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Provider Newsletter | Issue 19

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Quick reference guide to Alliance Services

Our one-page flyer lists frequently used member services, which can be shared with Alliance members or used as a quick reference for provider staff.

Information about the following services are included:

  • Care Management Support.
  • Mental Health Services.
  • Tus Xov Tooj Nug Kev Pab Los Ntawm Tus Kws Tu Neeg Mob.
  • Transportation Services.
  • Language Assistance.

View the quick reference guide.

 

Webinar on 2022 CBI Program

The Alliance will host its annual Care-Based Incentive (CBI) workshop webinar on Wednesday, October 20, 2021. The webinar will cover information on changes for the upcoming 2022 CBI Program, while including tips and valuable resource information.

Due to the COVID-19 pandemic, the Alliance will be hosting only one webinar for all three counties. We encourage office staff and providers to attend the event.

Webinar event:

Wednesday, October 20, 2021

Noon to 1:30 p.m.

Topics covered:

  • CBI Program overview.
  • New measures
  • Modified, exploratory and retired measures.
  • Alliance resources.

Register online or by calling a Provider Relations Representative at 800-700-3874, ext. 5504.

Can’t make it? A recording of the webinar will be posted to the Provider Training page of our website following the live event.

 

Coding and billing updates for flu season

We have coding and billing updates to share with providers for the 2021-2022 influenza season. This article also includes details on The Vaccines For Children (VCF) program.

All Alliance lines of business

(Effective Date September 1, 2021 thru June 30, 2022)

For members linked to your practice, another PCP (no Referral needed), or administrative members:
Vaccine Name Dosage Age Group CPT Code
Afluria® (IIV4)

 

0.5 mL PFS 10-bx* 3 Years & Older 90686
5 mL MDV

24.5 mcg/dose

3 Years & Older 90688
Afluria® Pediatric (IIV4) 0.25 mL PFS 10-bx* 6 to 35 months 90685

90687

Fluad® (IIV) 0.5 mL PFS 10-bx* 65 years & older 90694
Fluarix® (IIV4) 0.5 mL PFS 10-bx* 6 months & older 90686
Flublok® (RIV4) 0.5 mL PFS 10-bx* 18 years & older 90682
Flucelvax® (ccIIV4)

 

0.5 mL PFS 10-bx* 2 years & older 90674
5 mL MDV

25 mcg/dose

2 years & older 90756
FluLaval® (IIV4) 0.5 mL PFS 10-bx* 6 months & older 90686
FluMist® (LAIV4) 0.2 mL spray 10-bx* 2 to 49 years 90672
Fluzone® (IIV4)

 

0.5 mL PFS 10-bx* 6 months & older 90686
0.5 mL SDV 10-bx* 6 months & older 90686
5 mL MDV

25 mcg/dose

6 to 35 months 90687
5 mL MDV

25 mcg/dose

3 Years & Older 90688
Fluzone® High-Dose (IIV) 0.7 mL PFS 10-bx* 65 years & older 90662

 

Immunization Registries
Vaccine Name Immunization Service Name with CVX*
Afluria® (IIV4)

 

Influenza, injectable, quadrivalent, pres free (150)
Influenza, injectable, quadrivalent (158)
Afluria® Pediatric (IIV4) Influenza, injectable, quadrivalent, pres free, ped (161)
Fluad® (IIV) Influenza, trivalent, adjuvanted (144)
Fluad®  (allV4) Influenza, injectable, quadrivalent, pres free (205)
Fluarix® (IIV4) Influenza, injectable, quadrivalent, pres free (150)
Flublok® (RIV4) Influenza, recombinant, quad, inject, pres free (185)
Flucelvax® (ccIIV4)

 

Influenza, injectable, MDCK, pres free, quadrivalent (171)
Influenza, injectable, MDCK, quadrivalent  (186)
FluLaval® (IIV4) Influenza, injectable, quadrivalent, pres free (150)
FluMist® (LAIV4) Influenza, live, intranasal, quadrivalent (149)
Fluzone® (IIV4)

 

Influenza, injectable, quadrivalent, pres free (150)
Influenza, injectable, quadrivalent, (158)
Fluzone® High-Dose (IIV) Influenza, high dose seasonal (197, 135)

*Correct CVX code for immunization registries is needed for Care Based Incentives (CBI).

Vaccines For Children (VFC) Program

The Vaccines For Children (VFC) program is a federally funded program that provides vaccines at no cost to eligible children who might not otherwise be vaccinated because of inability to pay.

Information on the VFC Program:

  • Only children less than age 19 are eligible for the VFC program.
  • Children are eligible if they are one of the following:
    • Medicaid eligible.
    • Uninsured.
    • Underinsured.
    • American Indian/Native American.
  • When using VFC stock, append modifier SL to the vaccine code.
  • Modifier SL indicates VFC stock used & only allows reimbursement for the administration of vaccine.

Per Medi-Cal Guidelines: “Medi-Cal vaccine injection codes billed for recipients eligible to receive VFC program vaccines will be reimbursed only in documented cases of vaccine shortage, disease epidemic, vaccine delivery problems, or instances when the recipient does not meet the special circumstances required for VFC special-order vaccines.  A provider’s non-enrollment in the VFC program is not a justified exception.”

However, the Alliance will make an exception for non VFC providers. How to bill:

  • Do not bill the CPT code with the SL modifier.
  • Document “non-VFC” in box 19 of the CMS claim form or box 80 of the UB-04 claim form.
  • Send the claim to CCAH Attention: Sharlene Gianopoulos.

Claim forms

All claims must be billed on UB-04, CMS-1500 or their electronic equivalent.

 

Reminder: PAAS Survey and timely access standards

Each year, the Alliance administers the Provider Appointment Availability Survey (PAAS) to assess our network’s ability to provide care within timely access standards. The following information outlines the delivery process of this survey and provides a summary of timely access standards monitored through the PAAS.

The Alliance launched the PAAS for 2021 in late August. Some providers have already received a survey by email. If there was no response within 5 business days, providers will receive a survey call. Please encourage reception staff to participate in survey calls and be aware that you may receive requests to complete the PAAS survey from multiple health plans.

The Alliance realizes that providers have been faced with many challenges during these unprecedented times, and that access to care has been heavily impacted by our current environment. We are committed to conducting outreach that is as minimally impactful to the daily operations of your office as possible.

The Alliance also recognizes the different modalities of care utilized by providers this year, including telephonic appointments. Please note that telehealth appointments demonstrate the means to provide timely access to care, and should be included in your responses, if available. 

Timely access standards monitored through the PAAS include the following:

Urgent Care Appointments Wait Times
Services that do not require prior authorization 48 hours
Specialty services that require prior authorization 96 hours
Non-Urgent Care Appointments Wait Times
Non-Physician Mental Health Providers and Primary Care (including first prenatal and preventive visits) 10 business days
Specialist and Ancillary Appointments 15 business days
Physical Therapy or Mammography appointment for the diagnosis or treatment of injury, illness or other health condition 15 business days

Qhov kevpab cuam Timely Access to Care page on our website provides full details and specific guidelines on timely access to care.

Thank you for your participation in this year’s PAAS. If you have questions, please contact an Alliance Provider Relations Representative at 800-700-3874, ext. 5504.