PROVIDER JUNE NEWS

NEW Utilization Management guide

Need help navigating prior authorizations? Our new Utilization Management (UM) guide makes it easier to understand our utilization management process and how we partner with you to ensure the best care for members.

Review our policies

Payment policies: Stay in the know

UPDATED
Off-Campus Outpatient Clinic Services

Provides updated guidance on the use of Modifier PN for off-campus outpatient clinic services.

NEW
Provider Terminations and the Q6 Modifier

Outlines requirements for appropriate billing using the Q6 modifier when a provider

terminates from a practice.

Top policies to keep your team aligned

Whether you're new to Devoted or simply revisiting the basics, we’re spotlighting important policies to help keep your team aligned and informed:

• • Vision Services: Coverage for ophthalmological care related to diagnosis  and treatment of the eyes.
• • Sepsis DRG: Clinical criteria used when determining the medical necessity of sepsis-related treatment.
• • RHC Billing: Reimburse services provided at Rural Health Clinics.
• • Primary Care Services: Guidelines and care information delivered by a PCP.
• • Organ Transplants: Coverage and billing requirements for Medicare-covered organ transplants.
• • FQHC Billing: Coverage and billing requirements for services provided by Federally Qualified Health Centers.
• • Ambulatory Surgical Center: Guidelines for coverage and payment services at Ambulatory Surgical Centers.

For a complete list of our policies, visit our payment policies page.

Inside Devoted’s Special Investigations Unit (SIU)

The Devoted Special Investigations Unit plays an important role in maintaining the integrity of the Medicare Advantage program. Through proactive fraud, waste, and abuse detection and prevention, the SIU helps ensure that our members receive high-quality, responsible care.

Here’s how the SIU supports our shared mission:

1. 1. Fraud detection: We utilize advanced data analytics to identify unusual billing patterns.
2. 2. Investigation: Upon detecting potential fraud, we conduct thorough investigations, which may include claim and medical record reviews.
3. 3. Education: We provide training and resources to help providers understand compliance issues and avoid unintentional errors.
4. 4. Collaboration: The SIU works closely with compliance, legal, and network teams, as well as federal and state agencies to enhance fraud prevention efforts.
5. 5. Reporting: We document findings and report confirmed fraud cases to relevant authorities when warranted.
6. 6. Continuous improvement: The SIU adapts its strategies based on emerging trends to effectively combat potential fraud threats.

Together, we can ensure our Medicare Advantage program remains ethical, secure, and member focused. Thank you for supporting the important work of the SIU.

Risk adjustment best practices for dementia

June is Alzheimer’s and Brain Health Awareness month. Dementia is a group of brain disorders that cause deterioration of cognitive abilities, slowly affecting memory, thinking, and the ability to manage everyday tasks. Alzheimer’s disease is the most common type, followed by vascular dementia — often linked to conditions like hypertension, heart disease, and stroke.

• • Risk factors that increase the likelihood of developing dementia include, but are not limited to: age, hypertension, diabetes, obesity, smoking, depression, and social isolation.
• • Signs and symptoms can include forgetfulness, misplacing things, confusion, losing track of time, difficulty with problem solving and word finding, and getting lost when walking or driving. Many patients with dementia can have mood and behavior changes as well.

When documenting dementia, include the underlying cause (e.g., Alzheimer’s, vascular, Parkinson’s), the severity (mild, moderate, or severe), and any associated mood or behavioral symptoms, such as agitation, anxiety, or depression.

Health Outcomes Survey administration

Centers for Medicare & Medicaid Services (CMS) will administer the Health Outcomes Survey (HOS) from July through November to a random sample of Medicare Advantage members. The survey measures changes in members’ physical and mental health over time and impacts Star ratings.

You can help by reviewing our Improving healthcare quality resources and talking to your patients about physical activity and ways to stay active; walking and balance issues, including falls; mental health awareness; and bladder control issues.

New medication prior authorization rules coming

Effective June 1, 2025, members aged 70 or older who are newly prescribed the medications listed below will require prior authorization. Members who are

already taking these medications will not require prior authorization.

✔ Amitriptyline tablets
✔ Doxepin capsules, solution
✔ Imipramine tablets

For the complete 2025 formulary, please refer to the Search Our Drug List pharmacy page on our website at devoted.com/search-drugs/. 

Prior authorization requests can be submitted electronically by completing an online coverage determination form, available on devoted.com/providers, or faxing the coverage determination form to 1-855-633-7673.

New 2025 Star ratings measure: Polypharmacy

CMS has added 2 new quality measures to Medicare Part D Star Ratings this year.

View our new Stars Polypharmacy Detail Report to see claims-level detail on your patients' relevant prescriptions. This report is available where you download provider reporting (Devoted Health provider portal and/or SFTP).

These measures focus on the safe and effective use of medications. We have several guides to assist healthcare providers in making informed prescribing decisions:

• • Muscle relaxers and their risks for elderly patients
• • Tapering benzodiazepines
• • Antimuscarinics and risk in older adults
  
  

Clinical tips when considering a prescription for anticholinergic medication

• •Does the medication provide benefits that outweigh the risks?
• • Can I treat this condition with nonpharmacologic therapies or a safer medication?
• •Monitor for the onset of adverse effects. Anticholinergic side effects include: dry mouth, blurred vision, constipation, urinary retention, confusion, disorientation, and dizziness.

Step therapy requirements for ophthalmic anti-VEGF treatments

In January 2025, we temporarily suspended step therapy prior authorization requirements for certain ophthalmic anti-VEGF treatments in response to national supply concerns for repackaged bevacizumab (Avastin). We are grateful for your partnership in helping to ensure continued access to care during that time.

Effective May 1, 2025, our standard step therapy requirements for ophthalmic anti-VEGF treatments were reinstated. This update reflects stabilization in the Avastin supply and a return to normal availability. For more information, visit our Part B Step Therapy List.

Get up to speed on statins

Our new Statin Stat Sheet includes up-to-date guidelines, dosing info, and tips to help you prescribe with confidence.
Get your guide now

SNP MOC Training Reminder

The Centers for Medicare & Medicaid Services (CMS) requires that all contracted providers who provide services to our SNP members receive the Model of Care training annually. We kindly ask that your organization review our 2025 Model of Care and ensure that the training is shared with all providers responsible for delivering care to SNP members throughout the year. Have questions about our SNP plans? Our FAQ Flyer has you covered.

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