News and Highlights

2016 HEDIS Documentation and Coding Guidelines (PDF)

Group Health's quick reference guide of common HEDIS measures includes newly issued statin measures for patients with cardiovascular disease and diabetes.

Pharmacy News: April 2016 (PDF)

Information about drugs empagliflozin, zetia and PCSK9 inhibitors, antibiotics for acute otitis media in children, and proton pump inhibitors.

Drug Screenings Payment Policy Removed

The CPT coding listed in the policy is no longer valid.

Modifiers Payment Policy (PDF)

See updated information on the P3, P4, and P5 modifiers. These do not impact reimbursement.

Injectable Drugs Requiring Prior Authorization

Non-Medicare Drug List updated April 1.

Formulary Decision Highlights: March 2016 (PDF)

Highlights from the March 9 meeting.

Omni PPO Plans

See what's offered, which services require preauthorization, and get information about claims submissions.

Post-Operative Orthopedic Surgery Therapy Protocols

Standardized protocols for therapy care after surgery.

March Clinical Tips

See Clinical Pearls — recommendations you can integrate into your daily practice.

Provider E-News

See monthly clinical practice and business updates.

Changes to Medical Necessity Review Criteria for Gynecomastia (PDF)

Effective May 15, Group Health is adopting MCG care guidelines for gynecomastia.

Provider Update: March 2016 (PDF)

HEDIS medical record review season, updated guidelines, and more.

New Payment Policy: CAD for Mammography (PDF)

Group Health does not separately reimburse CAD for mammography services for all commercial members.

Review Services Updates: February 2016 (PDF)

Criteria updates, approved and non-approved technology.

HEDIS® Medical Record Review Season: February - May 2016

Get information and see FAQs about the HEDIS medical record review.

New Group Health Payment Policies

Updated policies for Access and OMNI PPO Plans Out-Of-Network Reimbursement, and Pharmacist Reimbursement.

Annual NCQA Notification

Updates to our guidelines, services, provider manual, and other important information.

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