Short Takes: Inpatient Admissions, HEDIS Changes, and Hemophilia Drug Program

Inpatient Admissions: Reconsideration Requests for “No Clinical Information” Denials

Facility providers should submit a reconsideration request for denied admissions for Commercial inpatient medical care due to a lack of clinical information on the original authorization submission. NOTE: Reconsideration requests only apply to Commercial lines of business. To read the Special Bulletin, click here.

HEDIS Changes in 2024: Diabetes, Cervical and Colorectal Cancer Screenings

The 2024 Healthcare Effectiveness Data and Information Set (HEDIS®) includes changes to the following measurements:

  1. Diabetes
  2. Cervical Cancer Screening
  3. Colorectal Cancer Screening

To learn more about the changes, click here.

Hemophilia and Bleeding Disorder Drug Program: New Pharmacy and Drugs Added

Effective March 1, 2024, Alliance Rx Walgreens Pharmacy is being added as an exclusive specialty pharmacy for members in Highmark’s Hemophilia and Bleeding Disorder Drug Program. The other two pharmacies in the program are Soleo Health and the Hemophilia Treatment Center of Western Pennsylvania. Option Care Health will no longer be participating in the program effective March 1, 2024.

In addition, the following three drugs will be available through the program on March 1, 2024:

  • J7199 - Altuviiio
  • J7204 - Esperoct
  • J7212 – Sevenfact

To learn more, click here.

Medical Policy S-123 Published on Jan. 22, 2024

The publication of Medical Policy (MP) S-123 Lung and Lobar Lung Transplant was delayed. Originally scheduled for Jan. 15, 2024, the policy was published on Jan. 22, 2024. To view MP S-123, go to the Provider Resource Center. On the top task bar, click the drop-down arrow for MEDICAL POLICY SEARCH, select MEDICAL POLICIES, and then type “S-123” into the search bar.