Kentucky New Horizon
Throughout the year, we publish New Horizon, our newsletter for providers with patients with coverage through Humana Healthy Horizons® in Kentucky. We post content from the current issue below and also link to content from previous issues.
The November 2022 edition includes articles about:
- The grievance and appeals submission window
- Use updated anesthesia codes for your claims billing process
- The reinstatement of substance use disorder (SUD) prior authorization requests
- Benefit limits for urine drug testing
- Provider relations team expansion
- Improving asthma care and reducing costs
- Tobacco-cessation program for our enrollees 12 and older
- Screening your patients for depression
- Providing timely follow-up after hospital discharge for your patients with substance use disorder
- Medical record reviews
- Earning continuing education credits through Relias
- Front-end Availity Essentials edits for incoming claims data
- Simplify doing business with Humana
Download the current edition of New Horizon
Humana Healthy Horizons updates submission timelines for grievances and appeals
Humana Healthy Horizons® in Kentucky recently updated its policy to provide more consistent time frames for healthcare providers to submit grievances and appeals, as well as comply with KRS 205.534 (1)(d). Effective Nov. 1, 2022, healthcare providers have 60 days from Humana Healthy Horizons’ date of notice action or date of original claim submission denial to file a grievance or appeal. For more information, healthcare providers can view this notification, PDF.
Use updated codes for your anesthesia claim billing process
As of July 1, 2022, all fee-for-service anesthesia claims require the use of selected anesthesiologist and certified registered nurse anesthetist (CRNA) modifiers, per Kentucky Department for Medicaid Services (Kentucky DMS) guidance on anesthesia modifier billing. Anesthesia claims require the use of one of these modifiers, PDF.
Humana Healthy Horizons announces a reinstatement of SUD prior authorization requests
As of July 1, 2022, Humana Healthy Horizons reinstated prior authorization requirements for SUD inpatient and residential services. This update follows Kentucky DMS guidance issued in May 2022. To learn more about SUD prior authorization submission guidelines, please consult this network notification, PDF.
Understand benefit limits for urine drug testing for better treatment
Urine drug testing (UDT) claims for payment are processed by Humana Healthy Horizons as indicated by Kentucky DMS policy, per the healthcare provider’s contract with Humana and/or the Humana out-of-network payment policy. Once the enrollee exceeds the benefit limit, as established by Kentucky DMS, Humana denies the claim. The healthcare provider, however, may appeal the claim denial.
Humana Healthy Horizons recommends healthcare providers submit medical records as supporting documentation to prove the medical necessity for the service with the appeal request. Also, claims paid for UDT services that exceed the enrollees’ benefit are reviewed for recovery. Similarly, Humana Healthy Horizons recommends healthcare providers submit medical records as supporting documentation to prove the medical necessity for the service when disputing an overpayment recovery. (Please note: effective Nov. 1, 2022, the grievance and appeals window changes to 60 days, as described earlier in this newsletter.)
To learn more about the UDT policy, please view the notice, PDF
Humana Healthy Horizons expands its provider relations team to better serve providers
The Humana Healthy Horizons in Kentucky provider relations team welcomes new representatives. Find yours here, PDF. Should you have questions regarding this list, email us at KYMCDPR@humana.com.
Small actions can improve asthma care and reduce costs
Significant asthma-related costs, such as emergency room visits and hospitalizations, are preventable by implementing appropriate ratios of long-term controller medications and quick-reliever medications. Long-term controller medications promote control of persistent asthma, while quick-reliever medications treat acute exacerbations.
The Asthma Medication Ratio (AMR) Healthcare Effectiveness Data and Information Set (HEDIS®)1 measure identifies enrollees ages 5-64 with persistent asthma and a ratio of controller medications to total asthma medications of 0.50 or greater during the measurement year.
Healthcare provider actions that improve asthma care include:
- Educate patients on the importance of long-term controller medications to manage the disease.
- Schedule follow-up appointments with patients.
- Ensure proper coding is used for the patient’s condition and medications.
- Consider 90-day prescriptions with refills.
- Refer patients to care management for care coordination.
Tobacco cessation program can help enrollees as young as 12
Smoking is the leading cause of preventable death in the U.S. We are here to help your patients break the cycle of nicotine addiction and provide the support they need for a healthier life.
It is rewarding for enrollees, too. They can earn up to $50 in rewards for completion of the tobacco cessation program. The program basics:
Eligibility: Enrollees ages 12 and older
Coaching: Up to 8 health coaching/cessation support calls within 12 months of the first coaching session. For enrollees 18 and older, nicotine replacement therapy is available on request.
Enrollment: Access the Go365 Humana Healthy Horizons® app or call 877-264-2550 (TTY: 711) to learn more and sign up. Enrollees can visit Humana.com/KentuckyQuits to learn more.
Screenings can help assess patients at risk for depression
The American Psychiatric Association estimates that 1 in 6 people will experience depression sometime in their life.2 Women are twice as likely to become depressed as men. Depression can affect anyone, from teens to seniors.
Diagnostic screenings enable physicians to assess patients for early signs of depression. Humana Healthy Horizons has tools and resources you and your practice can use to screen for depression. To begin, visit the depression screening resources page.
Healthcare providers also help by ensuring their patients are educated on and referred to community or external resources for support, including:
Support SUD patients with timely follow-up after hospital discharge
Discharge from a hospital is a critical transition point in a patient’s care. Poor care coordination at discharge can lead to adverse events for patients and avoidable readmission, especially during the first 30 days after discharge.
Patients with behavioral health and SUD diagnoses also are especially vulnerable during transitions of care. Research suggests that for people with serious mental illness, low-intensity interventions, such as appointment reminders, can be effective following an emergency hospital visit in encouraging follow-up care in the outpatient setting.3
Healthcare providers can improve coordination of care and follow-up after discharge by:
Referring a patient to the Humana case management team, as appropriate, by emailing KYMCDCaseManagement@humana.com.
- Discussing with patients the importance of follow-up care and conducting medication reconciliation to ensure patient understanding
- Assessing and referring a patient with social determinants of health issues
- Coordinating care between healthcare providers and case management
- Reaching out to patients who cancel appointments to reschedule them as soon as possible
- Confirming patient contact information is correct and updated
Medical record reviews help highlight strengths and identify areas for opportunity
Medical record documentation reviews are performed by the Humana Healthy Horizons quality improvement team as part of regulatory requirements and can provide insights into healthcare provider strengths as well as areas of opportunity.
Here are some best practices for documentation of targeted case management (TCM) services, based on Kentucky administrative regulations:
- TCM comprehensive assessment, updated annually to include a complete narrative of the enrollee’s history, a review/list of enrollee strengths, and information gathered from other sources
- TCM care plan, with goals specific to needs reported by the enrollee from the comprehensive assessment and updated when additional needs are identified, with a course of action to address them
- TCM service contact notes completed and signed within 48 hours of service date
- Quarterly monitoring must be completed every 90 days with enrollee or enrollee’s representative to review and update the care plan and ensure the program is meeting the enrollee’s needs. Quarterly monitoring documentation should also include enrollee strengths.
The above guidelines are not a complete list of documentation elements. For the full list of TCM regulations, please visit Kentucky Administrative Regulations - Legislative Research Commission.
Healthcare providers can schedule a feedback session with the behavioral health quality improvement (BH QI) team to obtain further insight into TCM documentation requirements. Contact our BH QI team at KYQIMedicaid@humana.com.
Earn continuing education credits with access to Relias
Humana Healthy Horizons healthcare providers have access to Relias, a web-based library where they can explore topics such as addiction, behavioral health, integrated care and mental health. These behavioral health-focused training modules provide information to support comprehensive care and address unique enrollee needs. The extensive Relias library includes courses designed to help healthcare providers succeed in the emerging value-based healthcare delivery system.
Healthcare providers can also earn continuing education credits by completing the courses. To get started, access Relias at Humana.com/KYTraining.
Front-end Availity Essentials edits added to improve incoming claims data
Availity Essentials added front-end claim edits to improve the accuracy and completeness of incoming electronic claims data. These edits also reduce the likelihood of claim denials within our claims platform and the turnaround time associated with the remittances.
These new claim edits follow guidelines set by Kentucky DMS, specific to behavioral health, non-behavioral health and National Provider Identifier (NPI) billing requirements.
These edits generate specific messages on why the electronic claim was rejected and help healthcare providers correct the error(s) for resubmission.
The following claim activity edits in Availity Essentials are either already implemented or will be implemented before the end of 2022:
- Assertive community treatment
- Billing limitation for provider type 54
- Certified community behavioral health clinic
- Coordination of Benefits (COB) qualifier requirements for enrollees with Medicare coverage
- Crisis intervention mental health services
- Mobile crisis services
- Catastrophe/disaster-related (CR) modifier requirements
- Multisystemic therapy for juveniles
- Narcotics treatment program
- NPI validation for billing, rendering, attending, referring and ordering providers
- Point of service 99 allowances
- Provider type validation for referring, ordering and attending NPIs
- Rendering provider requirements tied to billing provider groups
- Substance use disorder
- Targeted case management
- Taxonomy confirmation for billing, rendering and attending providers
- Transcranial magnetic stimulation
- Urinary drug testing
Healthcare providers can access KDMS claim billing guidelines here.
For more information on these edits, visit Humana.com/KYNotices. If you have questions, call provider services at 800-444-9137 (TTY: 711), Monday – Friday, 7 a.m. – 7 p.m., Eastern time.
Use Making It Easier presentations to simplify doing business with Humana
“Making It Easier for Physicians and Other Healthcare Providers” is a series of educational presentations about Humana claims payment policies and processes.
Download the Tools and Resources for Physicians and Other Healthcare Providers Resource Guide, PDF to learn about Humana’s inventory of useful tools and resources, which can simplify your claims-related and other interactions with Humana.
Visit Humana.com/MakingItEasier today, or Availity.com, in the Humana Payer Space under the Resources tab.
Look for the STAY CONNECTED widget on Humana.com/MakingItEasier and subscribe to be notified when new content is added.
Kentucky New Horizon Archive
Access previous editions of New Horizon
Previous editions of the Kentucky New Horizon provider newsletter
1HEDIS Measurement Year 2022, Volume 1. HEDIS measures monitor for metabolic syndrome in mental health patients with a variety of disorders. HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
2“What Is Depression?” American Psychiatric Association, last accessed Nov. 9, 2020, https://www.psychiatry.org/patients-families/depression/what-is-depression.
3HEDIS Measurement Year 2022 Volume 1, www.ncqa.org/hedis/measures/