February 2023 Provider Newsletter

A MESSAGE FROM DR. GEORGE E. MATTHEWS, CMO
CPR SAVES LIVES

On January 2, 2023, during a Monday Night Football game after making what appeared to be a routine tackle, Damar Hamlin attempted to stand up and then collapsed. He had suffered a cardiac arrest. Like millions of Americans, I was stunned to see that this football player’s condition required CPR and defibrillation. Mr. Hamlin survived this event because he promptly received that appropriate initial care, CPR followed by restoration of rhythm by defibrillation. Mr. Hamlin’s chance of survival from this catastrophic event was significantly enhanced because he was in otherwise excellent physical health with no evidence of a pre-existing cardiovascular illness.

January 2023 Provider Newsletter

A MESSAGE FROM DR. GEORGE E. MATTHEWS, CMO
New Year’s Resolution: Good Health to All

As we bid adieu to 2022 and look forward to 2023, let us reflect upon the successes and accomplishments of the past year and the challenges and opportunities that the new year affords us. It is no surprise that we have weathered yet another COVID-19 experience as well as the influenza season and a particularly concerning RSV (respiratory syncytial virus) season. Our ability to deal with the threats posed by these illnesses have allowed us to look confidently toward the future with the appreciation of what we have learned from experience and what we are better prepared for to come.

December 2022 Provider Newsletter

A MESSAGE FROM DR. GEORGE E. MATTHEWS, CMO
THE GIFT OF SELF-CARE
Friedrich Nietzsche is often quoted as stating “That which does not kill us makes us stronger”. Certainly, surviving an existential threat such as the COVID-19 pandemic is to be acknowledged and celebrated. Yet this survival may come at a cost. That cost being burnout and the resultant depression, posttraumatic stress disorder and other mental health challenges.
As this year draws to a close, we can look back and appreciate that despite multiple challenges, providers and health care workers remain standing (unbowed, unbent, and unbroken). As providers however we must take a moment to reflect that the well-being of ourselves and our colleagues is rooted in part in addressing the underlying factors which might contribute to burnout.

November 2022 Provider Newsletter

A MESSAGE FROM DR. GEORGE E. MATTHEWS, CMO
THE GREAT AMERICAN SMOKEOUT
NOVEMBER 17, 2022

The American Cancer Society has designated November 17, 2022, as the Great American Smoke Out, which serves as an opportunity for people who smoke to make a plan to quit or commit to a healthy smoke-free life. Additionally, November 2022 has been designated lung cancer awareness month as well as COPD awareness month, as the 2 illnesses are intricately associated with smoking/tobacco use. The United States is home to 34 million adults who smoke. Smoking results in approximately 480,000 deaths per year or about 1 in 5 deaths.

October 2022 Provider Newsletter

A MESSAGE FROM DR. GEORGE E. MATTHEWS, CMO
OCTOBER IS NATIONAL BREAST CANCER AWARENESS MONTH
OCTOBER 4-8, NATIONAL PRIMARY CARE WEEK

As we transition into the fall and in particular the month of October, we can appreciate the beauty of the season. October also offers another important aspect, that of being designated National Breast Cancer Awareness Month.

Breast cancer is the second most common cancer among women in the United States (some kinds of skin cancer are the most common). Each year in the United States, approximately 264,000 women and 2400 men are diagnosed with breast cancer. Even more concerning, 16% of women and 20% of men who are diagnosed with breast cancer will die from the disease and African American women die from breast cancer at a higher rate than Caucasian women.

September 2022 Provider Newsletter

MONROE PLAN INTRODUCES THRIVE AT HOME “GAP CLOSURE” PROGRAM
Tap into this no cost, value added clinical resource to reach difficult to engage Medicaid and HARP patients. Monroe Plan’s qualified team will schedule & complete preventative testing in the patient’s home.

We know that Medicaid and HARP patients often face significant obstacles to getting to the care they need such as limited transportation, childcare, and economic means. We also know that limited practice resources and time can impact quality of care. The in-home services provided through Thrive at Home can augment your team AND help patients overcome obstacles to accessing care. Most importantly, this program can serve as a gateway to reconnecting the patient with their primary and specialist caregivers!

Monroe Plan Introduces Thrive at Home “Gap Closure” Program

Monroe Plan Introduces Thrive at Home “Gap Closure” Program

Our Thrive at Home offers a no cost, additional clinical resource to our IPA providers.
Our Thrive at Home Outreach and Clinical Team will schedule and perform preventative testing and follow up right in the patients home which makes all the difference in reaching difficult-to-engage Medicaid and HARP patients.

We know that Medicaid and HARP patients often face significant obstacles to getting to the care they need such as limited transportation, childcare, and economic means. We also know that limited practice resources and time can impact quality of care. The in-home services provided through Thrive at Home can augment your team AND help patients overcome obstacles to accessing care. Most importantly, this program can serve as a gateway to reconnecting the patient with their primary and specialist caregivers! To learn more, please contact Samantha Tolbert, Clinical Quality Program Manager at thriveathome@monroeplan.com.

August 2022 Provider Newsletter

A MESSAGE FROM DR. GEORGE MATTHEWS, CMO
AUGUST IS NATIONAL IMMUNIZATION MONTH
“An Ounce of Prevention is Worth a Pound of Cure” Benjamin Franklin
Having experienced the COVID pandemic and acknowledging the impact of the COVID vaccines in preventing or mitigating the severity of illness, we may all appreciate the utility of vaccinations as a critical tool in maintaining good health. Vaccinations have traditionally been considered predominantly for birth to age 18. The conditions that we administer vaccinations for have previously been considered a scourge among the young resulting in death or significant impairment. Illnesses such as polio, diphtheria, tetanus, and whooping cough no longer provide concern in parents in whose babies have been vaccinated. Toddlers are now able to receive vaccinations for measles mumps, rubella, hepatitis, chickenpox (varicella) and flu. Again, it must be realized that these conditions provide for significant morbidity and mortality in the unvaccinated.

July 2022 Provider Newsletter

A MESSAGE FROM DR. GEORGE MATTHEWS, CMO
JULY IS NATIONAL MINORITY MENTAL HEALTH AWARENESS MONTH

Having endured the impact of the COVID-19 pandemic and more recently the hate filled racist attack in Buffalo New York it is not surprising that racial and ethnic minority communities face unique psychological challenges. Unfortunately, the opportunity to receive appropriate support for the mental health challenges is thwarted due to cultural stigma and the lack of access to mental health care services. Let us put the problem in perspective.

The Office of Minority Health from the US Department of Health and Human Services describes the following statistical assessment “In 2019 suicide was the second leading cause of death 4 blacks or African-Americans ages 15-24. Poverty level affects mental health status. African-Americans living below the poverty level as compared to those over twice the poverty level are twice as likely to report serious psychological distress”.

June 2022 Provider Newsletter

DR. MATTHEWS, MONROE PLAN’S CMO, INSIGHTS ON MEN’S HEALTH MONTH

As we think about our male patients, as well as those men that are most important to us (whether that is ourselves, our partner, father, son, or brother), we must reflect on how we can assist these individuals in maintaining a healthy lifestyle. According to the Centers of Disease Control, in the United States, men die an average of 5 years earlier than women. Men of color may experience even shorter lifespans. That being said, the leading causes of death in men aged 18 older are Heart Disease, Cancer, COVID-19, Accidents, and Stroke.

May 2022 Provider Newsletter

MONROE PLAN WELCOMES NEW CMO, DR. GEORGE E. MATTHEWS
We are excited to share that Dr. George E. Matthews has joined Monroe Plan for Medical Care as our new Chief Medical Officer. Along with a wealth of clinical and leadership experience, Dr. Matthews brings a career long commitment to community health naturally affiliating him with Monroe Plan’s mission to serve the underserved.
Dr. Matthews has practiced as a cardiologist in Western New York for the past 35 years. Building on a philosophy that the effective practice of medicine is an art as well as science, he has been driven to improve the quality of life for his patients by providing the highest quality of care.

April Provider Newsletter 2022

APRIL IS NATIONAL MINORITY HEALTH MONTH
The death rate for Blacks/African Americans is generally higher than whites for heart diseases, stroke, cancer, asthma, influenza and pneumonia, diabetes, HIV/AIDS, and homicide.

American Indians/Alaska Natives also have a high prevalence and risk factors for mental health and suicide, unintentional injuries, obesity, substance use, sudden infant death syndrome (SIDS), teenage pregnancy, diabetes, liver disease, and hepatitis.

Puerto Ricans have a low-birth-weight rate that is almost twice that of non-Hispanic whites. Also, Puerto Ricans suffer disproportionately from asthma, HIVAIDS and infant mortality. Mexican Americans suffer disproportionately from diabetes.

Ensure your practice engages in cultural competency training on an annual basis.
Cultural literacy leads to better engagement and connection to care providers.

Provider Bulletins

If providers would like their patients to continue PCA/CDPAS services, updated MD orders must be faxed to Molina UM (866-879-4742) at least 30 days prior to authorization ending.  The form (DOH 4359) must be completed in FULL.  A missing CIN or DOB nullifies the form;  incomplete forms are considered unacceptable as per NYS DOH Regs.  Noncompliant orders will lead to your patient losing their aide services and it can take about 4-6 weeks for services to restart. Please review the forms for completeness before faxing to Molina.

 

Did you know that every Molina member receiving these services has an assigned RN Case Manager who speaks to the member every month? Please contact the Monroe Plan triage line at 844-337-7144 to get connected to the assigned Case Manager. S/he can assist you by providing support in submitting the 4359, answering questions regarding the LTSS process or address any concerns about your patient receiving these services.

 

To access the Physician Order Form, click here: Physician’s Order for Personal Care/Consumer Directed Personal Assistance Services (ny.gov)

 

Respectfully,

 

Monroe Plan for Medical Care Provider Network

Effective November 1, 2021, Molina Healthcare of NY (“Molina”) will be using a new vendor to manage its vision benefit for members enrolled in its Medicaid Managed Care, Essential Plan, HARP, and Child Health Plus products. The name of the new vendor is Superior Vision.

Click here to download: Superior Vision – Molina Provider Notice 11/2021

Please download the Coding crosswalk for claims submission for guidance

Click here to download

Effective for dates of service on or after October 15, 2020 note the coding changes required for claims processing as it
relates to PT, OT and ST services rendered to Molina Health Plan members.

Click here to download: PT, OT, ST Coding Changes Notice

This notice tells you about this upcoming change Please read this notice carefully and save it for future reference.

Click here to download: Pharmacy Carve Out Member Letter Notice

You can also access this notice at: health.ny.gov

Effective July 1, 2020, YourCare Health Plan’s Medicaid Managed Care, HARP, Essential Plan, and Child
Health Plus transitioned to Molina Healthcare of New York, Inc. Concurrently, Monroe Plan for Medical Care and affiliated entities entered into an agreement with Molina to provide network management and care management services.

Click here to download: Monroe Plan – Molina Fact Sheet

Monroe Plan Introduces Thrive at Home “Gap Closure” Program 

Our Thrive at Home offers a no cost, additional clinical resource to our IPA providers.

Our Thrive at Home Outreach and Clinical Team will schedule and perform preventative testing and follow up right in the patients home which makes all the difference in reaching difficult-to-engage Medicaid and HARP patients.  

We know that Medicaid and HARP patients often face significant obstacles to getting to the care they need such as limited transportation, childcare, and economic means.  We also know that limited practice resources and time can impact quality of care. The in-home services provided through Thrive at Home can augment your team AND help patients overcome obstacles to accessing care. Most importantly, this program can serve as a gateway to reconnecting the patient with their primary and specialist caregivers! Click here to learn more.

 

Mainstream Medicaid Managed Care Providers are required to ensure the cultural competence of practice staff and to certify annual completion of New York State approved cultural competence training curriculum. The approved training, titled Think Cultural Health, offers several provider specific programs online, at no cost: https://thinkculturalhealth.hhs.gov/education. Providers and appropriate staff should/should have complete(d) this training by October 1st, 2022, and annually thereafter. If you have not shared your certificate of completion, please forward your certificate of completion to:  providerrelations@monroeplan.com.

As Always,

 

Monroe Plan for Medical Care Provider Network Management

 

 

 

TO: Participating Monroe Plan IPA and YourCare IPA Network PT-OT-ST Providers

FROM: Monroe Plan for Medical Care and YourCare IPA Provider Relations Department

DATE: November 15, 2022

SUBJECT: Changes to Prior Authorization Requirements and Billing Codes Available to Bill

Effective November 1, 2022 please find below additional codes and/or prior authorization requirements that will apply to certain therapy services rendered to Molina Healthcare Medicaid Managed Care, HARP, Essential Plan, and Child Health Plus members.

Please note that prior authorization will be required after 12 visits for Physical, Occupational, and Speech Therapy services for the codes listed below. Reimbursement will be made based on your Monroe Plan IPA or Your Care IPA contracted rates and community fee schedules.

The CPT codes referenced above are:
92507 TX SPEECH LANG VOICE COMMJ AND AUDITORY PROC IND
92508 TX SPEECH LANGUAGE VOICE COMMJ AUDITRY 2 OR GRT INDIV
97110 THERAPEUTIC PX 1 OR GRT AREAS EACH 15 MIN EXERCISES
97112 THER PX 1 OR GT AREAS EACH 15 MIN NEUROMUSC REEDUCA
97129 THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES
97130 THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES
97530 THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN
97542 WHEELCHAIR MGMT EA 15 MIN

The Codification Matrix on the Molina Healthcare website has also been updated and posted with the above referenced changes. In addition, this notification will be posted to the Monroe Plan website for future reference.
As always, please do not hesitate to contact us directly at our general Provider Relations e-mail address providerrelations@monroeplan.com with any questions pertaining to this information. You may also contact Molina Healthcare’s Utilization Management Department at 1-877-872-4716 regarding the new prior authorization requirements.

Thank you for all you do for our members and our communities at large.

TO: Participating Monroe Plan IPA and YourCare IPA Network Home Care Providers

FROM: Monroe Plan for Medical Care and YourCare IPA Provider Relations Department

DATE: November 15, 2022

SUBJECT: Changes to Molina Healthcare Home Care Prior Authorization Requirements
Please find below changes in prior authorization requirements for certain procedure codes that will apply to home care services rendered to Molina Healthcare Medicaid Managed Care, HARP, Essential Plan, and Child Health Plus members.

Effective November 1, 2022, prior authorization will be required for home health care services rendered after the first six (6) visits for the following CPT codes:
• S9123 – RN Per Hour
• T1030 – RN Per Diem
• T1031 – LPN Per Diem
• S9131 – PT, Per Diem
• S9128 – ST, Per Diem
• S9129 – OT, Per Diem
• S9122 – HHA, hourly

The Codification Matrix on the Molina Healthcare website has also been updated and posted with the above referenced changes. In addition, this notification will be posted to the Monroe Plan website for future reference.

As always, please do not hesitate to contact us directly at our general Provider Relations e-mail address providerrelations@monroeplan.com with any questions pertaining to this information. You may also contact Molina Healthcare’s Utilization Management Department at 1-877-872-4716 regarding the new prior authorization requirements.

Thank you for all you do for our members and our communities at large.

TO: Participating Monroe Plan IPA and YourCare IPA Network Providers

FROM: Monroe Plan for Medical Care and YourCare IPA Provider Relations Department

DATE: November 15, 2022

SUBJECT: Professional Office Lab Billing and Reimbursement Update When Using Modifiers

This notice is to provide guidance and clarification when billing lab codes using a CPT code and related modifiers for laboratory services provided in a professional office setting. This change will be effective January 1, 2023 and is applicable to any lab services rendered to Molina Healthcare Medicaid Managed Care, HARP, Essential Plan, and Child Health Plus members.

The intent of this change is to mirror NYS Medicaid billing guidelines and provide clarification as to payment rates when modifiers are used by your office for lab services.

Modifier 26 / Professional Component: Lab procedures are a combination of a physician component and a technical component. When the professional component, only, is performed and reported separately, the service may be identified by adding the modifier “26” to the procedure number. Reimbursement will then equate to 40% of the maximum global Community Lab Fee Schedule amount.

Modifier TC / Technical Component: When the technical component, only, is performed and reported separately, the service may be identified by adding the modifier “TC” to the procedure number. Reimbursement will then equate to 60% of the maximum global Community Lab Fee Schedule amount.
If no modifier is included with the laboratory code billed, then the full global fee as reflected in the community-based fee schedule will be reimbursed.

The Monroe Plan and YourCare IPA community-based laboratory fee schedule effective January 1, 2023, which is equivalent to 100% of the prevailing New York State Medicaid Lab fee schedule, will be posted to the Monroe Plan website (www.monroeplan.com) under the IPA and Provider Services tab.
As always, please do not hesitate to contact us directly at our general Provider Relations e-mail address providerrelations@monroeplan.com with any questions pertaining to this information.

Thank you for all you do for our members and our communities at large.

Click here to download the Monroe Plan-YourCare IPA Laboratory 2023 Fee Schedule

Monroe-Plan-YourCare-IPA-Laboratory_Fee_Schedule-Effective-Jan-01-2023

TO: Participating Monroe Plan IPA and YourCare IPA Network Providers

FROM: Monroe Plan for Medical Care and YourCare IPA Provider Relations Department

DATE: December 1, 2022

SUBJECT: New York State Benefit Changes Effective 1/1/2023 for Medicaid Managed Care (MMC), Health and Recovery Plan (HARP), Essential Plan (EP), and Child Health Plus (CHP) Products

In accordance with New York State requirements, this notice is to provide updated member benefit information effective January 1, 2023, regarding the products referenced above as administered by Molina Healthcare of New York Inc.

Please note that some benefits may have limitations and if there are questions as to whether a service is covered or requires Prior Authorization, please reference the Prior Authorization tools located on the Molina website.
For additional information and a chart summary of the specific added benefits and services, please refer to the
attachment to this notice as well as visiting Molina’s website link below at:
https://www.molinahealthcare.com/providers/ny/medicaid/comm/bulletin.aspx
This notice and the updated grid will also be posted to the Monroe Plan website at (www.monroeplan.com) under the IPA and Provider Services tab.

As always, please do not hesitate to contact us directly at our general Provider Relations e-mail address providerrelations@monroeplan.com with any questions pertaining to this information.
Thank you for all you do for our members and our communities at large.

Click here to review benefit changes. 

 

Network Compliance

Cultural Competency Training for Monroe Plan IPA Providers

Mainstream Medicaid Managed Care Providers are required to ensure the cultural competence of practice staff and to certify annual completion of New York State approved cultural competence training curriculum. The approved training, titled Think Cultural Health, offers several provider specific programs online, at no cost: https://thinkculturalhealth.hhs.gov/education. Providers and appropriate staff should complete this training in the next 12 months and annually thereafter. Once finished, please share your certificate of completion with us at providerrelations@monroeplan.com.
Be sure to review the bulletin and resource below to ensure cultural competency and compliance!

Click here to download: NYSDOH Cultural Competency Notice

Click here to download: Are You Culturally Competent?

To be sure your practice is accurately represented in Molina’s (MHNY) Provider Directories, you will want to regularly submit updated rosters to pfmemails@monroeplan.com.

Thank you for your cooperation!

Click here to download

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