ATTENTION:

Consumers should be on the lookout for calls from scammers that request your bank account information while claiming to represent the State of Wisconsin and the BadgerCare Plus health care program. The BadgerCare Plus program is administered by the Wisconsin Department of Health Services (DHS). Anyone who legitimately calls you from the BadgerCare Plus program will already have your account information, but they may ask you to verify your birthdate to ensure they are talking with the correct person. Click here for the full news release.

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
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 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.