05/15/2018

Managed Care Committee Reimbursement

Featuring this month: Priority Health

TidBits thanks to MSHO Managed Care Committee Member

ROBIN FREY, CHONC, CPS

Did you know...

Biosimilars preferred over Remicade® effective July 1

Beginning July 1, 2018, Priority Health will be preferring the use of biosimilar infliximab products over Remicade® for commercial, individual and Medicaid products.

Rationale

Priority Health has covered the use of Remicade® (infliximab) for a variety of autoimmune disorders since its approval by the FDA in 1999. The biosimilar infliximab products Inflectra™ (infliximab-dyyb), and Renflexis™ (infliximab-abda) were approved by the FDA in 2016 and 2017, respectively.

Today, with two biosimilars on the market, there is now healthier competition and established ASP pricing, making coverage of the biosimilar products more economically favorable. Remicade® typically is used in the treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, Crohn's disease, plaque psoriasis or ulcerative colitis.

For patients currently on Remicade

Affected providers and members will receive a letter outlining the following changes in the coming weeks:

All existing approvals for Remicade® (J1745) will be given a June 30, 2018, end date.
We will enter authorizations for the biosimilar inflixumab products to replace any remaining doses on current authorizations - the same dose, frequency, location and approval dates will apply. Providers do not need to complete new prior authorization requests for patients who have existing infliximab approvals on file.

No new approval letter will be sent when we update the authorization.

Providers may choose to prescribe either Inflectra™ or Renflexis™.

Beginning July 1

Remicade® infusions will not be covered.

Providers need to request prior authorization for a biosimilar inflixumab product for patients starting infliximab infusions on or after July 1, 2018.

Did you know...

Practitioner Medicare billing edits change effective June 1

Currently, if a provider bills multiple units on single or multiple lines of a claim form and the total units for the CPT code exceed the Medically Unlikely Edits (MUE) limit, Priority Health may partially pay the claim line(s) up to the allowed units, depending on how the provider billed.

Effective June 1, 2018, clinical edits to practitioner claims will align with criteria defined by the MUE adjudication indicator (MAI). If the total units for a code exceeds the MUE limit, then all units will be denied instead of a partial payment being made.

About the MAI

The MUE program was established by the Centers for Medicare and Medicaid Services (CMS) to reduce the Medicare Part B paid claims error rate. Additional specific information about the MAI can be found in the CMS Manual one-time notice, Revised Modification to the Medically Unlikely Edit Program, from 2015. Here is a summary from that document:

At the onset or implementation of the MUE Program, regarding the adjudication process, the MUE value for a Healthcare Common Procedural Coding System (HCPCS) code was only adjudicated against the units of service (UOS) reported on each line of a claim. On April 1, 2013, CMS modified the MUE program so that some MUE values would be date of service edits rather than claim line edits. Therefore, at that time, CMS is introduced a new data field to the MUE edit table termed “MUE adjudication indicator” or “MAI”. CMS is currently assigning a MAI to each HCPCS code.

Did you know...

New process: Unlisted codes on facility claims

Effective May 1, 2018, Priority Health will require a notation on facility claims submitted with unlisted CPT or HCPCS codes describing what item or service is being supplied.

Facility claims reported with unlisted CPT or HCPCS codes may be denied if this information is not supplied.  

This requirement is already in place for professional claims submitted for professional services reported with unlisted CPT or HCPCS codes.  

Where to include the note

On electronic claims: Use the note segment, NTE-Third party Organization Notes
On paper UB-04s: Use the remark section, FL80

NOTE: A different Michigan Payer will be featured monthly.

 Visit the MSHO Website for a listing of the Michigan Health Plans and the MSHO Managed Care Committee.

CLICK HERE