Connection supplemental articles and policies - May 2009

Download the print version

Connection - May 2009 (pdf, 82 KB)

Supplemental articles

• Health reimbursement arrangements and UltraBenefits
• FCHP fee schedule updates
• Formulary update – Commercial plan and Medicare Part D
  

Payment policies

The following policies are new:

• Gastroenterology Payment Policy
• Human Leukocyte Antigen Testing Payment Policy

The following policies have been reviewed. Changes are indicated on the policies and summarized in the print version of Connection:

• Ambulatory Surgery – Facility Payment Policy
• Emergency Department Payment Policy
• Inpatient Medical Review and Payment Policy
• Maximum Units Payment Policy
• Medical Nutrition Therapy Payment Policy
• Non-covered Services Payment Policy
• Observation Status Payment Policy
• Unlisted Surgical Procedures and Services for Facilities Payment Policy
• Vaccine Payment Policy

Health reimbursement arrangements and UltraBenefits

Fallon Community Health Plan has partnered with our wholly owned subsidiary, UltraBenefits, Inc., to provide a new opportunity to our employers: An integrated Health Reimbursement Arrangement (HRA) compatible with any FCHP plan design option.

An HRA is a tax-advantaged plan that allows employers to fund an account for employees that can reimburse certain eligible expenses on a tax-free basis, as defined by sections 105 and 213 of the Internal Revenue Code (IRC). Combined with a high-deductible health plan, HRAs can save employers significant money on their employee benefit plans. The account is employer owned. They fund the account and determine what expenses the account will cover.

Eligible claims under the HRA plan are automatically sent to UltraBenefits and payments are sent directly to the provider. This integration allows for timely payment and is fully funded by the employer, eliminating the member from the process.

If you have a question on this new arrangement, please contact Provider Relations at 1-866-ASK-FCHP, prompt 4.

FCHP fee schedule updates

Update to FCHP Auxiliary Fee Schedule
 Effective July 1, the following codes will be added to the FCHP Auxiliary Fee Schedule:
      99441 - $35.00
      99442 - $35.00
      99443 - $35.00
      36415 - $3.00
      36416 - $3.00
 Effective July 1, the following codes will have a new rate assignment:
      90471 - $23.00
      90472 - $11.00
      90473 - $15.00
      90474 - $10.00
The rates listed above reflect the 100% fee-schedule rate. To obtain provider-specific rates, you must adjust the rates according to your provider contract.  

Update to FCHP Auxiliary Laboratory Fee Schedule
Effective July 1, the following code will be added to the FCHP Auxiliary Laboratory Fee Schedule:
   36415 - $3.00
This rate reflects the 100% fee-schedule rate. To obtain provider-specific rates, you must adjust the rates according to your provider contract.

If you have any questions about these fee schedule changes, please feel free to contact your FCHP Contract Manager.

Formulary updates

Fallon Community Health Plan often makes changes to its formularies, including changing prior authorization requirements and adding new medications. Please note the following changes to our commercial plan and Medicare Part D formularies.

Commercial plan formulary

Additions

New to Market Policy*
Acanya (clindamycin/benzoyl peroxide)
Afinitor (everolimus)
Aplenzin (bupropion HBr)
Kapidex (dexlansoprazole)
Prilosec Powder Packets (omeprazole)
Rapaflo (silodosin)
Sumaxin (sulfacetamide/sulfur pads)
Toviaz (fesoterodine)
Triaz Cloths (benzoyl peroxide 6%)
Uloric (febuxostat)
Uramaxin (urea nail gel)
Uramxin (urea cream 45%)
Vectical (calcitriol ointment)
Vimpat (lacosamide)

* FCHP’s New to Market Policy was enacted to ensure patient safety and to allow for adequate time for the development, review and approval of clinical criteria. When a new medication first becomes available, it will fall under this policy and be excluded from coverage. A process is in place that allows for the quick review of provider requests for non-covered pharmaceuticals.

Medicare Part D formulary