Provider Digest | Volume 169

Date: 05/07/25

6 Degrees Health: New Vendor for Prepay Clean Claim Reviews

Trillium Community Health Plan, Health Net Health Plan of Oregon, Inc., Wellcare By Health Net and Wellcare By Trillium Advantage will be transitioning from Optum to 6 Degrees Health for our clean claim reviews. The go-live date is June 1, 2025.

This transition will be seamless for our provider community and reflects our ongoing efforts to make it easier to do business with our health plans. 6 Degrees Health offers providers the ability to submit records via mail, fax or electronically (by email). You will begin seeing record request correspondence from 6 Degrees Heath.

If you have any questions, please contact your assigned health plan Provider Engagement Representative:

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Effective August 6, 2025: Medicaid & Medicare Billing/Coding Edits

Thank you for your continued partnership with Trillium Community Health Plan, Wellcare By Health Net and Wellcare By Trillium Advantage.

As you know, we are committed to continuously evaluating and improving overall Payment Integrity solutions as required by State and Federal governing entities. As a reminder, we have partnered with Optum who is supporting us in performing prepayment claim review. The purpose of our review is to verify the extent and nature of the services rendered for the patient’s condition and that the claim is coded correctly for the services billed.

For claims received on or after August 6, 2025, providers may experience a slight increase in written requests for medical record submission prior to payment based on the areas outlined below. These requests will come from Optum and will contain instructions for providing the documentation. Should the requested documents not be returned, the claim(s) will be denied. Providers will have the ability to dispute findings through Optum directly in the event of a disagreement.

Edit Area: Critical Care Coding Requirements Unlikely to be Met
Description: This review seeks to ensure appropriate critical care billing for illnesses or injuries.
Lines of Business: Medicaid, Medicare

Edit Area: Upcoding of Percutaneous Nephrostolithotomy (PCNL) Procedures
Description: This review of professional and outpatient claims seeks to ensure that documentation supports billing a complex Percutaneous Nephrostolithotomy (PCNL) Procedure.
Lines of Business: Medicaid, Medicare

Thank you for your continued participation and cooperation in our ongoing efforts to render quality health care to our members. We look forward to helping you provide the highest quality of care for our members.

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Effective August 6, 2025: New Medicaid Policy for Newborn Inpatient Stays

Thank you for your continued partnership with Trillium Community Health Plan (Trillium). As you know, we are committed to continuously evaluating and improving overall Payment Integrity solutions as required by State and Federal governing entities. We are writing today to inform you of a new policy that Trillium will be implementing effective on or after August 6, 2025.

Policy Number: CC.PP.075
Policy Name: Newborn Inpatient Stays
Line of Business Impacted: Medicaid
EX Code: EXfz (Retain Pay): Healthy Newborn Claim paid per policy, remit records for reconsideration.
Description: Review claims for coding appropriateness when normal newborn stays with non-NICU revenue codes are billed.

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Health Net Commercial Clinical Policies Update

Effective July 1, 2025, Health Net Health Plan of Oregon, Inc. (Health Net) will be retiring the following Commercial clinical policies. You can find all active Commercial clinical policies on our Policies and Criteria webpage. (Note: After July 1, the below policies will no longer be posted on our website.)

Policy Number & Title: CP.MP.26 Articular Cartilage Defect Repairs
Justification: Policy retired by Centene Corporation 01/2025

Thank you for your partnership in helping our members stay healthy. If you have any questions, please contact your assigned Provider Engagement Representative.

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Reminder: OHA Appointment Access Requirements for Trillium Medicaid Providers

To ensure access to care and improved health outcomes, Trillium Medicaid providers are contractually obligated to comply with the Oregon Health Authority access requirements. Please review the below access requirements and contact your dedicated Provider Engagement Representative if you have any questions.

OHA Appointment Access Requirements

Providers shall make Covered Services available 24 hours a day, seven (7) days a week. For after-hours care, Providers are to have an on-call physician/nurse or a messaging system advising members how to seek after-hours care.

All Providers are required to prioritize timely access for prioritized population members:

Pregnant women
Children ages birth through (5) years

Physical Health (Primary Care and Specialists) Appointment Access Standards

Appointment Type & Access Standard

Emergency: Immediate or referred to an emergency department depending on the member’s condition
Urgent: Within 72 hours or as indicated in initial screening and in accordance with OAR 410-141-3840 (48 hours NCQA)
Well Care (Routine): Within 4 weeks, or as otherwise required by applicable care coordination rules including OAR 410-141-3860- 410-141-3870

Behavioral Health (Non-Specialty/Non-Priority Populations) Appointment Access Standards

Appointment Type & Access Standard

Urgent Care: Within 24 hours
Routine Care: Assessment within seven (7) days of the request, with a second appointment occurring as clinically appropriate.

Specialty Behavioral Health (Priority Populations) Appointment Access Standards

Priority access order for entry per OAR 309-019-0135:

Individuals who are pregnant and using substances intravenously
Individuals who are pregnant
Individuals who are using substances intravenously; and
Individuals or families with dependent children.

* If a timeframe cannot be met due to lack of capacity, the member must be placed on a waitlist and provided interim services within 72 hours of being put on a waitlist. Interim services must be provided.

Appointment Type & Access Standard

Urgent Care: Within 24 hours
Opioid use disorder: Assessment and entry within 72 hours
Medication assisted treatment: As quickly as possible, not to exceed 72 hours for assessment and entry
IV drug users including heroin: Immediate assessment and entry. Admission for treatment in a residential level of care is required within fourteen (14) days of request, or, if interim series are necessary due to capacity restrictions, admission must commence within 120 days from placement on a waitlist
Children with serious emotional disturbance (as defined in OAR 410-141-3500): Any limits that the Authority may specify in the contract or in sub regulatory guidance
Pregnant women, veterans and their families, women with children, unpaid caregivers, families, and children ages birth through five years, individuals with HIV/AIDS or tuberculosis, individuals at the risk of first episode psychosis and the I/DD population: Immediate assessment and entry. If interim services are necessary due to capacity restrictions, treatment at appropriate level of care must commence within 120 days from placement on a waitlist

* For additional information, see OAR 410-141-3840, OAR 410-141-3860, OAR 410-141-3870, and OAR 309-019-0135.

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