Get the latest clinical, policy, and quality updates
PROVIDER SEPTEMBER NEWS
Partnering with You for Faster Prior Authorization Processing
At Devoted, we prioritize exceptional service for our providers so you can focus on patient care. Here are some tips for efficient prior authorization (PA) processing:
Submit through the Provider Portal: The fastest way to submit a PA request is online, allowing immediate processing.
Check PA Requirements: Confirm if a service requires PA with just a few clicks in the Provider Portal to save valuable time.
Include Complete Documentation: Submitting full clinical documentation helps us process requests without delays. Helpful documents include:
Office visit notes
Imaging/lab reports
History and physical
Consult notes
Progress notes (PT/OT/ST)
Medication lists
Discharge summaries
Psychosocial consult notes
Our goal is to streamline the prior authorization process to enhance the quality of care for our patients. Bookmark ourUtilization Management Quick Reference Guidefor future reference.
Stay up-to-date with Devoted Health's latest payment policies and be sure to review regularly on our website. Policies going into effect on 1/1/26 will be posted by 12/1/25. The latest updates are listed below:
Inpatient Readmissions(update) - Outlines Devoted’s policy on inpatient readmissions, including a sample set of scenarios and the how policy would apply.
Vision Services & Ophthalmologic Services (update) - Defines Devoted’s coverage policy for vision services, clarifying the distinction between routine vision care and medically necessary ophthalmologic services.
Compliance and Fraud Prevention
The healthcare industry is witnessing a recent trend related to fraud, waste, and abuse (FWA). Reports indicate that non-contracted durable medical equipment (DME) providers are attempting to order and submit claims for unnecessary supplies, such as braces and orthotics, wound dressings, and catheters. We encourage all providers to stay vigilant and to familiarize themselves with this emerging issue. If you receive any member inquiries related to this scheme, please report your concerns to Devoted's Special Investigations Unit (SIU) at SIU@devoted.com.
Fax Fraud Alert
The Centers for Medicare & Medicaid Services (CMS) has issued an alert to bring awareness to a phishing scheme involving fraudulent fax requests for patient records.These deceptive faxes may appear to be legitimate, sometimes using CMS or National Archives and Records Administration (NARA) headers, and often demand all patient information and medical records for Medicare patients within a 72-hour deadline. These requests are fraudulent.
If you receive such a request:
Do NOT comply with the request
Report it to Devoted's Special Investigations Unit at SIU@Devoted.com and include a copy of the request you received
Your vigilance is crucial in protecting patient information and preventing fraud. Please review the official CMS alertfor full details.
Key Guidelines on Billing Practices
As a reminder, in accordance with CMS regulations and provider agreements, Devoted Health members only have to pay our plan’s cost-sharing amounts when they get services covered by our plan. We do not allow providers to “balance bill” or otherwise charge members more than the amount of cost-sharing their plan says they must pay, this includes billing members for services where payment from Devoted Health has not been obtained, such as due to claim cleanliness issues, other billing issues, or for failing to coordinate benefits, for example.
For Members with Medicaid, the provider is to obtain a copy of the member’s Medicaid card to bill Medicaid after receiving the Remittance Advice from Devoted Health. No cost shares (copayments, coinsurance, or deductibles) are to be collected or billed at the time of the visit from a member with Medicaid coverage.
As a reminder, you may only bill members directly for denials or adjustments that have a Patient Responsibility (PR) Claim Adjustment Group Code. In certain situations, a member may be responsible for paying for a healthcare service we don’t cover. This is limited to situations where either your office or our team can prove that the member was notified before they received a specific service that the service wasn’t covered by us, or that the service would only be covered if the member received a referral.
If you’re not sure if a service is covered, please check with us before you deliver that service. If you’re not sure if a member has Medicaid, or their level of Medicaid coverage, you can use our Medicaid eligibility check function in Availity.
New Stars Gap Reporting
Update to Stars “PCP Visit” Gap Reporting
What is Changing?
We are sunsetting the quarterly CAHPS Scorecards and Panel Lists to integrate our provider CAHPS asks with all other Stars gaps in our Stars Actionable Gap Report
In replacement of the CAHPS Scorecards and Panel Lists for member outreach, the Stars Actionable Gap Report will now include a PCP Visit Gap, with accompanying action-details on high ED utilizers, new members, and more!
These gaps will be based on real-time data, meaning gaps will be removed as claims are received and refreshed every 24-48 hours
When?
Live! Currently available in Provider Portal and through SFTP on the Stars Actionable Gap Report (as of August 1, 2025)
Risk Adjustment Documentation
To maintain the integrity of our members’ health data reporting to CMS, our Program Integrity team conducts risk adjustment internal audits throughout the year. These include various sampling methodologies, such as targeted audits of diagnoses at high risk for being miscoded such as stroke, acute myocardial infarction, embolism, thromboembolism, and cancer in alignment with methodologies published by the US DHHS Office of Inspector General.¹
To ensure documentation accuracy and to paint the true clinical picture of your patients, make sure you:
Report all conditions that are confirmed, active, and managed during each encounter with a treatment plan for each condition
Document acute conditions as historical once resolved
Note acuity of high risk diagnoses. When conditions can be both acute or chronic, like embolism and DVT, it is important to note the acuity
Check out the Resources section in Devoted's payer space in Availity to access our Documentation Tip Sheets including our Tip Sheet on Common Documentation and Coding Errors.
¹ TOOLKIT To Help Decrease Improper Payments in Medicare Advantage Through the Identification of High-Risk Diagnosis Codes. December 2023 | A-07-23-01213. DHHS OIG.
Reminders
Update your provider data
Review your National Provider Identifier (NPI) data in the National Plan & Provider Enumeration System (NPPES) as soon as possible to make sure it’s accurate.
Blood glucose test strip supplies
Accu-Chek testing supplies will be covered starting August 1 for members. Members can keep using the testing supplies currently in use.
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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