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Provider Monthly: New system upgrade, a message for providers enrolled during COVID and the latest clinical guidelines for July 2021

Featured Story:

Pediatrician Perspective Part 1: should I vaccinate my child?

Now that the FDA has authorized vaccination for adolescents ages 12-17, parents have questions. After surveying some of our members about concerns and hesitancy, we compiled some of the most common questions to ask Pediatrician and Medical Director at AllWays Health Partners, Dr. Lisa M. Scarfo, MD. Continue reading for part 1 of 2 to learn what Lisa had to say about getting kids vaccinated, the impact this year has had on students' development, and how to get adolescents socializing with their friends again safely.doctor-in-face-mask-giving-vaccine-to-little-boy-who-came-to-the-picture-id1298103455

Keep reading

To view last month's newsletter or any previous month, visit our Admin Newsletter Archive.

In this issue:

  • Update to outpatient requests on our authorization tool
  • Update for practices that enrolled new providers during COVID
  • Check your eligibility at every open enrollment
  • Clinical practice guidelines
  • Claims editing system upgrade
  • NEW reporting for providers to show patients' vaccine status
  • Hospital inpatient utilization report
  • New medical policy
  • Revised medical policies
  • Reminder: new member search tool
  • Formulary updates
  • CPT codes

Update to outpatient requests on our authorization tool

To increase the number of authorization requests that are automatically approved, effective July 18, 2021 users will no longer be able to bypass the clinical questions under the outpatient template in our authorization tool for the following requests:

  • Acupuncture
  • Cardiac Imaging
  • Chiropractic
  • DME Enteral Product
  • DME Purchase
  • DME Rental
  • High Tech Radiology
  • Occupational/Physical Therapy
  • Orthotics/Prosthetic Device
  • Other Medical
  • Outpatient Infusion
  • Pain Management
  • Speech Therapy
  • Surgical Day Care

When you click medical review, you will be prompted to answer a series of questions:

  • The criteria is presented in a series of simple, rules-driven questions
  • The answers you provide about the patient’s clinical presentation lead to recommendations
  • The best evidence-based recommendation is suggested for the clinical scenario presented
  • Once you answer all the questions, click on “View Recommendations”

ICYMI, watch the full webinar recording to learn about the tool step-by-step.


Update for practices that enrolled new providers during COVID

For any practices that enrolled new providers during COVID, please update us on the following:

  • If the provider has left your organization – please let us know and we will remove the provider from their roster.
  • If the provider has decided to stay on – please let us know so that we can update the enrollment information and get them appropriately credentialed.

For any questions, contact PEC@allwayshealth.org


Check your eligibility at every open enrollment

As a reminder, open enrollment is upon us and members may have changes to their plans on July 1. For that reason, it’s important to check eligibility at every visit. In addition, we have new ASO (also known as self-insured) plans, and some of your existing patients may be transitioning to an ASO plan. ASO members are labeled “Commercial ASO” in the Plan Type field on the eligibility screen of the provider portal.


Clinical practice guidelines

AllWays Health Partners adopts regional and national clinical practice guidelines that apply to our members—based on scientific evidence, professional standards, expert opinions, and input from board-certified practitioners. These guidelines are designed to assist clinicians with evaluating and treating patients—intended to improve the quality and consistency of care provided to our members. Each policy is reviewed by our health plan clinicians and approved on at least a biennial basis. You can find these under "Practice guidelines" on our website.


Claims editing system upgrade

We're upgrading our claims editing system to better reflect the industry standards within the New England market. Beginning August 16 we'll be moving to ClaimsXten. This will improve claim accuracy and reduce appeals. For more information, visit their website.


NEW reporting for providers to show patients' vaccine status

Coming soon! To support vaccination efforts, we're adding a new report to our provider portal that gives you access to most of your patients' COVID-19 vaccine status. You will be able to find this under the "reports" tab—listing all commercial HMO members on your panel who are partially vaccinated or unvaccinated. The new report will be available by the end of July, and we will notify you once it is live. Stay tuned!


Hospital inpatient utilization report

The latest quarterly hospital inpatient utilization report is now available. To review this report, click on the Reports tab in the Provider Portal and select Clinical Reports. If you do not have access to the Provider Portal, you may register online at allwaysprovider.org.


New medical policy

A new medical policy; Breyanzi  has been posted to allwayshealthpartners.org with an 7/1/2021 effective date.  Please go HERE to see the updated policy.  

The table below is a brief summary of the criteria.


Revised medical policies

Four revised medical policy updates have been posted to allwayshealthpartners.org with a 7/1/2021 effective date.  Please go HERE to see the updated policy.  

The table below is a summary of the edits.

The Home Health Care medical policy has been posted to allwayshealthpartners.org with an 7/1/2021 effective date.  Please go HERE to see the updated policy.  

No significant changes were made to the policy. The table below is a brief summary.

The Dental Treatment Setting medical policy has been posted to allwayshealthpartners.org with an 7/1/2021 effective date.  Please go HERE to see the updated policy.  

No significant changes were made to the policy. The table below is a brief summary.

Please review the policy and attest to having reviewed it. You can find the Policy Review and Attestation list HERE.  


New member search tool

We’ve added extra authentication factors for added security within our member search tool. Now, you’ll be required to fill out additional field such as Member ID and Last Name to search eligibility. See screenshot below:


Formulary updates


Code Updates

CPT code updates

Drug code updates

New codes summary




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