New This Year
Based on your survey feedback, we’re introducing a new structure for VOAs. Webinars will continue to be scheduled every over month, but there will be three specifically for billers and coders held April 13, August 10 and December 14. The remaining webinars will cover a variety of topics including updates on products, risk adjustment, formulary changes, Medicare and Medicaid quality, behavioral health and more.

Recap of February’s VOA
We kicked off this year’s VOA schedule by highlighting our online tools and resources available to help you work with us. Watch a recording of the webinar and access the downloads and resources from the presentation.

On April 23, we’ll implement the new clinical edits listed below, impacting professional claims only:

• All products

  • Trastuzumab Biologics, Multiple Vials

  • Missing Injection Code on Claim for Xiaflex® for Peyronie’s Disease

  • Misuse of JW Modifier

• Medicaid only

  • Telemedicine Services Billed Without GT Modifier, With POS 02

  • Telemedicine Services Billed With GT Modifier, Without POS 02 or 10

READ MORE 

Why do I Need to Submit an Appeal?
To make sure we remain in compliance with CMS policy, we can’t simply reprocess disputed Medicare claims for non-contracted providers. This is because non-contracted providers must include a signed Waiver of Liability (WOL) with any reconsideration request for a Medicare claim, ensuring they won’t bill the member regardless the outcome.

How do I Submit an Appeal?
We highly recommend submitting appeals through prism, our online provider portal. All providers, contracted and not, can have a prism account. Submitting through prism, rather than via fax, with ensure the fastest response.

For details on both the prism and fax processes, visit the Appeals post service: Non-contracted provider webpage.

What if I Just Have a Question About How a Claim Was Processed?
If you’re simply wondering why a claim was denied, want us to explain a clinical edit that was applied to your claim or have another question about how your claim was processed, you can submit your question to our teams through prism’s Claims Inquiry or General Requests features. You can also call our Provider Hotline.

However, if you disagree with the outcome of your inquiry, you’ll need to submit an appeal.

What We’re Doing and Why
A patient’s decision about their care can be a big, life-changing decision. 2nd.MD through Accolade is a leader in virtual medical decision-making, connecting people facing high-impact medical scenarios with top specialists through video consultations, to help them make informed health care decisions.

Currently, 2nd.MD is offered as a service in the Commercial Group market as part of PriorityGPS and Virtual Care Partners for select employer groups through our partnership with Accolade. Beginning May 1, 2023, we’re expanding this program to most employers. Our goal in expanding this program is to:

• Help members feel confident and educated in their treatment and care plan recommended by their physician.
• Give members the option for re-evaluations for specific high-cost services such as surgeries and procedures for musculoskeletal, cardiac, women’s health and gastrointestinal issues.
• Give members the resources to discuss potential alternative treatment options with their local physician.
• Improve the time to obtain a second opinion from weeks to days

How it Works
Members who choose to seek a second medical opinion through 2nd.MD will receive a 30-minute live consultation with a nurse and specialist physician to review their medical history. The care team will provide the member a post-consult summary with their recommendations. Members can choose to share the second opinion summary with their treating provider and determine next steps.

What Providers Need to Know
It’s important for patients to feel confident in their care and empowered to share the decision-making process with their doctor. 2nd.MD provides a second medical opinion, and members will decide how to proceed with their care and/or share their summary report with their physician. 2nd.MD acts as an extension of the members care and refers the member back to their treating physician for follow-up.

How We’re communicating to Members
Members who qualify for a consultation from 2nd.MD will receive outbound communications from Accolade starting in May. Depending on the member’s plan, they may proactively reach out to 2nd.MD for a second medical opinion. The member summary provides information for providers to request a peer-to-peer conversation with the 2nd MD provider, if desired.