests
- Waiving cost-sharing for COVID-19 treatments in doctor’s offices or emergency rooms and services delivered via telehealth
- Removing prior authorizations requirements
- Waiving prescription refill limits
- Relaxing restrictions on home or mail delivery of prescription drugs
- Expanding access to certain telehealth services
Absolute Total Care has been working in close partnership with state, local and federal authorities to serve and protect patients during the COVID-19 outbreak, including ensuring that its members and providers have the most up-to-date information to protect themselves and their families from the virus. We remain committed to protecting our communities during the outbreak.
To ensure you are keeping your environment safe from the coronavirus, please refer to the CDC guidelines.
NIA COVID-19 Response
Date: 03/18/20
For the past several weeks, the National Imaging Associates, Inc. (NIA) leadership team has been actively monitoring the coronavirus (COVID-19) outbreak and responding with measures to ensure our team members are safe and services to our clients and providers are not interrupted. We have followed the guidelines issued by the Centers for Disease Control (CDC) and the states in which we operate and reside.
We are very mindful of the impact this outbreak has on you, our valued provider. Given our work with you plays a vital role in the health of millions, it is necessary during this uncertain time to adapt some of our workplace practices. To more effectively and efficiently service providers, we are working to ensure that our operations continue with little or no interruption. In an effort to manage the anticipated increase in call volume, we ask that you use our website, www.RadMD.com to obtain authorizations, upload clinical documentation and verify authorization requests as often as possible.
For more information, please view the NIA COVID-19 Response (PDF) or visit the NIA webpage.
Member Information: Public Health Emergency
Date: 03/23/20
In response to the emergence of Coronavirus Disease 2019 (COVID-19), Health and Human Services Secretary Alex M. Azar II declared a public health emergency for the entire United States.
Your health and safety are our primary concerns and we do not want any undue barriers to keep you from getting your medication or seeing a medical professional.
We have removed the refill too soon edits for your prescription drugs and removed the out-of-network authorization requirements for out-of-network providers. You must still use Medicaid-certified facilities and providers.
Prior authorization for medical services or medication may still be needed for medical necessity. This change is in effect until the emergency notice is closed.
For public health emergencies, the lift for your prescription drugs refill too soon edit will remain in effect until the emergency no longer exists.
In the event of an emergency, please dial 9-1-1 or visit your closest medical facility. If you have any questions, please call Member Services at 1-866-433-6041 (TTY: 711).
For more information, please view the Department of Health & Human Services Press Release.
April
As COVID-19 Affects Job Situations, Some South Carolina Residents Must Look for New Health Coverage
Date: 04/08/20
Health insurance options are available for people whose health coverage was affected by job loss
More than 6.6 million people filed for unemployment benefits last week – breaking a record for the U.S. that was set the previous week.
For many of these Americans, however, losing a job doesn’t just create worry about providing for their families. It also raises concerns about protecting their health during a pandemic. About half of all Americans get their health insurance through their employer, so for many people, being newly unemployed brings with it uncertainty about how to navigate their health coverage options.
It’s important for South Carolinians who have lost their jobs to know that the Affordable Care Act includes a provision that gives people 60 days to enroll in health care after a qualifying life event, such as job loss.
There are a variety of affordable health coverage options, including Medicaid and the Health Insurance Marketplace through the Affordable Care Act (ACA). Each program has unique characteristics and requirements as outlined below:
- Medicaid offers free or low-cost health insurance coverage for lower income residents and the unemployed:
- In South Carolina, Medicaid coverage includes doctor visits, medications, home health care, durable medical equipment, dental and vision benefits for children.
- Certain criteria, including income, are considered in determining eligibility for South Carolina Medicaid. Note: CARES Act supplementary unemployment insurance benefits, which can increase unemployment benefits by $600 per week, do not impact eligibility for Medicaid programs.
- Enrollment is offered year-round, and healthcare services provided up to three months prior to enrollment can be covered retroactively.
- To enroll in Medicaid in South Carolina, visit apply.scdhhs.gov or call South Carolina Healthy Connections at 1-888-549-0820 (TTY: 1-888-842-3620).
- Health Insurance Marketplace is for anyone who doesn’t receive employer-provided coverage, and it allows people to choose from multiple health insurance plans to find the right coverage:
- Enrollment is available during a special enrollment period (SEP). Once a person experiences a qualifying life event such as job loss, they have 60 days to enroll.
- Financial assistance is available for Marketplace coverage if a person’s expected 2020 income will be 100%-400% of the federal poverty level, which is $12,490-$49,960 for an individual and $25,750-$103,000 for a family of four.
- To be eligible for coverage, a person must live in the United States, be a U.S. citizen or national, and can’t be incarcerated. Healthcare.gov has more details on eligibility.
- To find out what qualifies for SEP and shop for ACA coverage, visit Healthcare.gov or call 1-800-318-2596 (TTY: 1-855-889-4325).
Both Medicaid and Marketplace provide an alternative that’s often more affordable than COBRA, the health insurance program that allows people to continue their employer-provided coverage if they have lost their job, and it’s important to understand the differences. While COBRA maintains a person’s existing coverage, they will pay 100 percent of the cost plus an additional 2% in administrative costs. Subsidies to reduce costs are not available through COBRA, and coverage can last between 18 to 36 months, depending on the circumstances of job loss. However, it will eventually expire, and a person may be required to find new coverage, either through employment, Medicaid, or the ACA Marketplace.
“The impacts of the COVID-19 public health crisis are far reaching. It’s not only affecting people’s health, but also their employment situation and ability to access healthcare,” said John McClellan, Plan President & CEO. “At Absolute Total Care, we want to support our communities in making informed decisions about their health coverage options, so they can access the care they need.”
Absolute Total Care is available to help people navigate health insurance options during this public health crisis. For information about COVID-19, please visit the Center for Disease Control and Prevention’s (CDC) website. For any questions about health insurance coverage options, please visit Absolute Total Care’s website at www.absolutetotalcare.com or call 1-866-433-6041.
Absolute Total Care Sharing New COVID-19 Support Program to Assist Providers With Grant Writing, Small Business Loan Applications
Date: 04/15/20
Absolute Total Care is providing assistance to network providers in South Carolina who are seeking relief amid the COVID-19 pandemic through the Small Business Administration (SBA) and the CARES Act. Absolute Total Care is sharing access to a dedicated online portal of Provider Financial Support & Resources, where network providers can research benefits they may be eligible for and work directly with experts to apply for them. The portal was developed by Centene Corporation, a leading multi-national healthcare company. As part of the Centene family, Absolute Total Care is providing access to these resources to aid South Carolina providers in grant writing and business loan applications, among other key activities.
"Our providers are on the front lines every day, taking care of the most vulnerable populations across South Carolina,” said John McClellan, Plan President & CEO of Absolute Total Care. “In support of our provider partners and their fight against COVID-19, we are providing access to these key benefits and resources to help network providers that are being economically impacted.”
The program will help providers apply for various benefits including small business loans, a paycheck protection plan, and various grants they may be eligible for. This includes Federally Qualified Health Centers (FQHCs), behavioral health providers and community-based behavioral health organizations, Centers for Independent Living (CILs), and long-term service and supports organizations operating on the front lines.
This resource also helps providers explore additional funds through state offered loans and grants by working with nationally recognized healthcare consultants, organizations, state government agencies and former SBA executives. In addition to the online portal, provider partners will have access to webinars and one-on-one consulting with key experts.
Absolute Total Care and Centene have made it a priority to support providers, especially small providers, during the COVID-19 pandemic. Centene previously announced that its plans, including Absolute Total Care, would reduce the administrative burden to providers by eliminating the need for them to collect co-pays and removing authorization requirements for COVID-19 related treatment.
If you are an Absolute Total Care provider looking for more information about benefits you may be eligible for, please visit https://www.centene.com/covid-19-resource-center/provider-assistance.html for more information.
Note on SBA Announcement
The information provided does not represent all of the information available or that you may need for making your financial decisions or completing your application. The Federal and State government(s) are best able to provide resources and assistance. We recommended that you contact your financial institution or advisor before making any financial decisions.
Absolute Total Care donates Personal Protective Equipment to support South Carolina FQHC providers
Date: 04/13/20
Absolute Total Care has made a donation towards obtaining personal protective equipment (PPE) to the South Carolina Primary Health Care Association, to support the state’s FQHC’s front-line healthcare workers in combatting COVID-19.
The PPE will be distributed amongst South Carolina’s Federally Qualified Health Centers (FQHCs), to help protect healthcare workers who are caring for residents of South Carolina during the COVID-19 pandemic.
FQHCs are often the safety-net providers in rural communities, providing healthcare for individuals who are seeking care, regardless of their ability to pay.
“FQHCs play a vital role in providing quality healthcare to our members”, said John McClellan, Plan President & CEO of Absolute Total Care. “Many of our members depend on FQHCs for their primary care needs, and we wanted to support these providers where they need it most right now.”
As in other areas of the country, securing necessary PPE for healthcare workers is a major issue in South Carolina, and one that requires quick solutions for the health and safety of all South Carolinians.
Working alongside the South Carolina Primary Health Care Association, Absolute Total Care is able to assist in identifying suppliers and cover the costs for masks, face shields, gloves, and other items essential to providing safe, quality care.
“We are so pleased that Absolute Total Care recognizes the vital role community health centers are playing in identifying, containing and ending this pandemic,” said Lathran Johnson Woodard, Chief Executive Officer of the S.C. Primary Health Care Association. “Health centers in South Carolina continue their commitment to working with Absolute Total Care in providing quality primary and preventive care services throughout the state’s communities.”
Provider Webinar: How Federally Qualified Health Centers Can Launch Telehealth Services to Meet Patient Needs During COVID-19
Date: 04/28/20
Brought to you by Absolute Total Care, WellCare, and Centene Corporation
Tuesday, April 28, 2020
12 – 1 p.m. CST
Register in advance for this webinar:
https://centene.zoom.us/meeting/register/tJwrcOChrT4sH9Cii_PgNWqB9D5rUA7T4Mqi
After registering, you will receive a confirmation email containing information about joining the webinar.
Registration Fee
This event is free-of-charge.
Webinar Purpose
The COVID-19 pandemic has drastically changed health care delivery. Federally qualified health centers (FQHCs) play a critical role in assuring that vital sections of our population continue to engage in their health throughout this new reality. In response to the need for FQHCs to sustain and expand access to services during and beyond the pandemic, Absolute Total Care, WellCare and Centene have partnered with the Primary Care Development Corporation to discuss how FQHCs can launch telehealth services during this time. Webinar participants will gain valuable insights on how to launch telehealth services and continue to provide patient-centered care.
The session will be followed by three brief presentations from telehealth solution vendors.
You won’t want to miss this important webinar! Sign up today!
Your Presenters
- Grant Henderson oversees Centene’s Virtual Care strategy, partnering with Health Plans and National Product leadership to deploy member centric solutions that provide virtual care access that increases quality while reducing overall costs.
- Nicki Andrews works with organizations to transform care delivery which has included work with mental health providers, AIDS services providers, and diabetes management programming.
- Maia Morse works with primary care organizations such as FQHCs and school-based health centers to transform care delivery across the nation. Maia is a certified professional coder as well as an NCQA PCMH certified content expert.
- Sarahjane Rath is a curriculum development and training specialist that has worked extensively in care coordination and training efforts. Her recent focus has been on supporting providers to develop tools to improve communication with patients and patient engagement overall in the care system.
Centene Overview
Centene Corporation is a Fortune 100 company and a leading multi-national healthcare enterprise committed to helping people live healthier lives. The company covers nearly 1 in 15 individuals across the nation, including Medicaid and Medicare members (including Medicare Prescription Drug Plans) as well as individuals and families served by the Health Insurance Marketplace, the TRICARE program, and individuals in correctional facilities.
Primary Care Development Corporation Overview
Primary Care Development Corporation (PCDC) is a national nonprofit organization that empowers primary care providers to deliver quality care. From founding as a lender to health centers, we have become an integrated one-stop-shop for organizations seeking financing, training, and technical assistance around the country. PCDC’s experience in all aspects of primary care – from construction to delivery – helps us promote and catalyze excellence in the field. Since 1993 PCDC has helped more than 2,000 primary care practices in 35+ states to improve delivery of care and has leveraged over $1.1 billion in affordable financing to enhance primary care capacity in low-income communities.
Provider Webinar: Identifying and Caring for Patients at Risk for Suicide during the COVID-19 Pandemic
Date: 04/28/20
Wednesday, April 29, 2020
3 p.m. ET
COVID-19 is exacerbating risk factors for suicide, which is being reflected in significant increases in calls to local and national suicide hotlines. Many patients who die by suicide visited their primary care provider within the month of their death, and most were not connected to mental health treatment. As such, primary care providers and their teams are in a unique and critical position to identify and care for patients at risk for suicide.
This training provides concrete steps for primary care providers to identify and care for patients at risk for suicide. Providers will learn how, during the course of any primary care visit (including telephonic visits), to provide suicide safer care and gain a greater understanding of suicide and risk. Join this informative webinar, and a community of over 1500 primary care providers and their teams who have been trained to date, to gain practice tips and knowledge on how to provide evidence-based primary care treatment to patients at risk for suicide.
Presenter
Virna Little, PSyD, LCSW-r, SAP, CCM, Chief Operating Officer, Concert Health
Register for the webinar on identifying and caring for patients at risk for suicide.
Provider Webinar: Caring for the Healers: Preventing Suicide Among Providers
Date: 04/28/20
Wednesday, May 6, 2020
3 p.m. ET
Physicians and other providers are particularly vulnerable to negative mental health effects and increased suicide risk during the COVID-19 pandemic, likely due to balancing the duty of caring for their patients and the concern for their own health and wellbeing and that of their friends and family.
This training will provide specific tactics to help support your primary care providers and team members through systematic and organizational approaches to address suicide risk and prevent deaths by suicide among employees. Learn how to create a response plan that can be applied during the COVID-19 pandemic to help your organization reduce the risk for suicide across your providers and team members.
Presenter
Virna Little, PSyD, LCSW-r, SAP, CCM, Chief Operating Officer, Concert Health
Register for the webinar on preventing suicide among providers.
How to Create Positive New Habits in our New World
Date: 04/29/20
Our lives and routines have changed because of COVID-19. Gyms are closed, parks are closed, shopping trips are limited, and personal hygiene is more important than ever. How can we stay healthy with our habits broken? Here are some tips to help you.
May
Absolute Total Care (Medicare-Medicaid Plan) Updated Billing Guidance for Medicaid Long-Term Care Providers
Date: 05/04/20
As a valued partner, we want to ensure that you are aware of changes Absolute Total Care (Medicare-Medicaid Plan) is making that affect Medicaid long-term care (LTC) providers.
Effective immediately, Absolute Total Care will no longer require Medicaid LTC providers to submit a signed Form 181 or Phoenix documentation prior to claims submission for members enrolled in Absolute Total Care’s South Carolina Healthy Connections Prime Medicare-Medicaid Plan. Absolute Total Care reserves the right to request this documentation retrospectively on an as-needed or ad-hoc basis to support post-payment reviews as well as any state or federal audits.
Medicaid LTC providers should continue to include the following information from Section III of the signed Form 181 on the UB-04:
- Patient Liability in Field 39a.
- Value Code = 23
- Value Amount = Patient liability amount for the month being billed.
- The Value Amount can be entered with or without the decimal applied to demonstrate dollars and cents.
- Authorized Begin Date in Field 63.
- Treatment Authorization Codes = the member’s Medicaid LTC eligibility effective date in MM/DD/YYYY or MM-DD-YYYY formats (may use MMDDYYYY if unable to use / or -).
Note: Medicaid LTC providers participating in the Phoenix pilot should enter the patient liability and eligibility begin date from Phoenix.
Claims for Medicaid LTC submitted without appropriate UB-04 fields completed will deny at the time of the claim submission.
Providers should continue to follow the prior authorization process and clearly indicate which type of stay is being requested.
For further information and guidance, please review the South Carolina Healthy Connections Prime FAQs for Nursing Facilities (PDF).
Secure Provider Portal Offers Ability to Submit Claim Reconsideration
Date: 05/19/20
Did you know that you can submit a claim reconsideration in our Secure Provider Portal? This new feature provides you with a claim reconsiderations process that is streamlined, paperless, and efficient. You will also be able to track the claim’s processing progress in the portal as well.
For additional information, please view the Provider Portal Enhancements: Claim Reconsideration and Denial Explanations (PDF), contact your Provider Relations Representative, or call Provider Services at 1-866-433-6041.
Medicaid Provider Dispute Update
Date: 05/19/20
Effective July 1, 2020, providers will have 60 calendar days from receipt of notice of an adverse action to submit a Medicaid dispute. Disputes must be submitted in writing and include a Provider Dispute Form, which can be found on the Provider Manuals and Forms page and supporting documentation and should be sent to:
Absolute Total Care
P.O. Box 3050
Farmington, MO 63640-3821
Please contact your Provider Relations Representative or call Provider Services at 1-866-433-6041 for additional information.
Medicaid Pharmacy Benefit Changes
Date: 05/27/20
At Absolute Total Care, your health is important to us. We are always looking for new ways to provide you with quality healthcare. As of July 1, 2020, there will be a change to your pharmacy benefits.
Starting July 1, 2020, all medications for Absolute Total Care will require a $3.40 copay. This copay is applied for adult members 19 years of age and older. Asthma, chronic obstructive pulmonary disease (COPD), and diabetes medications currently on our Prescription Drug List (PDL) will continue to be offered at a $0.00 copay for adult members. All medications for pregnant members and members 18 years of age and younger do not require a copay and will remain $0.00.
We want to help you understand your benefits and this change. If you have any questions about this change, please call us at 1-866-433-6041 ext. 64455 (TTY: 711).
June
Introducing VerifyHCP
Date: 06/10/20
We are proud to introduce our contracted clinicians to Verify Health Care Portal (VerifyHCP®), a quick and easy clinician directory verification portal developed by LexisNexis® Risk Solutions. To make attestation more efficient for you and your staff, VerifyHCP enables practices to validate or update pre-populated directory information in one place across all participating health plans.
Updated practice information allows us to provide patients with current directory information so they can select in-network providers, choose health plans, and ultimately access care. Our goal is to make this process as easy as possible for clinicians and their practices and to receive 100% response to outreach requests. Clinicians who do not respond to verification requests may face delayed claim reimbursements and removal from directories.
Clinician and practice outreach
Outreach to confirm and update directory information will begin on June 15, 2020. Several outreach methods will be used including email, fax, and phone, with email being the primary method. Clinicians and practices will be directed to register and log in to VerifyHCP to confirm their directory information on file is accurate. VerifyHCP is a secure, free website for clinicians and their staff to use to confirm directory information, as required by the Centers for Medicare & Medicaid Services (CMS) and various state laws.
Contact LexisNexis Risk Solutions Tech Support at https://healthcare.custhelp.com/app/ask with questions about the portal.
Thank you again for our ongoing partnership.
July
Medicare DRG Increases for COVID-19 Treatment Services under Coronavirus Aid, Relief, and Economic Security (Cares) Act
Date: 07/06/20
The Centers for Medicare & Medicaid Services (CMS) have released guidance for implementing several provisions included in the Coronavirus Aid, Relief, and Economic Security (CARES) Act. Allwell from Absolute Total Care will be following this guidance as we adjudicate Medicare claims for applicable COVID-19 inpatient treatment services.
The CARES Act provides for a 20% increase to the inpatient prospective payment system (IPPS) Diagnosis Related Group (DRG) rate for COVID-19 patients for the duration of the public health emergency. The increase will be applied to claims that include the applicable COVID-19 ICD-10-CM diagnosis code and meet the date of service requirements, as follows:
- Discharges occurring on or after January 27 and on or before March 31:
- B97.29 – Other coronavirus as the cause of diseases classified elsewhere
- CDC coding guidance for cases discharging on March 31 and prior
- Discharges occurring on or after April 1:
- U07.1 – COVID-19
- CDC coding guidance for cases discharging on April 1 and after
For discharges with the diagnosis codes above, Allwell from Absolute Total Care will follow the Medicare billing guidance published by CMS. Inpatient claims for these COVID-19 discharges that have already been received will be automatically reprocessed to reflect the payment increase.
This guidance is in response to the COVID-19 pandemic and may be retired at a future date.
Sources
CMS:
- New Waivers for Inpatient Prospective Payment System (IPPS) Hospitals, Long-Term Care Hospitals (LTCHs), and Inpatient Rehabilitation Facilities (IRFs) due to Provisions of the CARES Act
- July 2020 Quarterly Update to the Inpatient Prospective Payment System (IPPS) Fiscal Year (FY) 2020 Pricer
The Centers for Disease Control (CDC):
- ICD-10-CM Official Coding and Reporting Guidelines April 1, 2020 through September 30, 2020
- ICD-10-CM Official Coding Guidelines - Supplement Coding encounters related to COVID-19 Coronavirus Outbreak
September
When It Comes to the Flu, You Call the Shots
Date: 09/15/20
You have the best interest of your patients at heart. More than that, you have their trust. Your recommendation is the most effective way to ensure they get their flu shot.
More than 90% of patients are likely to get the flu shot when their provider recommends it —including those who had initial doubts.
When talking with your patients:
- Make a strong recommendation to your patients to get their flu shot. Research shows that patients are more likely to get a flu shot if their doctor recommends it.
- You can use the SHARE method[1] to provide information:
- SHARE reasons to get the flu shot based on their age or other risk factors.
- HIGHLIGHT positive experiences with the flu shot to reinforce benefits.
- ADDRESS concerns about the vaccine, including effectiveness, side effects, safety, and misconceptions. Patients are less likely to push back than you may think.
- REMIND patients that the flu shot not only protects them but also everyone around them.
- EXPLAIN that getting the flu can mean taking sick days from work or missing fun with family and friends.
Follow-up is important! If your patient did not get the flu shot during their visit, there’s a chance they didn’t get it at all. Talk to your patients about where and when they’ll get their flu shot, and make a note to confirm during their next visit.
If they still have not gotten their shot, talk with them again about any questions or concerns — and be sure to repeat your strong recommendation. Most people know the flu shot is important. They may just need your reminder!
Flu Prevention Is a Win-Win
There are many advantages to promoting flu prevention:
- Healthier patients.
- Decreased severity of illness for those who do get sick.
- Reduced community spread.
- More satisfied patients to help you achieve your practice’s quality goals.
We’ve Got Your Back
You have a key role to play in recommending your patients get the flu shot, and Absolute Total Care is here to help.
Our Flu Prevention Campaign encourages people to get their flu shot. Flyers are available in English and Spanish for a range of patients. Please share these flyers with your patients.
Remember, you can help stop the flu! Strongly recommend to all of your patients to get their annual flu shot.
Questions?
Absolute Total Care is here to support you and your practice. If you have any questions about flu prevention, patient education tools, or incentives, call us at 1-866-433-6041.
For general questions about COVID-19, visit cdc.gov. For Absolute Total Care COVID-19 resources, visit our Provider Coronavirus Information webpage or call us at 1-866-433-6041.
October
Join Us For A Virtual Provider Town Hall
Date: 10/16/20
Absolute Total Care cordially invites you to attend our virtual town hall information sessions. Join providers from across the state to learn about our health plans as well as the tools and resources to make your job easier.
We are holding three sessions to provide an option that works best with your schedule. More information about the town halls and links to register individually can be found in the Virtual Town Hall Invitation (PDF). Participants may also register by emailing ATCNetworkRelations@centene.com.
2021 Prior Authorization Updates
Date: 10/30/20
Absolute Total Care requires prior authorization as a condition of payment for many services. This notice contains information regarding such prior authorization requirements and is applicable to all Medicare products offered by Absolute Total Care.
Absolute Total Care is committed to delivering cost effective, quality care our members. This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice.
Effective January 1, 2021, prior authorization requirements for certain Medicare services will be updated. For more information about these updates, please view the 2021 Prior Authorization Updates (PDF) and the 2021 Prior Authorization List Part B Appendix A (PDF).
November
Absolute Total Care 2021 List of Covered Drugs (Formulary) Changes
Date: 11/06/20
On January 1, 2021, some drugs will no longer be covered on our Allwell from Absolute Total Care and Absolute Total Care (Medicare-Medicaid Plan) List of Covered Drugs (Formulary). To assist our providers, we have included the lists of the most commonly prescribed drugs being removed along with the drug’s 2021 Formulary alternative(s) below. Please refer to these lists to identify the appropriate options for your patients.
- 2021 List of Covered Drugs (Formulary) Absolute Total Care (Medicare-Medicand Plan) Changes (PDF)
- 2021 List of Covered Drugs (Formulary) Allwell from Absolute Total Care DSNP Changes (PDF)
- 2021 List of Covered Drugs (Formulary) Allwell from Absolute Total Care HMO Changes (PDF)
New Century Health Implementation
Date: 11/12/20
Beginning January 11, 2021, all oncology-related chemotherapeutic drugs and supportive agents will require prior authorization from New Century Health (NCH) before being administered in a physician’s office, outpatient hospital, or ambulatory setting. This prior authorization requirement applies to both pharmacy-dispensed and office-administered medication requests for Allwell from Absolute Total Care and Absolute Total Care (Medicare-Medicaid Plan) members.
Please refer to the New Century Health Implementation Notification (PDF) and New Century Health FAQ (PDF) for more information.
Provider Webinar: Physical Medicine Program
Date: 11/24/20
Absolute Total Care has expanded our partnership with National Imaging Associates, Inc. (NIA) to provide utilization management for outpatient rehabilitative and habilitative physical medicine services on behalf of Ambetter from Absolute Total Care. Join one of the educational webinars on the NIA Physical Medicine Program prior authorization process. For webinar dates and more information, please view the NIA Provider Webinar (PDF).
January
IMPORTANT NOTICE: Pharmacy Network Change
Date: 01/14/18
The Absolute Total Care Pharmacy Network is changing. Effective February 15, 2019, Walgreens and Rite Aid will no longer be in our network.
We want to make sure our members get their medicine. Members will need to move their medicine(s) to a new pharmacy by February 15, 2019. Members can do this in one of these ways:
- Call or go to the new pharmacy and ask for the medicine to be moved
- Ask their doctor to call the new pharmacy with the medicine information
- Take a written prescription to the new pharmacy
Members can search for other pharmacies on our website by using the Find a Provider Tool. Go to absolutetotalcare.com and click on “Find a Provider” or click here to open the Find a Provider Tool.
We are here to help. If members have questions they can call Member Services at 1-866-433-6041 (TTY: 711).
May
Behavioral Health Prior Authorization Requirement
Date: 05/01/19
Absolute Total Care is committed to delivering cost effective care to our members. This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice. Absolute Total Care accomplishes this goal by utilizing prior authorization and benefit limit guidelines to verify the medical necessity of a treatment.
For Licensed Individual Practitioners (LIPS) providers, prior authorization will be required starting June 1, 2019 for any combination of the following procedure codes for continued services after the 24th encounter within a calendar year per member: 90832, 90834, 90836, 90837, 90838, 90845, 90846, 90847, 90849, and 90853.
Additionally, for all provider types, Absolute Total Care will reset its benefit limits for all codes identified above to match the benefit limits currently outlined by the South Carolina Department of Health and Human Services (SCDHHS). Details on benefit limits for each code per provider type are outlined in the provider manuals provided on the SCDHHS website.
You may submit the prior authorization requests utilizing our Secure Web Portal at absolutetotalcare.com. If you are not currently registered on our Secure Web Portal, you may register through a quick and simple online process. If your request is approved you will receive verification through the Secure Web Portal. You may also submit the prior authorization request by faxing an Outpatient Treatment Request (OTR) form to 1-866-694-3649. The OTR form can be found at cenpatico.com under Provider Tools.
If you have questions about this update, please reach out to Provider Services at 1-866-433-6041. For more information, visit our Behavioral Health webpage.
Provider Dispute Policy Update
Date: 05/06/19
Absolute Total Care’s goal is to ensure disputes are processed as expeditiously as possible. Effective June 1, 2019, Absolute Total Care will require a completed Provider Dispute Form to be submitted in order for the request to be considered a formal provider dispute. The appropriate forms and information on where to send provider dispute information can be found in the Provider Resources section of our website.
Absolute Total Care Launches Surgical Quality and Safety Management Program
Date: 05/16/19
Absolute Total Care is pleased to announce the launch of a new and innovative Surgical Quality and Safety Management Program, effective July 1, 2019. The program is designed to work collaboratively with physicians to promote patient safety through the practice of high quality and cost-effective care for Absolute Total Care members undergoing Musculoskeletal Surgical Procedures. For more information, please view the Surgical Quality and Safety Management Program Memo (PDF) or visit the TurningPoint Healthcare Solutions webpage.
October
Allwell from Absolute Total Care Prior Authorization Update Effective January 1, 2020
Date: 10/31/19
Allwell from Absolute Total Care is committed to delivering cost effective quality care for our members. This effort requires us to ensure that our members only receive treatment that is medically necessary according to current standards of practice. Prior authorization is a process initiated by the ordering physician in which we verify the medical necessity of a treatment in advance using independent objective medical criteria.
Effective January 1, 2020, prior authorization requirements for certain Medicare services will be updated. For more information about these updates, please view the 2020 Prior Authorization Updates (PDF).
January
Important Notice: Pharmacy Network Change
Date: 01/14/18
The Absolute Total Care Pharmacy Network is changing. Effective February 15, 2019, Walgreens and Rite Aid will no longer be in our network.
We want to make sure our members get their medicine. Members will need to move their medicine(s) to a new pharmacy by February 15, 2019. Members can do this in one of these ways:
- Call or go to the new pharmacy and ask for the medicine to be moved
- Ask their doctor to call the new pharmacy with the medicine information
- Take a written prescription to the new pharmacy
Members can search for other pharmacies on our website by using the Find a Provider Tool. Go to absolutetotalcare.com and click on “Find a Provider” or click here to open the Find a Provider Tool.
We are here to help. If members have questions they can call Member Services at 1-866-433-6041 (TTY: 711).
May
Medicaid Eligibility Loss
Date: 05/25/18
Providers:
Absolute Total Care would like to make you aware of a very important update that has come to our attention as it relates to Medicaid eligibility loss affecting our members. To learn more, please reference this letter. Thank you for continuing to provide excellent healthcare services to our members.
August
Medically Necessary Eye Care Services
Date: 08/08/18
Thank you for your continued participation with Absolute Total Care. We would like to remind you that Absolute Total Care has contracted with Envolve Vision to administer the medically necessary eye care services performed by an optometrist. To learn more, please view the Medically Necessary Eye Care Services (PDF) memo.
September
Hurricane Florence: What You Need To Know
Date: 09/12/18
UPDATED 12/18/2018: Effective December 20, 2018, refill too soon edits and out-of-network authorization requirements for out-of-network providers are in place. Please contact Member Services at 1-866-433-6041 (TTY: 711) for additional information.
Due to Hurricane Florence in the State of South Carolina, Governor Henry McMaster declared a state of emergency for the entire state.
Hurricane warnings and mandatory evacuations have been issued for all coastal counties, effective: Tuesday, September 11 at Noon. Please note additional evacuations may be ordered as the storm approaches and emergency shelters will be opened based on need.
Your health and safety are our primary concerns and if you leave your home to avoid this emergency, we do not want any undue barriers to keep you from getting your medication or to seeing a medical professional.
For our members who live in one of these impacted areas, we have removed the refill too soon edits for your prescription drugs, and removed the out-of-network authorization requirements for out-of-network providers. You must still use Medicaid certified facilities and providers.
Prior authorization for medical services or medication may still be needed for medical necessity. This change is in effect until the emergency notice is closed.
For public health emergencies, the lift for your prescription drugs refill too soon edit will remain in effect until the emergency no longer exists or upon the expiration of the 90-day period beginning from the initial declaration, whichever occurs first.
In the event of an emergency, please dial 9-1-1 or visit your closest medical facility. If you have any questions, please call Member Services at 1-866-433-6041 (TTY: 711).
March
Medicare Outpatient Observation Notice
Date: 03/06/17
In accordance with the Federal Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act, all hospitals and critical access hospitals (CAHs) are required to provide the Medicare Outpatient Observation Notice (MOON) effective immediately. The MOON notifies Medicare beneficiaries that they are classified as an outpatient receiving observation services and are not considered an inpatient of a hospital or CAH.
Click here to read more.
August
Introducing Allwell
Date: 08/21/17
Allwell is a new kind of health plan that puts you at the center of everything we do.
We provide easy-to-understand information and member support to keep you active in life so you can enjoy what's meaningful to you. Whether it's dining at only the best places or driving in the fast lane, we're here to help you be in charge of your health. So as you enter the next exciting stage in your life, you'll be ready and confident for whatever's next.
We want to learn more about you! Visit www.allinwithallwell.com to share your all in experience.
October
Medicare Prior Authorization Update Effective January 1, 2018
Date: 10/30/17
Absolute Total Care is committed to delivering cost effective quality care to our members. This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice. Prior authorization is a process initiated by the ordering physician in which we verify the medical necessity of a treatment in advance using independent, objective medical criteria.
Effective January 1, 2018, certain services listed as covered services will require prior authorization. This information is applicable to all Medicare products offered by Absolute Total Care.
Click here to view the prior authorization update.
Updated Payment Policies Effective October 18, 2017
Date: 10/30/17
Absolute Total Care is publishing its payment policies to inform providers about acceptable billing practices and reimbursement methodologies for certain procedures and services. These policies will be applied as medical claims reimbursement edits within our claims adjudication system. This is in addition to all other reimbursement processes that Absolute Total Care currently employs.
Absolute Total Care believes that publishing this information will help providers bill claims more accurately, therefore reducing unnecessary denials and delays in claims processing and payments.
Click here to view all updated payment policies. The effective date for these updated policies is October 18, 2017, unless otherwise stated.
March
Asthma Symposium for School Nurses
Date: 03/04/16
In partnership with the South Carolina State Department of Education (SCSDE), Absolute Total Care hosted an Asthma Symposium on February 15th for South Carolina school nurses at SCETV studio in Richland County. The symposium was broadcast via live video feed on the SCSDE website and accessible to school nurses throughout the state.
June
Absolute Total Care is hosting a Community Health & Wellness Expo!
Date: Saturday, July 9th
Time: 9am – 3pm
Place: West End Community Development Center
404 Vardry Street, Greenville, SC 29601
September
Deadline for Provider Revalidation is Sept. 24, Provider Termination is Sept. 25
Date: 09/16/16
Federal regulations mandate that the South Carolina Department of Health and Human Services (SCDHHS) revalidate the enrollment of all providers serving Medicaid beneficiaries. In accordance with this federal mandate, South Carolina Healthy Connections Medicaid providers that have not completed and submitted the provider enrollment revalidation application will be terminated September 25, 2016.
Click here to read more.
Absolute Total Care's Health & Wellness Expo
Date: 09/23/16
Join Absolute Total Care at our Community Health and Wellness Expo on Saturday, September 24 from 10 a.m. to 3 p.m. at Bible Way Church of Atlas Road, 2508 Atlas Road, Columbia. We will have health screenings, a kid's zone with fun activities, Zumba, and more. For more information, view our flyer or call Absolute Total Care at 1-866-433-6041 (TTY: 711)
December
Deadline for Provider Re-enrollment with SCDHHS is Dec. 31
Date: 12/15/16
Per federal regulations, South Carolina Healthy Connections Medicaid providers were required to revalidate the enrollment of all providers serving Medicaid beneficiaries in September 2016 to avoid termination. If a provider did not complete and submit the provider enrollment revalidation application by September 25, 2016, they must re-enroll with SCDHHS by December 31, 2016 or Absolute Total Care is required to terminate the provider from the Absolute Total Care Provider Network and deny all claims submitted for dates of service beginning on January 1, 2017.
Click here to read more.
Availity Conversion
Date: 12/21/16
In an effort to improve claims processing, Absolute Total Care has selected Availity as its primary gateway connection. This change will allow Absolute Total Care to better service its providers with more advanced engagement and communication strategies. There should be no impact to provider claims and other transactions.
Click here to read more.