Provider Updates & Notices

The following updates have been posted and archived for your viewing. These updates and notices will help keep you informed of the changes that may affect you. If you have any questions about these updates, please contact Provider Relations at (715) 552-4300 or (888) 203-7770 for assistance.

Posted Date Effective Date Title
8/11/2016 8/1/2016 Prior Authorization Category Update
Posted Date: 8/11/2016
Effective Date: 8/1/2016
Products: Group Health Cooperative of Eau Claire Commercial , Group Health Cooperative BadgerCare Plus, Group Health Cooperative Medicaid SSI

Outpatient care has been changed to Home Health.

Prior Authorization is no longer required for:

  • Palliative Care
  • Hospice Services

If you have any questions about prior authorization guidelines, please visit group-health.com or contact the Cooperative at (715) 552-4300 or (888) 203-7770.

8/11/2016 8/1/2016 Prior Authorization Update: Injection Codes
Posted Date: 8/11/2016
Effective Date: 8/1/2016
Products: Group Health Cooperative of Eau Claire Commercial , Group Health Cooperative BadgerCare Plus, Group Health Cooperative Medicaid SSI

Prior Authorization is not required for the following codes:

  • 20605: injection intermediate joint/bursa
  • 20610: injection major joint/bursa
  • 62273: epidural blood patch
  • 27096: SI joint injection
  • 62310: injection: epidural cervical/thoracic
  • 62311: injection: epidural lumbar/caudal
  • 76000: fluoroscopy, physicians time up to one hour
  • 76001: fluoroscopy, physicians time more than one hour, assisting a non-radiologic MD
  • 77001: fluoroscopic guidance for a central access device placement
  • 77002: fluoroscopic guidance for needle placement
  • 77003: fluoroscopic guidance and localization of a needle or catheter tip for spine or paraspinous injections

All other prior authorization remains the same for drugs outpatient injections or infusions with billed charges over $500. Please see the prior authorization grid on our provider section of our website.

If you have any questions about prior authorization guidelines, please visit group-health.com or contact the Cooperative at (715) 552-4300 or (888) 203-7770.

7/18/2016 8/1/2016 Navitus Cost-Share Changes
Posted Date: 7/18/2016
Effective Date: 8/1/2016
Products: Group Health Cooperative of Eau Claire State of Wisconsin (ETF)

Preferred Insulin Products Moved to Level One

Effective August 1, 2016 the insulin products listed below will be moved to cost-share Level 1 ($5 copayment) on the Navitus commercial formulary and Navitus MedicareRx formulary. These insulin products are currently covered at cost-share Level 2 (20% coinsurance with $50 maximum).

  • LANTUS (10mL vial; 3mL SoloStar pen)
  • LEVEMIR (10mL vial; 3mL FlexPen; 3mL FlexTouch pen)
  • NOVOLIN 70/30 (10mL vial)
  • NOVOLIN N (10mL vial)
  • NOVOLIN R (U-100/10mL vial)
  • NOVOLOG (10mL vial; 3mL PenFill Cartridge; 3mL FlexPen pen; 3mL FlexTouch pen)
  • NOVOLOG Mix 70/30 (10mL vial; 3mL FlexPen)
  • TRESIBA (U-100/3mL FlexTouch pen; U-200/3mL FlexTouch pen)

This cost-share change only applies to Group Health Cooperative of Eau Claire members who have coverage through the State and Wisconsin Public Employers Group Health Insurance Programs. For any questions you may have on this benefit adjustment, please contact Stacey or Carol in Provider Relations by calling (715) 552-4300 or (888) 203-7770.

Group Health Cooperative of Eau Claire does not discriminate on the basis of disability in the provision of programs, services, or activities. If you need this printed material interpreted or in an alternative format, or need assistance in using any of our services, please contact Group Health Cooperative of Eau Claire – Compliance Office at (715) 552-4300 (TTY services available 1-800-947-3529).

5/4/2016 5/1/2016 Breast Pump Benefit Update
Posted Date: 5/4/2016
Effective Date: 5/1/2016
Products: Group Health Cooperative of Eau Claire Commercial and State of Wisconsin (ETF)

Dual-electric breast pumps are a covered benefit for certain commercial groups only, subject to these formulary limitations. The Cooperative is allowing members to obtain these pumps from any contracted provider; however, in recognition of the fact that medical equipment providers utilize different vendors and stock different brands, the Cooperative is allowing for providers to dispense any standard, in-stock, dual electric breast pumps (code E0603). Providers may work with the prescribing physician and member to identify which pump(s) best meet the member’s needs. Only pumps dispensed and billed under E0603 will be reimbursed by the Cooperative, and the Cooperative will reimburse the provider the lesser of billed usual/customary charges or $200.00 per pump. There are numerous high-quality dual-electric pumps available in this price range, both at wholesale and at retail/over-the-counter. Please note that payment is payment in full by the Cooperative, and members may not be balance-billed for any amounts exceeding the $200.00 pump formulary. Non-formulary pumps will not be reimbursed and are considered a non-covered benefit.

If your facility is unable to dispense any E0603 pumps within this formulary limitation, please have the member contact the Cooperative at (715) 552-4300 or (888) 203-7770 to identify another network provider. The member may also choose to purchase a non-formulary pump (any pumps exceeding $200.00), however the cost will be the member’s full responsibility. If there are extenuating medical circumstances involving a member for which a standard pump is insufficient (for example, long-term rental of a hospital grade pump is needed), please contact the Cooperative.

3/23/2016 3/23/2016 State of Wisconsin (ETF) Wellness Assessment Form
Posted Date: 3/23/2016
Effective Date: 3/23/2016
Products: Group Health Cooperative of Eau Claire State of Wisconsin (ETF)

A Group Health Cooperative of Eau Claire member presenting this wellness assessment form is voluntarily participating in a worksite wellness program through the State of Wisconsin that includes an annual biometric screening. Please complete the screening in section 2 of the attached form based upon your clinical practice guidelines and the U.S. Preventive Services Task Force (USPSTF) recommendations. Services related to Well Wisconsin should be coded and billed as preventive services as the intent of the Well Wisconsin program is to encourage annual health screenings that do not result in cost-share to the members. Labs or other services that are not subject to an "A" or "B" recommendation from the USPSTF based upon the member's age, sex, and risk factors, as well as any services for diagnostic purposes, are not considered part of the Well Wisconsin program. These non-preventive and/or diagnostic services should be completed at subsequent visits so the member is aware that cost share may apply. A sample Wellness Assessment form is attached.

Please note: If a member has recent results that fit within USPSTF guidelines (for example, a cholesterol check within the last 3-5 years), Well Wisconsin is not mandating new lab work each year in order for this element to be considered completed.

Wellness Assessment Form

2/23/2016 2/1/2016 Change to prior authorization of anesthesia for children 5 and under
Posted Date: 2/23/2016
Effective Date: 2/1/2016
Products: Group Health Cooperative of Eau Claire, Group Health Cooperative BadgerCare Plus, Group Health Cooperative Medicaid SSI

The prior authorization guideline for Dental Anesthesia not performed in the clinic setting has been changed to state that dental anesthesia services for children 5 years old and under does not require prior authorization.

Dental anesthesia services or oral surgery not performed in the clinic setting for 6 years and older continue to require prior authorization.

If you have any questions or concerns, please contact Stacey or Carol in Provider Relations at (715) 552-4300.

1/21/2016 1/1/2016 ForwardHealth Behavioral Health/Autism Benefit
Posted Date: 1/21/2016
Effective Date: 1/1/2016
Products: Group Health Cooperative of Eau Claire, Group Health Cooperative BadgerCare Plus, Group Health Cooperative Medicaid SSI, Compcare BadgerCare Plus, Compcare Medicaid SSI

Effective for dates of service on and after January 1, 2016 the Wisconsin Department of Health and Health Services (DHS) will begin coverage of a new behavioral health treatment benefit.

Since July 2014, the federal Centers for Medicare and Medicaid Services (CMS) required states to provide coverage of autism treatment through each state's Medicaid programs.

The new benefit was first introduced and outlined in the October 2015 update, titled "Provider Enrollment for the New Behavioral Treatment Benefit." This update can be accessed on the ForwardHealth Portal at forwardhealth.wi.gov.

The behavioral health benefit will be administered fee-for-service for all Medicaid enrolled members who meet medical necessity guidelines for covered services. This benefit is carved out for BadgerCare Plus and Medicaid SSI members. Prior authorization requests and claims will be processed by ForwardHealth and not the member's HMO.

This behavioral health benefit does not include screening or diagnostic services such as developmental screening, psychological testing, neuropsychological testing, genetic testing, or other necessary medical evaluations. Please also note that this benefit cannot be provided concurrently with some HMO-covered services, such as mental health day treatment, and certain community services. Because of this, please continue to work with the Group Health Cooperative of Eau Claire Health Management Department regarding all services not covered under this benefit as well as to assist with the determination as to whether a patient has an existing authorization for behavioral treatment.

For additional information, please see the ForwardHealth Update, December 2015, No. 2015-62, "New ForwardHealth Behavioral Treatment Benefit."

If you have any questions or concerns, please contact Stacey or Carol in Provider Relations at (715) 552-4300.

1/19/2016 1/1/2016 Changes to Medicaid Billing Requirements
Posted Date: 1/19/2016
Effective Date: 1/1/2016
Products: Group Health Cooperative of Eau Claire, Group Health Cooperative BadgerCare Plus, Group Health Cooperative Medicaid SSI, Compcare BadgerCare Plus, Compcare Medicaid SSI

Effective with dates of service on or after January 1, 2016, the Wisconsin Department of Health Services (DHS) is requiring HMOs to ensure that all other payor sources are exhausted prior to issuing payment on claims for Medicaid members. While this has been longstanding Federal and State policy to ensure the continued solvency of the program, there are several noteworthy changes that will affect all providers in how claims are billed to and paid by the Cooperative, some of which we are hopeful will eliminate some of the administrative burden associated with benefits coordination. Much of this was driven by changes/clarifications in the Deficit Reduction Act.

  • Relinquishment forms are no longer necessary. The Cooperative will no longer require (or accept) relinquishment forms to be submitted in order to issue payment on claims where other insurance (like third party liability) may be involved. Instead, however, we will be requiring a copy or verification of any denial (EOB, etc.) from other insurance prior to issuing payment. This is a direct result of changes mandated in the DHS-HMO contract. Providers will be required to bill other applicable insurance sources and receive a denial prior to the Cooperative issuing payment on a claim.
  • Third party liability. In cases of disputed liability (e.g., a worker's compensation claim that the carrier is denying, claims being actively litigated, etc.), the Cooperative will only require one denial before related claims will process for payment (again, without the need for submission of relinquishment forms each time). For example, if we are notified of a possible worker's compensation claim involving an injury to a member's neck, and with the initial billing the provider submits documentation that the claim is disputed (e.g., denied by the worker's compensation insurance), then the Cooperative will process and pay subsequent neck claims that are related without requiring a relinquishment form or additional EOBs/proof of denial. However, in cases of undisputed third party liability claims, such as a worker's compensation claim that has been accepted by the insurance and for which medical payments are being issued, the Cooperative will be required to treat the worker's compensation insurance as primary and coordinate benefits accordingly.
  • Medical payments coverage is not considered third party liability for purposes of DHS 106. Any coverage for medical payments that is available and issuable without regard to liability is considered primary to Medicaid payment. This includes a Medicaid members' own auto or other liability policy that includes medical payment provisions separate from liability-related payments. For example, many auto insurance policies include $10,000 of medical payments coverage that is issued to their insured regardless of fault. What this means is that if a Medicaid member is involved in an auto or other accident, the Cooperative will be pending claims or denying claims for coordination of benefits until the medical payments coverage is exhausted, unless we have verification that it has been issued. Importantly, in situations where the medical payments coverage has been issued to a Medicaid member and the payment is itemized/attributable to specific claims, the Cooperative will be denying payment of those claims. Providers will be expected to seek recovery directly from the member.
  • Providers are expected to code for liability. In cases of auto accidents, worker's compensation, etc., providers will be expected to code claims for liability in accordance with CMS guidance and TPL/COB clarifications under the Deficit Reduction Act (please see: https://www.medicaid.gov/federal-policy-guidance/downloads/faq-09-04-2014.pdf). While we appreciate that this can be challenging, it will also help expedite payments to you by not pending claims unnecessarily.

The Wisconsin Department of Health Services (DHS) has not yet posted the 2016-2017 final contract publicly. If you would like a copy of the actual contract language pertaining to COB/TPL/subrogation, or have any questions or concerns, please contact Stacey or Carol in Provider Relations at (715) 552-4300.

8/11/2015 9/1/2015 Provider Manuals Update
Posted Date: 8/11/2015
Effective Date: 9/1/2015
Products: Group Health Cooperative of Eau Claire, Group Health Cooperative BadgerCare Plus, Group Health Cooperative Medicaid SSI, Compcare BadgerCare Plus, Compcare Medicaid SSI

The updated provider manuals are available online at ghc.ec/providermanuals. If you do not have internet access, please call (715) 852-5706 to request a copy be sent to you by mail.

Effective September 1, 2015 updates to the provider manual include:

Section Description Page Numbers
1 - Claims Information Added “Unless otherwise states in the Provider Services Agreement” to the timely filing deadline. BCP / Medicaid: 7
Commercial: 7
Added ICD-10 to the listing of utilized coding sources. BCP / Medicaid: 7
Commercial: 7
Added G4 Health Systems to listing of Clearinghouses. BCP / Medicaid: 7
Commercial: 7
Providers are strongly encouraged to obtain written statement in advance, documenting that the member has accepted responsibility for the payment for service. BCP / Medicaid: 8
Commercial: N/A
Provider timely filing guidelines apply to claims being submitted with relinquishment forms. This time frame is generally one year from the date of service, unless dictated otherwise in the Provider Agreement. BCP / Medicaid: 9
Commercial: N/A
Or as outlined in the Provider Services Agreement BCP / Medicaid: 11
Commercial: 9
Updated to current HCFA -1500 form BCP / Medicaid: 12 & 13
Commercial: 10 & 11
Added “or as outlined in the Provider Services Agreement” to the Claim Appeal Process. BCP / Medicaid: 24
Commercial: 16
3 - Quality Improvement Added section of HealthCare Effectiveness Data and Information Set (HEDIS) BCP / Medicaid: 32
Commercial: No Change
Updated BadgerCare Plus and Medicaid SSI Quality Requirements for current year. BCP / Medicaid: 32 & 33
Commercial: N/A
5 - Enrollment & Eligibility Removed group designations for Benchmark and Core Plans as these no longer exist. Replaced with group designations for Childless Adults as this is a new group. BCP / Medicaid: 37
Commercial: N/A
Removed specific eligibility criteria and replaced with general program eligibility. BCP / Medicaid: 37
Commercial: N/A
Removed reference to Benchmark and Core Plans as these no longer exist. BCP / Medicaid: 39
Commercial: N/A
6 - Covered Services Updated in its entirety to reflect member benefits at the time of printing. BCP / Medicaid: 40
Commercial: N/A
7 - Health Management Reviews for Medical Necessity Medical appropriateness for hospital admission associated with labor and delivery charges is only required if discharge is greater than two (2) days following vaginal delivery or is greater than four (4) days following cesarean delivery. No notification of inpatient admission by hospital is needed if admission is less than or equal to these timeframes. BCP / Medicaid: 43
Commercial: 32
8 - Behavioral Health & AODA Services Removed references to Omne Clinic, Inc. and replaced with Vantage Point Clinic. BCP / Medicaid: 46
Commercial: N/A
9 - Authorization Guidelines Prior authorization of hospital admission associated with labor and delivery charges is only required if discharge is greater than two (2) days following vaginal delivery or is greater than four (4) days following cesarean delivery. No notification of inpatient admission by hospital is needed if admission is less than or equal to these timeframes. BCP / Medicaid: 48
Commercial: 37
Removed references to Omne Clinic, Inc. and replaced with Vantage Point Clinic. BCP / Medicaid: 49
Commercial: N/A
Prior Authorization is required if a prescription change occurs resulting in the need for replacement of eyeglasses beyond the benefit of two pair within the member’s annual membership year. BCP / Medicaid: 49
Commercial: N/A
Prior Authorization is no longer required for Cardiac Rehab. This was earlier communicated to providers. BCP / Medicaid: 51
Commercial: 39
12 - HealthCheck Removed statement advising that information will be provided to the Provider regarding percentage of allowable HealthCheck screenings that the clinic has completed. BCP / Medicaid: 54
Commercial: N/A
13 - DHS BadgerCare Plus & Medicaid SSI Contact Information Removed option of addressing correspondence to Forward Health. Replaced with option of making inquiries through Forward Health Website. BCP / Medicaid: 55
Commercial: N/A
Appendix A – Health Management Forms Inserted all current versions of request forms BCP / Medicaid: 60-68
Commercial: 46-52
Appendix B – Behavioral Health Inserted all current versions of request forms BCP / Medicaid: 69-76
Commercial: 54-60
Appendix C – County Handbook Removed section discussing copayments. This is discussed earlier in the topic. BCP / Medicaid: 78
Commercial: N/A
Added information regarding coordinating care between county and HMO for PNCC program. BCP / Medicaid: 79
Commercial: N/A
Added the role of Health Management department related to the PNCC program. BCP / Medicaid: 80
Commercial: N/A
Removed section outlining covered HealthCheck services, required components of the Comprehensive Health Check Exam, HealthCheck Schedule, and Coordination of Care MOUs as these topics were all discussed earlier in this section. BCP / Medicaid: 80
Commercial: N/A
Removed line discussing copayments for vaccines. This is discussed earlier in the manual. BCP / Medicaid: 80
Commercial: N/A
Removed coding guidance from manual. BCP / Medicaid: 81
Commercial: N/A
Removed PNCC Information as this was previously discussed. BCP / Medicaid: 83
Commercial: N/A
7/1/2015 8/1/2015 Authorization of Stay and Notification of Birth Event
Posted Date: 7/1/2015
Effective Date: 8/1/2015
Products: Group Health Cooperative of Eau Claire, Group Health Cooperative BadgerCare Plus, Group Health Cooperative Medicaid SSI, Compcare BadgerCare Plus, Compcare Medicaid SSI

Effective August 1, 2015 a request for authorization and notification of a birth event will not be necessary. Notification will only be required in the event of an extended stay due to the medical condition of the mother and/or baby. An extended stay is considered any length of stay greater than two (2) days for a vaginal delivery or greater than four (4) days for a cesarean delivery. This notification will be required within one (1) business day of the decision to extend the stay. This change applies to all Enrollees of Group Health Cooperative of Eau Claire and Compcare.

As a reminder, when billing these services for Badgercare and Medicaid SSI Enrollees please continue to do the following: 1) submit claims with the appropriate diagnosis code relating to the birth weight of the child; 2) If the child is born weighing less than 1,200 grams submit claim with medical record as this is required by the Department of Health and Human Services.

Please contact the Provider Services department 888-203-7770 for additional questions relating to this change.

5/1/2015 5/1/2015 Learn through our Newsletter
Posted Date: 5/1/2015
Effective Date: 5/1/2015
Products: Group Health Cooperative BadgerCare Plus, Group Health Cooperative Medicaid SSI, Compcare BadgerCare Plus, Compcare Medicaid SSI

Group Health Cooperative of Eau Claire recently introduced an informative quarterly newsletter. Each issue provides a range of timely articles and helpful hints intended to enhance the relationship we have with our members and providers.

Each newsletter also includes a summary and link to any provider updates that occurred during the last several months. We provide informational articles on the issues that matter to you. For example, a recent newsletter showcased helpful information regarding billing for HealthCheck services and electronic claim submission options. Please see the enclosed newsletter for reference.

We look forward to sending you and your staff the electronic version of this and future newsletters. If you have any questions regarding this new email newsletter, or to get signed up please send an email to provider.relations@group-health.com that includes the names, titles, and email addresses of those you wish to sign up for this service.

If you have any questions regarding this new email newsletter, please contact the Provider Services department at (866) 563-3020.

4/27/2015 5/1/2015 A New Telehealth Benefit for Members
Posted Date: 4/27/2015
Effective Date: 5/1/2015
Products: Group Health Cooperative of Eau Claire, Group Health Cooperative BadgerCare Plus, Group Health Cooperative Medicaid SSI, Compcare BadgerCare Plus, Compcare Medicaid SSI

Group Health Cooperative of Eau Claire will be introducing a new telehealth service called Teladoc beginning May 1, 2015. This new benefit will be available to all members through Group Health Cooperative and Compcare.

Teladoc is the first and largest telehealth provider in the nation, founded in 2002. This new benefit is being introduced to members as part of a proactive initiative to reduce unnecessary use of the Emergency Room.

Teladoc will evaluate and treat common illnesses such as:

  • Cold & Flu Symptoms
  • Allergies
  • Bronchitis
  • Skin Problems
  • Sinus Problems

Group Health Cooperative and Compcare members who use the Teladoc service can elect to have a report of their virtual appointment submitted to their primary care physician. All of the doctors in the national Teladoc network are U.S. Board certified family practitioners, primary care providers, pediatricians and internists.

If there are any questions regarding this new member benefit, please do not hesitate to contact the Provider Relations department at provider.relations@group-health.com.

12/8/2014 7/1/2014 Reprocessing Procedures Regarding: Procedure Code Changes for Influenza Vaccinations
Posted Date: 12/8/2014
Effective Date: 7/1/2014
Products: Group Health Cooperative BadgerCare Plus, Group Health Cooperative Medicaid SSI, Compcare BadgerCare Plus, Compcare Medicaid SSI

Group Health Cooperative of Eau Claire is in receipt of the Forward Health Update from December 2014 (No. 2014-75) entitled Procedure Code Changes for Influenza Vaccinations. We will be reprocessing and reimbursing three (3) previously non-covered procedure codes for the Influenza virus vaccination: 90661, 90673, and 90688. Providers who have billed using any of these three procedure codes on or after July 1, 2014 are not required to resubmit their charges to us. Group Health Cooperative of Eau Claire will reprocess the claims automatically.

If you have any questions regarding the Forward Health Update please review the update. If you have any questions regarding our processing or claim status please contact the Provider Services department at (866) 563-3020.

11/11/2014 11/4/2014 Prior Authorization Requirement Changed: Cardiac Rehabilitation
Posted Date: 11/11/2014
Effective Date: 11/4/2014
Products: Group Health Cooperative of Eau Claire, Group Health Cooperative BadgerCare Plus, Group Health Cooperative Medicaid SSI, Compcare BadgerCare Plus, Compcare Medicaid SSI

Effective November 4, 2014, Group Health Cooperative of Eau Claire will no longer require prior authorization of cardiac rehabilitation services regardless of the number of medically necessary sessions. Prior to this date, the Cooperative had required prior authorization of these services after the sixth visit (including the initial evaluation) and prior to the seventh visit. The former prior authorization requirement for cardiac rehabilitation will still apply to dates of service before November 4th, 2014.

Organizations requiring additional information on this change are encouraged to contact the Provider Services department at (866) 563-3020.

8/8/2014 10/1/2014 EAPG - Claim Adjudication: Correct Billing
Posted Date: 8/8/2014
Effective Date: 10/1/2014
Products: Group Health Cooperative BadgerCare Plus, Group Health Cooperative Medicaid SSI, Compcare BadgerCare Plus, Compcare Medicaid SSI

Effective date of service (DOS) January 1, 2015 Group Health Cooperative of Eau Claire will begin utilizing Enhanced Ambulatory Patient Grouping (EAPG) when reimbursing providers for services provided to BadgerCare Plus and SSI Enrollees when performed in the outpatient hospital setting and billed on a UB-04 form. Additional correct billing checks will be turned on October 1, 2014 with no impact on provider reimbursement. These checks will impact adjudication for claims where the DOS is on or after January 1, 2015.

Under the current reimbursement methodology (Outpatient Rates-Per-Visit) for services provided to BadgerCare and SSI enrollees , outpatient hospital claims billed on a UB-04 form do not require additional verification to ensure billing accuracy. To assist with appropriate EAPG reimbursement, additional checks and balances will be applied to claims as part of the claim adjudication process. Group Health Cooperative of Eau Claire will apply these additional claim checks beginning with claims received on and after October 1, 2014. These checks will not deny your claim at this time; however, the claim will have an ANSI code corresponding to the inaccuracy in coding. This will provide your organization the opportunity to review your billing practices and make necessary revisions prior to the implementation of EAPG.

Beginning with DOS January 1, 2015, the entire UB-04 claim will be denied if there is an error. The line that hits the check will deny with the corresponding ANSI code and message, while all other lines on the claim, if present, will deny ANSI-133. No reimbursement amount can be determined until the claim is clean. Claims for services provided to commercial enrollees are not affected by EAPG. There will be no change in claim adjudication process for commercial enrollees.

If you require additional information on EAPGs please visit the Forward Health Enhanced Ambulatory Patient Groups (EAPG) Information Page at this link: https://www.forwardhealth.wi.gov/WIPortal/Tab/42/icscontent/html/EAPG/EAPGHome.htm.spage

Any questions regarding implementation of EAPG reimbursement at Group Health Cooperative of Eau Claire may be directed to any of the Provider Relations department contacts below.

Carol Ebel, RN
Contracting & Provider Relations Manager
715-852-2090
cebel@group-health.com

Allison Benson
Provider Relations & Contracting Coordinator
715-852-2017
abenson@group-health.com

Stacey Hallman
Provider Relations Contracting Specialist
715-852-5706
shallman@group-health.com
4/1/2014 4/1/2014 1500 Claim Form: Verify Diagnosis Pointer Value
Posted Date: 4/1/2014
Effective Date: 4/1/2014
Products: Group Health Cooperative of Eau Claire, Group Health Cooperative BadgerCare Plus, Group Health Cooperative Medicaid SSI, Compcare BadgerCare Plus, Compcare Medicaid SSI

The new National Uniform Claim Committee (NUCC) claim form is in use by many organizations at this time. The revised form has many minor changes to align with 5010 837P and accommodate ICD-10. One of the changes that is not so minor is in box 21. Where a diagnosis code had previously been labeled with a number 1-6, it is now labeled with a letter A-L. It has been identified that many providers have not correctly updated their claims system to reflect this. This is causing errors in the value(s) displaying in box 24 E, Diagnosis Pointer.

It is important to verify that the value(s) in box 24 E accurately reflect the options available for use in box 21. The values 1-6 or A-L will depend on the version of the form your system is using. At Group Health Cooperative of Eau Claire we are manually entering claims to account for this error. Claims are not denied for these errors at this time, but you may experience a delay in adjudication because of this. Please work to correct this as soon as your system will allow.

3/7/2014 3/7/2014 Revised - No Change in Claim Processing: Q Codes
Posted Date: 3/7/2014
Effective Date: 3/7/2014
Products: Group Health Cooperative BadgerCare Plus, Group Health Cooperative Medicaid SSI, Compcare BadgerCare Plus, Compcare Medicaid SSI

The following provider update is specific to the billing process for services provided to our Badgercare Plus and SSI membership. This update is a revision to the mailed update titled Change in Claim Processing: Q Codes and the Provider Update, posted to the web only, titled “Revised – Change in Claim Processing: Q Codes”.

Group Health Cooperative of Eau Claire was informed of a series of Q codes that were to be billed to the State of Wisconsin’s Fee for Service Program. We had stated, per our direction from the State, we would deny these codes using the ANSI code 109 and message “Bill to the State of WI”.

After ongoing dialogue with the state, we have determined that we will continue paying these Q codes until further notice. At this time the state has not been able to provide a clear listing of all Q codes which should be paid by the state.

In summary, Group Health Cooperative of Eau Claire welcomes your continued billing of the codes listed below. We will reimburse your claims as outlined in our agreement with your organization. We apologize for any confusion this may have created.

  • Original codes included in notice
  • Q0162
  • Q4074
  • Q9951
  • Q9959
  • Q9965
  • Q9966
  • Q9967
  • These codes were also included (Updated 2/13/14)
  • Q0138
  • Q0139
  • Q0144
  • Q0174
  • Q0177
  • Q0179
  • Q3025
  • Q4081
2/24/2014 2/1/2014 Practice Group Change: St. Luke’s Hospital and Clinics
Posted Date: 2/24/2014
Effective Date: 2/1/2014
Products: Group Health Cooperative BadgerCare Plus, Group Health Cooperative Medicaid SSI, Compcare BadgerCare Plus, Compcare Medicaid SSI

Effective February 1, 2014, the St. Luke’s Practice Group is terminated. The agreement between Group Health Cooperative of Eau Claire and St. Luke’s is not affected by the ending of the practice group.

Beginning this date, Cooperative members who have selected a St. Luke’s clinic as their designated Primary Care Clinic will no longer require a referral to seek care at a contracted non-St. Luke’s location.

2/13/2014 2/13/2014 Revised - Change in Claim Processing: Q Codes
Posted Date: 2/13/2014
Effective Date: 2/13/2014
Products: Group Health Cooperative BadgerCare Plus, Group Health Cooperative Medicaid SSI, Compcare BadgerCare Plus, Compcare Medicaid SSI

The following provider update is specific to the billing process for services provided to our BadgerCare Plus and SSI membership. Group Health Cooperative of Eau Claire has recently been made aware that the Q codes listed below are to only be billed to the State of Wisconsin’s Fee for Service Program. Effective immediately, Group Health Cooperative of Eau Claire will deny these codes using the ANSI code 109 and message “Bill to the State of WI”. Please bill the state for these codes going forward.

  • Q0162
  • Q4074
  • Q9951
  • Q9959
  • Q9965
  • Q9966
  • Q9967
  • Additional Q Codes
  • Q0138
  • Q0139
  • Q0144
  • Q0174
  • Q0177
  • Q0179
  • Q3025
  • Q4081
2/4/2014 2/4/2014 Change in Claim Processing: Q Codes
Posted Date: 2/4/2014
Effective Date: 2/4/2014
Products: Group Health Cooperative BadgerCare Plus, Group Health Cooperative Medicaid SSI, Compcare BadgerCare Plus, Compcare Medicaid SSI

The following provider update is specific to the billing process for services provided to our BadgerCare Plus and SSI membership. Group Health Cooperative of Eau Claire has recently been made aware that the Q codes listed below are to only be billed to the State of Wisconsin’s Fee for Service Program. Effective immediately, Group Health Cooperative of Eau Claire will deny these codes using the ANSI code 109 and message “Bill to the State of WI”. Please bill the state for these codes going forward.

  • Q0162
  • Q4074
  • Q9951
  • Q9959
  • Q9965
  • Q9966
  • Q9967
1/24/2014 1/24/2014 Revised - State of Wisconsin/Uniform Dental Covered Benefits Claims Submission Timeframe
Posted Date: 1/24/2014
Effective Date: 1/24/2014
Products: Group Health Cooperative of Eau Claire

During the month of November, Group Health Cooperative of Eau Claire mailed your dental clinic a notice (Update No. 2013-105) indicating the State of Wisconsin Department of Employee Trust Funds (ETF) Uniform Dental benefit would not provide coverage for dental services submitted for payment after ninety (90) calendar days from the date of service. The Cooperative has recently been made aware of a change to this process.

In a letter dated January 16, 2014, ETF has provided clarification of this timeframe for claims submission. They indicate that after further review they have decided to overturn their previous ruling and will now allow coverage for dental services submitted for payment within twelve (12) months of the date of service. This means that if a claim is submitted for services provided to a State of Wisconsin / ETF member after the twelve (12) month period has passed, it will be denied as “not a covered benefit” (ANSI 96).

The Cooperative does not generally notify providers of coverage changes made by groups. However, we wanted to provide you with notification of this change as it may have impact on your claim submission timeframe and does change information previously sent in Provider Update No. 2013-105. The timely filing and timely appeals requirements articulated in your contract with the Cooperative will still apply and are unaffected by this change to ETF Uniform Dental coverage.

1/1/2014 1/1/2014 Practice Group Change: SMDC/Essentia Health
Posted Date: 1/1/2014
Effective Date: 1/1/2014
Products: Group Health Cooperative BadgerCare Plus, Group Health Cooperative Medicaid SSI, Compcare BadgerCare Plus, Compcare Medicaid SSI

Effective January 1, 2014, the SMDC Practice Group, also known as Essentia Health Practice Group, is terminated. The agreement between Group Health Cooperative of Eau Claire and SMDC/Essentia Health is not affected by the ending of the practice group.

Beginning this date, Cooperative members who have selected a SMDC/Essentia Health clinic as their designated Primary Care Clinic will no longer require a referral to seek care at a contracted non-SMDC/Essentia Health location.

12/1/2013 12/1/2013 Our Contracted Eyewear Provider
Posted Date: 12/1/2013
Effective Date: 12/1/2013
Products: Group Health Cooperative BadgerCare Plus, Group Health Cooperative Medicaid SSI, Compcare BadgerCare Plus, Compcare Medicaid SSI

Effective December 1, 2013, ForwardHealth will have a new State Purchase Eyeglass Contract (SPEC) with Korrect Optical. Covered prescription eyewear for fee for service recipients will need to go through Korrect as of that date.

Group Health Cooperative of Ea uClaire would like to clarify for our participating providers that even though ForwardHealth will be changing SPEC, we have elected to remain with Classic Optical Laboratories, Inc. as our only contracted dispenser of covered prescription eyewear for our eligible BadgerCare Plus and Medicaid SSI members. Clinics participating with Group Health Cooperative of Eau Claire and Compcare in providing vision services to our members will have no change in the current process of filling prescription eyewear for our members.

Interested parties may refer to ForwardHealth Update No. 2013-58 dated October 2013 for additional information regarding ForwardHealth’s change.

12/1/2013 1/1/2014 State of Wisconsin Members with Chronic Low Back Pain Require Prior Authorization
Posted Date: 12/1/2013
Effective Date: 1/1/2014
Products: Group Health Cooperative of Eau Claire

Beginning January 1, 2014, prior authorization will be required for State of Wisconsin members prior to receiving a surgical consult for low back pain. The groups affected are State of Wisconsin members using group numbers 0875 and 0870.

State of Wisconsin members must complete conservative measures before receiving authorization to be surgically evaluated for low back pain. It is Group Health Cooperative of Eau Claire’s policy to provide State of Wisconsin members the opportunity to review options for conservative and appropriate treatment for low back pain with a nurse from our Health Management department prior to receiving a surgical consult.

Prior authorization may be requested using the Request Form for Surgical Consult for Low Back Pain that will be available online December 15, 2013.

11/1/2013 11/1/2013 Provider Manuals Update
Posted Date: 11/1/2013
Effective Date: 11/1/2013
Products: Group Health Cooperative of Eau Claire, Group Health Cooperative BadgerCare Plus, Group Health Cooperative Medicaid SSI, Compcare BadgerCare Plus, Compcare Medicaid SSI

Effective November 1, 2013, the provider manuals have been updated to include the following Appointment Scheduling Standards for Behavioral Health Care:

Waiting and Appointment Scheduling Standards:
The following is the Cooperative’s expectations for providers on accessibility of care and services to all members regardless of payer type:

Type of Care Expectation
Primary Care/Preventive Care Within 3 weeks of request
Specialty Care Within 5 weeks of request
Behavioral Health Care Within 5 weeks of request
Within 30 days of request upon discharge from inpatient stay
Urgent Care 24-48 hours
Emergent Care Immediate face-to-face
Office Waiting Time Within 30 minutes
11/1/2013 1/1/2014 State of Wisconsin/Uniform Dental Covered Benefits
Posted Date: 11/1/2013
Effective Date: 1/1/2014
Products: Group Health Cooperative of Eau Claire

Effective January 1, 2014, the ETF Uniform Dental benefit will not provide coverage for dental services submitted for payment after ninety (90) calendar days from the date of service. This means that if you submit a claim for dental services provided to a State of Wisconsin/ETF member after the ninety (90) day period has passed, it will be denied as "not a covered benefit" (ANSI 96) due to this change in covered benefits.

The Cooperative does not generally notify providers of coverage changes made by groups, however we wanted to provide you with notification of this change as it may have an impact on your claim submission timeframe for dental services provided to State of Wisconsin members. The timely filing and timely appeals requirements articulated in your contract with the Cooperative will still apply and are unaffected by this change to ETF Uniform Dental coverage.

8/1/2013 9/1/2013 Provider Manuals Update
Posted Date: 8/1/2013
Effective Date: 9/1/2013
Products: Group Health Cooperative of Eau Claire, Group Health Cooperative BadgerCare Plus, Group Health Cooperative Medicaid SSI, Compcare BadgerCare Plus, Compcare Medicaid SSI

Effective September 1, 2013 updates to the provider manual include:

Section Description Page Numbers
1 - Claims Information / Submission Reduction rules added for modifiers -52, -53, -54, -55 BCP / SSI: 27
Commercial: No Change
3 - Quality Improvement HEDIS measures BCP / SSI: N/A
Commercial: 24
Added pay-for-performance BCP / SSI: 32
Commercial: N/A
Added waiting time & appointment scheduling standards BCP / SSI: 33
Commercial: 25
9 - Authorization Guidelines Added eyeglass prior authorization information BCP / SSI: 55
Commercial: N/A
Prosthetics & Durable Medical Equipment - added authorization is not needed for nebulizers BCP / SSI: 57
Commercial: 40
11 - Transportation Updated SMV transportation provider name & information to that of MTM Transport BCP / SSI: 59
Commercial: N/A
15 - Fraud, Waste & Abuse Added up-to-date standards BCP / SSI: 64
Commercial: 41
7/1/2013 8/1/2013 Replacement Limit for Eyeglasses
Posted Date: 7/1/2013
Effective Date: 8/1/2013
Products: Group Health Cooperative BadgerCare Plus, Group Health Cooperative Medicaid SSI, Compcare BadgerCare Plus, Compcare Medicaid SSI

Effective August 1, 2013 Group Health Cooperative and Compcare will be implementing the following replacement limits for eyeglasses:

  • Member is allowed coverage of eyeglasses once per annual membership year.
  • Member will be allowed a replacement of eyeglasses once per annual membership year.
  • Classic Optical will decline orders submitted without an authorization for members who have exceeded the replacement limitation for eyeglasses (i.e., one replacement, per member, per annual membership year).
  • Providers may check with the Cooperative’s Provider Services Department prior to submitting the order to determine if the member has reached his or her replacement limitation. Provider Services 715-552-4333 or toll free 1-866-563-3020.
  • If a prescription change occurs resulting in the need for replacement of eyeglasses within the member’s annual membership year, authorization for payment will be required by Group Health Cooperative’s Health Management Department. The Authorization form for providers to complete prior to filling a new prescription is the Service Event Authorization form.
6/17/2013 6/17/2013 Affordable Care Act: Primary Care Rate Increase – ForwardHealth Portal Attestation
Posted Date: 6/17/2013
Effective Date: 6/17/2013
Products: Group Health Cooperative BadgerCare Plus, Group Health Cooperative Medicaid SSI, Compcare BadgerCare Plus, Compcare Medicaid SSI

ForwardHealth issued Update No. 2013-25 in April 2013 to instruct primary care practitioners of how they can receive a temporary rate increase for certain evaluation and management (E&M) and vaccine administration services.

The Cooperative will be working to ensure we pass on this temporary rate increase according to the ForwardHealth Update No. 2013-25. However, as stated on page 3 of the Update,

Providers or designated clinic administrative staff should attest directly to ForwardHealth in order to receive the rate increase. Providers should not submit attestation directly to HMOs; HMOs are not responsible for maintaining separate attestations to ForwardHealth.

The attestation can be completed online via the ForwardHealth Portal at www.forwardhealth.wi.gov/. To access the Primary Care Rate Attestation, click the Primary Care Rate Attestation link in the Providers box on the left side of the Portal home page.

1/1/2013 1/1/2013 Psychiatry CPT Code Changes
Posted Date: 1/1/2013
Effective Date: 1/1/2013
Products: Group Health Cooperative of Eau Claire, Group Health Cooperative BadgerCare Plus, Group Health Cooperative Medicaid SSI, Compcare BadgerCare Plus, Compcare Medicaid SSI

Effective January 1, 2013 Group Health is implementing the changes to the Psychiatry CPT codes and expects that our contracted providers have also implemented these changes. For additional information or for questions, please refere to the following guidance from the American Psychiatric Association:

http://www.psych.org/practice/managing-a-practice/cpt-changes-2013/current-procedural-terminology-cpt-code-changes-for-2013

In addition to adding new codes, redefining current codes, and deletion of codes, this change will now require that Psychiatrists follow the Prior Authorization guidelines below for use of add-on code 90863.

  • Authorization is required for visits following the first six visits (including evaluation) for outpatient mental health/AODA counseling.
1/1/2013 2/1/2013 Provider Manuals Update
Posted Date: 1/1/2013
Effective Date: 2/1/2013
Products: Group Health Cooperative of Eau Claire, Group Health Cooperative BadgerCare Plus, Group Health Cooperative Medicaid SSI, Compcare BadgerCare Plus, Compcare Medicaid SSI

Additions have been made to Section 9: Authorization Guidelines as reads below:

Please note: If a member receives services that require an approved authorization by the Cooperative and such authorization is not obtained, or the prior authorization was denied because services were not deemed medically necessary, all services (including out-of-network and future related services and/or follow-up care related to the services) will be denied. This includes ancillary, facility, and/or professional charges.

Our current Provider Manuals are online and available for viewing and will reflect the above changes by February 1, 2013.

11/15/2012 12/15/2012 Prior Authorization Guidelines Update for the Durable Medical Equipment Dollar Limit
Posted Date: 11/15/2012
Effective Date: 12/15/2012
Products: Group Health Cooperative of Eau Claire, Group Health Cooperative BadgerCare Plus, Group Health Cooperative Medicaid SSI, Compcare BadgerCare Plus, Compcare Medicaid SSI

Effective December 15, 2012, Group Health Cooperative of Eau Claire will be implementing a change to its prior authorization guidelines regarding durable medical equipment. All network providers will be required to request prior authorization for any equipment rental or purchase of $300 or greater.