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INSURANCE UPDATES
Check Federal and State Exclusion Lists if You See Medicaid and/or HARP Patients
Regulatory Updates

If you are a Medicaid and/or HARP provider, did you know you’re required to routinely review certain federal and state databases to check the status of employees and staff?

You should have a standard process for the review. Be ready to provide a copy of the procedure if asked. Use the Message Center in Emblem health secure provider portal. If you don’t have internet access, call Provider Customer Service at 866-447-9717, Monday to Friday, from 8 a.m. to 6 p.m.

The databases include:

  • Social Security Administration's Death Master file
  • National Plan and Provider Enumeration System (NPPES
  • Excluded Parties List System (EPLS), either the List of Excluded Individuals and Entities (LEIE) or the Medicare Excluded Database (MED)
  • Any such other databases as the Secretary may prescribe

It is also required to check the following at least monthly:

  • List of Excluded Individuals and Entities (LEIE) or the Medicare Excluded Database (MED)
  • Excluded Parties List System (EPLS)

Check the U.S. Department of the Treasury’s Office of Foreign Assets Control (OFAC) Sanctions List.

Source: www.emblemhealth.com

Regulatory Updates
MEDICARE ADVANTAGE BENEFITS TO FORMER AFFINITY MEMBERS

Beginning January 1, 2019, EmblemHealth will provide Medicare Advantage benefits to approximately 10,000 members who were previously in Affinity's Medicare Advantage plan

Members will receive 2019 member ID cards from EmblemHealth in December. There are four Affinity Medicare Advantage plans that will be administered by EmblemHealth:

  • EmblemHealth Affinity Medicare Ultimate (HMO SNP) – Comprehensive Denta
  • EmblemHealth Affinity Medicare Solutions (HMO SNP) – Preventive Dental
  • EmblemHealth Affinity Medicare Passport Essentials (HMO) – Preventive Dental
  • EmblemHealth Affinity Medicare Passport Essentials NYC (HMO) – Preventive Dental

Read more details here.

MODIFIER 24 WITH E/M SERVICES DURING POSTOPERATIVE PERIOD

A Centers for Medicare & Medicaid Services (CMS) policy states: “Separate payment is not allowed for evaluation and management (E/M) services billed during the postoperative period with modifier 24 (Unrelated E/M by the same physician during a postoperative period) without sufficient indication that the visit is unrelated to the surgery.”

Modifier 24 is intended for use with services that are absolutely unrelated to the surgery; it is not intended to be used for the medical management of a patient by the surgeon following surgery.

Major Procedure
Any evaluation and management services billed with modifier 24 during a major surgical procedure 90-day postoperative period with a complication of surgical and medical care diagnosis or an aftercare diagnosis will be denied.

Minor Procedure
Any evaluation and management services billed with modifier 24 during a minor surgical procedure 10-day postoperative period with a complication of surgical and medical care diagnosis or an aftercare diagnosis will be denied.

Read more details here.

Issues schedule

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Insights
November 2018