Short Takes: High-Dollar Facility Claims, 100-Day Supply for Generics, and Sequela Code Errors

IN THIS ISSUE:

Acute Care Facilities: Itemized Bills Required for Local and Host Claims Starting at $50,000

Providers will be required to submit itemized bills for high-dollar, inpatient care (costing $50,000 or more) at acute care facilities, effective February 6, 2024, for both local and host (out of area) claims. This new requirement — the previous threshold was $100,000 — is part of an initiative by Highmark to reduce billing and/or payment errors on high-dollar claims that occur both in-network (INN) and out-of-network (OON). For more information, click here.

Medicare Part D: Most Generics Available for 100-Day Supply in 2024

Effective January 1, 2024, Highmark is making some changes to the medications on our Medicare Part D formularies. These changes will ensure the safe and effective use of prescription medications while ensuring they are affordable for our members.

Most members with Medicare Part D coverage will be able to receive up to a 100-day supply for generic medications on Tier 1 and Tier 2 of Highmark’s formularies. When appropriate, roviders are encouraged to write prescriptions for this higher day supply. Some examples of Tier 1 or Tier 2 drugs eligible for a 100-day supply include Lisinopril, Metformin, and Atorvastatin.

To read the Special Bulletin, click here.

Claims Culprit: Sequela Code Errors Lead to Increased Denials

Highmark is seeing an uptick in claims with sequela code errors, resulting in increased denials for providers. To avoid this type of error, it is necessary to include both the original injury code that precipitated the sequela as well as the sequela code. Reminder: The sequela code can never serve as the primary or only diagnosis code; it must always be accompanied by the original injury or condition code. To learn more, go here

MID Program Changes: Mandatory Drug Category to Be Eliminated

Effective February 1, 2024, professional providers will be able to buy and bill all drugs listed in the Medical Injectable Drug (MID) Program, as the mandatory category — which includes 36 drugs — will be eliminated. Starting February 1, 2024, all drugs in the MID program will be considered voluntary across all regions, for all lines of business. To read the Special Bulletin, click here.