Pay BillSCOPE | Provider Update
May 2025
Clinical Matters
How physicians and providers can help manage their patients' hypertension
Wellness visits and physician support will help address this silent cause of death.
According to the Centers for Disease Control (CDC), approximately 108 million adults in the U.S. have hypertension and only about one in four have their condition under control.
Hypertension is known as a silent killer because individuals who have it often do not experience symptoms, and it may therefore go undetected. Hypertension can lead to heart disease or stroke, the first and fifth leading causes of death in the U.S., respectively. It can also lead to chronic heart failure and kidney failure. Hypertension contributes to more than 1,100 deaths per day and costs the nation $53 billion each year in direct medical expenses and lost productivity from premature death.
Hypertension disproportionately affects those with low income, those covered by public insurance, and those with no insurance. High blood pressure increases risk of:
- first heart attack
- first stroke
- chronic heart failure
- kidney disease.
Americans are more likely to develop high blood pressure, and at an earlier age and with greater severity. Many people with hypertension have comorbidities. About 60% of people with diabetes have hypertension. Physicians play an integral role in preventing, managing, and treating hypertension. To help patients manage their hypertension, it is essential they have their annual wellness screenings and blood pressure checks.
There is a HEDIS/Medicare STAR Measure regarding hypertension: Controlling Blood Pressure (CBP). The CBP measure includes members 18 to 85 years of age with a diagnosis of hypertension whose blood pressure (BP) was adequately controlled at less than 140/90 mm Hg.
For additional informatIon on the CBP measure, visit our HEDIS Reference Manual in the provider portal, under the Policies & Guidelines tab.
For resources on managing hypertension, view the CDC Hypertension toolkit.
USPSTF Updates Osteoporosis Screening Recommendations
The USPSTF recommendation notes that screening can include DXA BMD, with or without fracture risk assessment.
More than 50 million people in the U.S. live with osteoporosis, and most don't even know they have this condition until osteoporosis causes a broken bone. Osteoporosis is most common in people over the age of 50. Experts estimate that half of all females and 1 in 4 males have osteoporosis.
Screening for osteoporosis
The 2025 recommendation updates the 2018 USPSTF recommendation on screening for osteoporosis. In 2018, the USPSTF recommended screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in women 65 years or older and in postmenopausal women younger than 65 years who are at increased risk of osteoporosis, as determined by a formal clinical risk assessment tool. For the new recommendation, the USPSTF notes that screening can include DXA BMD, with or without fracture risk assessment. Other than that change, the rest of the new recommendation is generally consistent with the previous version.
Managing osteoporosis for women who had a fracture
The Medicare STAR measure of Osteoporosis Management in Women who had a fracture (OMW) focuses on females 67 to 85 years of age who suffered a fracture and had either a bone mineral density test (BMD) or a prescription for a drug to treat osteoporosis in the six months after the fracture. The time period of fracture claims covers July 1,2024 through June 30, 2025, with gap closure dates through December 31, 2025. Fractures to the finger, toe, face, and skull are not included in this measure. To close the gap for this measure, patients should:
- Complete a bone density scan within six months of the fracture date, or in the 24 months prior to the fracture date.
- Fulfill a prescription for osteoporosis.
- Complete an osteoporosis treatment (e.g., injection).
To assist with closing the OMW measure, an Independent Health Case Manager contacts members monthly to discuss the individual’s fracture, provide education on fractures and falls prevention, and discuss options for gap closure. The Case Manager will discuss the option of an in-home heel ultrasound with a local provider group, Stall Senior Medical (SSM). If the member is interested, the Case Manager will ask for consent for the member to be contacted by the SSM team and then SSM will call the member to schedule the appointment.
All results will be sent to the member’s Primary Care Physician (PCP) for follow-up. The Case Manager will also discuss other options for gap closure, depending on the member’s preference, and refer to the member’s PCP. Each call will be individualized based on the member’s needs.
Routine screening, treatment, and falls prevention education can help diagnose osteoporosis, and prevent future falls and fractures. Be sure to speak with your patients about the importance of screenings, and treatment options after a fracture.
Sources and References:
Osteoporosis, Cleveland Clinic, July 2020.
USPSTF 2025 Osteoporosis Recommendation
Independent Health's Bone Mass Measurements policy is posted in the secure portal.
May is Mental Health Awareness Month: resources available to members
Oftentimes patients may not know where to access care; we have online resources that can help.
In support of Mental Health Awareness Month, Independent Health is reminding our members that they have access to a comprehensive network of mental and behavioral health specialists, therapists, counselors and facilities.
It’s common for an individual to seek the help of their primary care physician for their mental health needs, so we have posted details on our website about mental health and substance use resources that are available through Independent Health as well as in Western New York.
In addition, Independent Health members who would like assistance from a behavioral health expert may use our Find A Provider feature.
Office Matters
Annual phone survey about NYS standards for appointment access and availability coming soon
Surveyors from SPH Analytics will call various practices to evaluate whether their appointment availability times comply with our Appointment Accessibility and After Hours Access policy.
To ensure compliance with standards established by New York State for our participating providers, Independent Health has engaged with the firm SPH Analytics to conduct brief surveys by phone regarding appointment access and availability for our members.
Over the next several weeks your office may receive a phone call from a surveyor from SPH Analytics to ask questions pertaining to your practice’s appointment availability times for both routine and after-hours care as outlined in our Appointment Accessibility and After Hours Access policy.
We have revised the policy to clarify that requiring previous medical records or requesting that the patient complete a health form should not be prerequisite for scheduling an appointment.
This survey will be directed to specific types of providers, including primary care, medical oncologists, OB/GYNs, clinical neuropsychologists, psychiatrists, psychologists, and certified social workers.
As an example, a surveyor identifying themselves as from SPH Analytics would call a primary care office to discuss the scenario of a patient who calls to ask for the timeframe to schedule an appointment. Each discussion with an SPH Analytics surveyor is recorded and shared with Independent Health.
All scenarios presented are based on the following types of care:
- Emergent
- Urgent
- Sick visits (routine non-urgent/emergent)
- Routine, non-urgent or preventive care
- Adult baseline and routine physicals
Please make your staff aware of this possible call to your practice so your staff may respond appropriately.
Independent Health's Appointment Accessibility and After-Hours Access policy is posted in the secure portal under policies.
Thank you for your efforts to help us adhere to the New York standards for appointment access and availability. If you have questions, please contact our Provider Relations Department at (716) 631-3282 or 1-800-736-5771, Monday through Friday from 8 a.m. to 5 p.m.
Preauthorization requirement changes for Joint Reconstruction, Replacement, & Revision
Independent Health is discontinuing the preauthorization requirements for certain orthopedic surgeries effective June 1, 2025, for the Medicare line of business.
Independent Health is discontinuing the preauthorization requirements for the following surgeries effective June 1, 2025, for the Medicare line of business.
However, these codes will continue to require preauthorization for Commercial, State Programs and Self-funded lines of business. Independent Health uses Milliman Care Guidelines (MCG) for these services. Independent Health will deny claims and related charges to provider liability for lack of pre-authorization/ notification. Independent Health members must not be held responsible for the cost of these denied services.
The surgeries that will no longer require pre-authorization for our Medicare line of business are:
- 27130 - Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft
- 27132 - Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft
- 27125 - Hemiarthroplasty, hip, partial (e.g., femoral stem prosthesis, bipolar arthroplasty)
- 27134 - Revision of total hip arthroplasty; both components, with or without autograft or allograft
- 27137 - Revision of total hip arthroplasty; acetabular component only, with or without autograft or allograft
- 27138 - Revision of total hip arthroplasty; femoral component only, with or without allograft
- 27427 - Ligamentous reconstruction (augmentation), knee; extra-articular
- 27428 - Ligamentous reconstruction (augmentation), knee; intra-articular (open)
- 27445 - Arthroplasty, knee, hinge prosthesis (eg, Walldius type)
- 27447 - Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty)
- 27437 - Arthroplasty, patella; without prosthesis
- 27438 - Arthroplasty, patella; with prosthesis
- 27446 - Arthroplasty, knee, condyle and plateau; medial OR lateral compartment
- 27486 - Revision of total knee arthroplasty, with or without allograft; 1 component
- 27487 - Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component
- 23470 - Arthroplasty, glenohumeral joint; hemiarthroplasty
- 23472 - Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (e.g., total shoulder))
- 23473 - Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component
- 23474 - Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component
Upcoming member campaigns to encourage our members to take greater control of their health
Coming up: social needs self-screening, osteoporosis outreach, eye exams for patients with diabetes and more.
Health-Related Social Needs Self Screening
This email campaign will encourage Essential Plan members to complete a self-administered health-related social needs screening as well as provide community resources for members to contact if an area of need is identified.
- Target Population: Essential Plan members
- Outreach Method: Email
- Timeframe: May 2025
Osteoporosis Management in Woman Who Had a Fracture (OMW) Member Outreach
Independent Health’s Case Manager will outreach telephonically to Medicare members that fall into the Osteoporosis Management in Woman Who Had a Fracture (OMW) measure.
Independent Health’s Case Manager will contact members to discuss their fracture, provide education on fractures and falls prevention, and discuss options for gap closure.
The Case Manager will discuss the option of an in-home heel ultrasound with Stall Senior Medical (SSM). If the member is interested, the Case Manager will ask for consent for the member to be contacted by the SSM team and then SSM will call the member to schedule the appointment. All results will be sent to the member’s Primary Care Physician (PCP) for follow-up.
The Case Manager will also discuss other options for gap closure, depending on the member’s preference, and refer back to the member’s PCP. Each call will be individualized based on the member’s needs.
- Target population: The OMW measure focuses on females 67 to 85 years of age who had a fracture and have six months following the fracture to close the gap by having a bone density scan, filling a script for an osteoporosis medication, or receiving an injection for osteoporosis treatment.
- Timeframe: This outreach is on-going. Monthly, new members who fall into this measure are called.
Eye Exam for Patients with Diabetes (EED) Member Outreach
Independent Health will be facilitating outreach telephonically to Medicare members that have a gap in care for the Eye Exam for Patients with Diabetes (EED) measure. Independent Health will call members and discuss the option of an in-home eye exam with Stall Senior Medical (SSM). If the member is interested, Independent Health will ask for consent for the member to be contacted by the SSM team and then SSM will call the member to schedule the appointment. All results will be sent to the members’ Primary Care Physician (PCP) for follow-up.
- Target population: Medicare HMO members with a diagnosis of Diabetes (type 1 or 2) who have not had a retinal eye exam. An eye exam in the year prior must be negative for any type of retinopathy. If year prior eye exam is positive, then an eye exam in the current measurement year is needed.
- Outreach method: Outbound telephone call campaign.
- Timeframe: Campaign to kick off in mid-to-late March and run through December 2025
Gaps in Care Reminder Calls
Independent Health’s Member Servicing team will perform telephonic outreach to provide education and encourage members with an open gap in care to reach out to their provider to schedule the appropriate appointments and/or get a vaccination to complete the gaps in care.
- Target populations: Medicaid Managed Care members who have open gaps for: breast cancer, colorectal, and/or cervical cancer screenings. Medicaid Managed Care and Child Health Plus members (ages 9-12) who have not started or who have started but not completed the series for HPV vaccinations.
- Timeframe: Call campaign is scheduled to begin in May 2025
Falls Prevention Campaign
This campaign targets Medicare members identified as having a high likelihood of falling or history of falls to provide fall prevention education and encourage members to speak to their doctor about ways to prevent falls.
- Target population: Medicare members who have a high likelihood of falling or a history of falls.
- Outreach method: Outbound telephone call and email campaign.
- Launch Date: Telephonic outreach will begin in late April; Email campaign will occur between May through July.
Physical Activity Campaign
This campaign targets Medicare members identified as having low physical activity levels to provide education regarding the benefits of physical activity and encourages members to speak to their doctor about ways to be more active.
- Target population: Medicare members who have low physical activity levels.
- Outreach method: Outbound telephone call and email campaign.
- Launch Date: Telephonic outreach will begin in late April; Email campaign will occur between May through July.
Bladder Control Campaign
This campaign targets Medicare members identified as having urinary incontinence and encourages them to speak to their PCP regarding urinary incontinence and potential solutions.
- Target population: Medicare members who self-identify as having urinary incontinence.
- Outreach method: Outbound telephone call and email campaign.
- Launch Date: Telephonic outreach will begin in late April; Email campaign will occur between May through July.
Physical and Mental Health Campaign
This campaign targets Medicare members identified as having concerns with their physical or mental health to provide education regarding who to contact about any physical and mental health concerns and encourages them to speak to their doctor about these concerns.
- Target population: Medicare members who are identified as having concerns with their physical or mental health.
- Outreach method: Outbound telephone call and email campaign.
- Launch Date: Telephonic outreach will begin in late April; Email campaign will occur between May through July.
Pharmacy Updates
Prime Therapeutics' drug policies moving to secure portal
Providers will have to log in to view drug policies
By the end of May, providers will need to be logged in to the Prime Therapeutics portal to view all drug policies associated with the program. Currently, drug policies are available without having to log in.
The date of this change has not been finalized. However, we encourage all providers who require access to the Prime Therapeutics’ drug policies to prepare for the change now.
- If you already have a portal account with Prime Therapeutics, no action is required. Your existing credentials will provide access to the drug policies when you log in at https://gatewaypa.com/.
- If you do not have a portal account with Prime Therapeutics, click on “new provider access request” on the portal landing page at https://gatewaypa.com/.
Prime Therapeutics, formerly Magellan, reviews prior authorizations for select oncology and specialty drugs that fall under either the medical or pharmacy benefit.
Formulary and Policy Changes
View our up-to-date formularies and policies online
Drug Formulary Changes
- Medicare Advantage formulary deletions for Individual & group plan members, effective May 1, 2025
- Pharmacy Benefit Dimensions 3-Tier formulary deletions, effective May 1, 2025
- Pharmacy Benefit Dimensions 5-Tier formulary deletions, effective May 1, 2025.
Access Independent Health's drug formularies here.
Drug Policies
Search for and view the most current versions of all drug policies when logged in to our provider portal.
Prime Therapeutics reviews select oncology and specialty drug prior authorization requests on Independent Health’s behalf. View Prime Therapeutics policies for the drugs it reviews.
To obtain a hard copy, please contact Independent Health Provider Relations by calling (716) 631-3282 or 1-800-736-5771, Monday through Friday from 8 a.m. to 5 p.m.
In the News
An Essential Talk: Sharing your Healthcare and End-of-Life Wishes
Healthy Vision blog, April 9, 2025
Spotlight
Top Takeaways this Month
June 2025 Policy Updates: New and revised policies will be posted to the secure portal on May 1. They are under the News tab in the secure portal. It is very important to review the monthly updates.
Please note that we post new and updated policies 30 days in advance of their effective date. We encourage providers to make it a practice to visit this page on the first of each month.
Coming up on May 21: Office Matters webinar, "The Positive Impact of Case Management." Register here
Participating Labs List: Review our updated list of participating laboratories.