Contents:

 

MIPA Contracted Health Plans & Products Managed by CMO

Effective January 1, 2016

HIP Commercial Products

Prime Network:

  • HIP Access I
  • HIP Prime HMO
  • HIP Child Health Plus (CHP)

Select Care Network:

  • Select Care - Healthy NY HMO
  • Select Care - HMO 40/60
  • Select Care - HMO 35/55
  • Select Care - HMO HD6300
  • Select Care - HMO 15/35

 

HIP Medicaid Products

Enhanced Care Prime Network:

  • EmblemHealth Enhanced Care (MMC)
  • EmblemHealth Enhanced Care Plus (HARP)

 

HIP Medicare Products

Medicare Essential Network:

  • EmblemHealth Essential (HMO)
  • EmblemHealth VIP High Option (HMO)

VIP Prime Network:

  • EmblemHealth VIP (HMO)
  • EmblemHealth Dual Eligible (HMO SNP)
  • Premier HMO

 

The Montefiore CMO logo and claims address appear on all member ID cards.

United/Oxford Products

  • AARP MedicareComplete
  • AARP MedicareComplete Plan 1
  • AARP MedicareComplete Plan 2
  • AARP MedicareComplete Plan 3
  • AARP MedicareComplete Mosaic
  • AARP MedicareComplete Essential
  • United Healthcare Group Medicare Advantage  

 

Note:

  • All United/Oxford claims must be sent directly to United/Oxford for processing. Claims sent elsewhere will not be routed to Oxford, but will be denied as “Bill Health Plan.”
  • Claims reimbursement methodology will follow United/Oxford guidelines. Payments will be based on your individual or group United/Oxford agreement.

CMO will continue to manage pre-certification requests, but will be follow Oxford’s authorization guidelines.

ICD-10 Coding: The Usual Cast of Characters

Codes in the ICD-10-CM code set can have three, four, five, six, or seven characters. Many three-character codes are used as headings for categories of codes; these three-character codes can further expand to four, five, or six characters to add more specific details regarding the diagnosis.

 

Documentation makes the difference

ICD-10 provides detailed information on diagnoses due to a greater level of specificity in the codes while providing a logical structure with clear, consistent definitions. This improves the amount and detail of data that can be sent electronically between health care organizations, resulting in improved quality of care and reduced costs.

ICD-10-CM characteristics affect which codes are assigned (e.g. timeframes in obstetrics involving trimesters or when coding acute myocardial infarctions which involve a duration of four weeks or less); how many codes are reported (i.e. combination codes vs. multiple codes); and how we report them (e.g. seventh characters, placeholders “x,” code sequence).

Combination codes

A combination code is a single code used to classify two diagnoses or a diagnosis with an associated secondary process (manifestation) or a diagnosis with an associated complication. Combination codes provide full identification of diagnostic conditions. When the combination code lacks necessary specificity in describing the manifestation or complication, an additional code should be used as a secondary code. An example follows:

Hypertensive chronic kidney disease stage III

ICD-9

403.90 Hypertensive chronic kidney disease with chronic kidney disease stage I through stage IV, or unspecified

585.3 Chronic kidney disease, stage III (moderate)

ICD-10

I12.9 Hypertensive chronic kidney disease with stage I through stage IV chronic kidney, or unspecified chronic kidney disease

N18.3 Chronic kidney disease, stage III (moderate)

Documentation tips for heart failure coding

  • Specify the acuity (acute, chronic, or acute on chronic)
  • Identify the type of failure (systolic, diastolic, combined)
  • List any relationship of hypertension and/or chronic kidney disease to heart failure
  • Identify the underlying cause (surgery, ectopic pregnancy, etc.)

 

Hypertensive heart disease with acute diastolic congestive heart failure

ICD-9

402.90 Hypertensive heart disease with heart failure

428.31 Acute diastolic heart failure

428.0 Congestive heart failure

ICD-10

I11.0 Hypertensive heart disease with heart failure

I50.31 Acute diastolic (congestive) heart failure

Combination codes for diabetes mellitus

Diabetes codes are now combination codes that include the type of diabetes (Type 1 or 2), the body system affected and complications affecting the body system (e.g. retinopathy, neuropathy, arthropathy, peripheral angiopathy with gangrene). Diabetes mellitus is no longer classified as controlled or uncontrolled in ICD-10. ICD-10 classifies inadequately controlled, out of control and poorly controlled diabetes mellitus to diabetes by type, with hyperglycemia. It is important to document the causal relationship for all diabetic complications.

Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy and macular edema, uncontrolled

ICD-9

250.52 Diabetes with ophthalmic manifestations, uncontrolled

362.05 Moderate nonproliferative diabetic retinopathy

362.07 Diabetic macular edema

ICD-10

E11.331 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema

E11.65 Type 2 diabetes mellitus with hyperglycemia

Laterality and severity

This guideline includes anatomically paired organ or site designations and may include right, left, or bilateral. Separate right and left codes may be reported if no bilateral code is provided. An example follows:

Right foot ulcer with necrosis of muscle

ICD-9

707.15 Ulcer of other part of foot (except pressure ulcer)

ICD-10

L97.513 Non-pressure chronic ulcer of other part of right foot with necrosis of muscle

 

If you have any questions, call the HCC coding department at 914-721-8563 or 914-721-8584 or send an email to CMOHCCCoding@montefiore.org.

IPA Referral and Prior Authorization Processes

Referral Requirements

There is no requirement for referral notifications for most specialty services for referrals within the IPA network.

Providers who refer patients outside of the IPA network are required to follow the patient’s health plan referral guidelines.

Aetna self-insured members are not managed by CMO. Health services for these enrollees require that referrals be submitted to the health plan per Aetna guidelines.

Prior-Authorizations Requirements

To ensure that patients enrolled in health plans with IPA contracts receive services covered by their current health insurance benefits, CMO requires that authorizations be requested for the following services:

  • Admissions (Elective/Emergent)
  • Bariatric Surgery
  • Durable Medical Equipment (DME)
  • Home Health Care – including Home Infusion Therapy
  • Infertility workup and treatment
  • Plastic/Cosmetic Surgery including, but not limited to
  • Rehabilitation/Physical/Speech/Occupational Therapy
  • Hyperbaric Treatments
  • Transportation for all non-emergency services
  • All referrals to out-of-network providers
  • Emergent admissions require 48-hour notification
  • Elective admissions require prior-authorization
  • Mohs Micrographic Surgery
  • Septoplasty
  • Ligation and stripping of varicose veins

Podiatry

  • Prior authorization for Podiatry services is not required.
  • Claims for Podiatry will be processed according to the member's benefit.

Behavioral Health

For Behavioral Health referrals, including HealthFirst, call UBA at 800-401-4822

For HIP Behavioral Health call 800-447-2526

 

Podiatry Reimbursement Methodology

IPA par podiatrists are reimbursed on a per visit maximum fee arrangement. Specific procedure codes, mostly for surgical procedures and orthopedic supplies, are excluded from the per visit fee methodology and will be paid fee-for-service. A list of these procedures is in the chart below:

Procedure Code(s)

 

Description

 

11426

Exc., Benign Lesion Scalp, Neck, Hand and Face, over 4.0 cm

11626

Exc., Malignant Lesion Scalp, Neck, Hand and Face, over 4.0 cm

14040

Adjacent Transfer Chin/Axillae/Foot, 10 sq. cm

14041

Adjacent Transfer Chin/Axillae/Foot, 10.1 – 30.0 sq. cm

15004, 15005

Surg. Preparation Recipient site, 1st 100 sq cm; each additional

20525

Removal Foreign Body Muscle/Tendon, deep, complicated

20670

Removal Implant, superficial (separate procedure)

20680

Removal Implant, deep

28001 – 28899

Foot and Toe Surgical Procedures

29891 – 29999

Endoscopy and Arthroscopy

64640

Destruction, other peripheral nerve

64722

Decompression, unspecified nerve (specify)

64776

Excision Neuroma, digit nerve 1/Both same

73720

MRI, Lower Extremity other than joint

73725

MRI, Angiography, Lower Extremity w/wo Contrast

A5500 – A5511

Diabetic Shoes, fitting and modific

L1900 – L1990

Ankle Foot Orthoses

L2106 – L2999

Ankle-Foot Orthotic, fracture orthotic, tibial fracture orthotic

L2232, L2275

Addition to lower extremity orthotic, ankle

L2340

Addition to lower extremity, pretibial shell

L2820 – L2999

Addition to lower extremity orthosis

L3000 – L3649

Orthopedic Shoes

L4205 – L4360,

L4386 – L4398

Repair/replace orthotic device or soft interface material; Ankle control

orthosis; Walking boot; ankle-foot orthosis; foot drop splint

L5000

Prosthetic, Partial foot, shoe insert with longitudinal arch, toe filler

L5010

Prosthetic, Partial foot, molded socket, ankle height, with toe filler

L5020

Prosthetic, Partial foot, molded socket, tibial tubercle height, with toe filler

 

Montefiore Care Management Services

Montefiore Care Management is a valuable resource for patients and families navigating the complexities of the healthcare system. By providing information, care coordination and health promotion programs, we can help your patients take control of their health. We focus on the “whole” patient, not just an isolated medical episode or a single chronic condition.

Our approach to care management stresses the importance of early identification of patients at risk and a collaborative, interdisciplinary team that develops and oversees individualized care plans and promotes patient self-monitoring and education. We emphasize interaction and communication among patients, providers, case managers, mental health agencies and other allied health professionals.

Our programs provide and reinforce health education, promote compliance with treatment regimens and preventative care guidelines, monitor health status and promote timely interventions when indicated. We seek to anticipate an individual's healthcare needs, to provide and coordinate the scope of necessary health services and to involve patients in establishing goals.

Our involvement spans the full continuum of care: hospital, rehab, outpatient, professional services, ancillary support, community-based programs, home care and other services that may be required to return a member to optimum health. Our programs are intended to meet the needs of members with complex or chronic illnesses, as well as to maintain the well-being of our healthier members.

Physicians who have an Oxford-UnitedHealthcare or Emblem Health Plan member whom they believe would benefit from Montefiore Care Management's services should call 914-378-6721 to speak to a CMO Case Manager.

 

CMO Provider Relations Staff Directory

CMO Provider Relations is the communication link between Montefiore Medical Center, MIPA providers, and contracted health plans. Provider Relations Liaisons offer a variety of services to MIPA providers and their office staff, including problem resolution/troubleshooting, orientation, educational sessions on CMO systems, claims filing policies and procedures, clinical guidelines, and quality reporting.

All MIPA physicians have an assigned Provider Relations Liaison based on the location of their practice.

Laura DeMaria

Director of Provider Relations

Phone: 914-721-8592

ldemaria@montefiore.org

Jacqueline Kolovic

Manager, Network Development

Phone: 914-721-2566

Jkolovic@montefiore.org

Alexis Adusei

Provider Relations Liaison

Phone: 914-721-8572

aadusei@montefiore.org

Montefiore-Affiliated Bronx Physicians

Laura Finnegan

Provider Relations Liaison

Phone: 914-721-8568

lfinnega@montefiore.org

Montefiore-Employed/Faculty Practice Physicians & Montefiore HMO (MLTC)

Horace McFarlane

Provider Relations Liaison

Phone: 914-721-8571

Hmcfarlane@montefiore.org

Electronic Data Interchange (EDI) Specialist & Post N Track Coordinator

Julian McMaster

Provider Relations Liaison

Phone: 914-721-8569

jmcmaste@montefiore.org

Montefiore Medical Group Physicians

Tugba Temurcan

Provider Relations Liaison

Phone: 914-721-8570

ttemurca@montefiore.org

Voluntary & Non-Montefiore-Affiliated-Physicians – Westchester Vendor Services

 

 

 

CMO Cares

The CMO website, www.cmocares.com, is an excellent resource of reference material for CMO! For specialists, it may be worthwhile to familiarize yourselves with the site as we keep up-to-date information with regard to radiology and diagnostic guidelines, MIPA Contracted Plans, and other useful tools pertaining to your specialty!

Annual Incentives Statement

CMO, The Care Management Company, LLC / CMO, Montefiore Care Management (CMO)

and University Behavioral Associates (UBA)

Annual Affirmative Statement about Incentives

 

The CMO and UBA are dedicated to ensuring the delivery of appropriate care to all health plan delegated members.

The following statement affirms that the CMO/UBA’s policies regarding Case Management (CM) and Utilization Management (UM) decision-making when conducted by a Clinical Peer Reviewer, CMO and/or UBA staff are (1) based only on appropriateness of care and service and existence of coverage; (2) does not specifically reward practitioners or other individuals for issuing denials of coverage; and (3) financial incentives for CM and UM decision makers do not encourage decisions that result in underutilization.