September 2025

The month of September is Suicide Prevention Awareness Month. It’s a time to raise awareness, promote prevention and encourage individuals who are struggling to seek help and support.  Along with the emotional toll that suicide takes on the millions of people affected directly and indirectly each year, it  also presents a major challenge to public health in the U.S. and worldwide, including lost productivity, and increased healthcare costs.

Suicide impacts all people, regardless of age, sex, or economic status. However, groups that experience racism, historical trauma, and long-lasting inequities such as disproportionate exposure to poverty have contributed to higher suicide rates among non-Hispanic AI/AN youth and other groups who have been marginalized.

There are many individual risk factors that contribute to this, such as:

• history of depression and other mental illnesses,
• chronic pain,
• criminal/legal problems,
• job/financial problems or loss,
• substance misuse,
• history of adverse childhood experiences,
• violence victimization and/or perpetration
• lack of social connections

The best way to help your patients is to assess for Depression/Suicidal Ideation by utilizing validated screening tools. We’re here to help.

We have several resources available in our secure provider portal:

• Behavioral Health toolkit (under resources)
•  Suicide Prevention | Suicide Prevention | CDC

We have informed relevant providers directly by secure message about upcoming prior authorization requirements and policy changes that will go into effect in the upcoming months. For reference, these changes are summarized below:

• Genetic Testing Codes for Medicare:  To align with Medical Policy Article A56199: Billing and Coding: Molecular Pathology Procedures , Independent Health will no longer cover Group 3 Tier 1 Non-covered codes listed below for our Medicare plans as of October 1, 2025.
• Prior authorization for CPT 76391 (Magnetic Resonance Elastrography): This procedure will require prior authorization through Evolent for commercial, Medicare and State Programs lines of business through Evolent, effective Oct. 1, 2025. 
• Prior authorization for select interventional cardiology and vascular services: As of October 15, services will require prior authorization through Evolent prior to being rendered in an outpatient or inpatient* (*professional component of elective services only) setting for adult commercial and Medicare lines of business, such as: Cardiac catheterization and intervention, Electrophysiology, Vascular radiology and intervention, Cardiac surgery, Vascular surgery. For additional information visit Evolent’s resources page about this.
• Prior authorization for physical medicine services: Beginning with services on and after October 15, 2025, physical therapy, occupational therapy, and speech therapy services will require prior authorization through Evolent prior to being rendered in provider offices, outpatient hospitals, and comprehensive rehabilitation facilities for our Medicare line of business. For additional information visit Evolent’s resources page about this.
• Prior authorization for radiation oncology: Effective November 1, 2025, for services on or after that date, Evolent will provide management services for the following radiation oncology therapy treatments on our commercial and Medicare lines of business for members aged 18 and older for primary and metastatic cancers being treated with:  Low-dose-rate (LDR) Brachytherapy, High-dose-rate (HDR) Brachytherapy, Image Guided Radiation Therapy (IGRT), Intensity Modulated Radiation Therapy (IMRT), Proton Beam Radiation Therapy (PBT), Three-dimensional Conformal Radiation Therapy (3D-CRT), Two-dimensional Conventional Radiation Therapy (2D), Stereotactic Radiosurgery (SRS), Stereotactic Body Radiation Therapy (SBRT). This prior authorization program does not include our State Programs or Self-funded products. More information is available here.  

Metabolic Monitoring for Children and Adolescents on Antipsychotics

The Independent Health Behavioral Health and Pediatric Case Management departments will outreach to parents or guardians of members under the age of 13 who have been prescribed an antipsychotic medication but have not received metabolic monitoring (glucose and cholesterol testing).   The Case Manager will provide the parent/guardian with education on the importance of metabolic screening for the child and encourage follow-up conversation with the provider regarding testing.

• Outreach method: Outbound telephone call campaign
• Target members: Commercial and Medicaid managed care members under the age of 13 who are prescribed antipsychotics and have not received metabolic monitoring (glucose and cholesterol testing).
• Timeframe: September & October 2025

Essential Plan Non-Utilizer Engagement Campaign

This campaign will engage Essential Plan members who are considered a non-utilizer (members with 7 or more months of continuous enrollment without any claim activity during that period) and who do not have an attributed PCP.  The goal of the campaign is to assist the member with finding a PCP and scheduling a preventive visit.

• Target Population: Essential Plan non-utilizers without a PCP
• Outreach Method: Telephonic outreach
• Timeframe: August-September 2025

State Member Incentive Program Campaigns

Independent Health State members will have until December 31, 2025, to complete various preventive care visits and screenings to receive an incentive for the following programs:

• Gaps-in-Care Program - State members can earn gift cards for completing various preventive care tests and screenings included in the program.
• Non-Utilizer Program - State members with 7 or more months of continuous enrollment without a claim on file are eligible to earn a gift card for completing an annual well visit.
• Maternity Management Program - State members can earn gift cards for completing a prenatal visit during the first 12 weeks of pregnancy and postpartum visit within 11 weeks after delivery.
• Timeframe: July through December 31, 2025

Health-Related Social Needs Self Screening

This campaign will encourage Essential Plan members to complete a health-related social needs screening as well as provide referral information for community resources if an area of need is identified.

• Target Population: Essential Plan members
• Outreach Method: Email and telephone
• Timeframe: July to December 2025

Osteoporosis Management in Women 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 Women 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 prescription 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. 

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. Medicare members who have open gaps for breast cancer and colorectal cancer screenings.
• Timeframe: Call campaign to run throughout 2025.

We have updated the Provider Inquiry Form that will help direct the inquiry to the proper team at Independent Health that can handle your request. 

Please download the form which is available in:

• The Secure Provider Portal: Click the Office Management tab in the red banner, then Office Forms > Administrative Forms.
• Public Provider pages: Under Frequently Used Forms > Provider Forms.

For your convenience, the form is available here, too.  

This form must accompany all claim denial disputes.  In addition, you must include the Provider Inquiry Form when you submit medical records for claims payment disputes. 

To align with CMS policies, Independent Health will require providers to include specific modifiers on claim lines to help ensure accurate reporting of drug wastage and compliance with billing requirements for single-dose medications. 

This requirement goes into effect for dates of service beginning on November 1, 2025, for all lines of business.   

When a drug is supplied only in a single-dose formulation, reimbursement will be denied if the claim line is submitted:

• Without modifier JZ (indicating no wastage occurred) or
• Without a separate line for the same drug billed with modifier JW (indicating the amount wasted).
• NOTE: Vaccines are not included; however, monoclonal antibody products and immunoglobulins are included and will be denied if billed without an appropriate modifier.

Drug Formulary Changes

View the formulary changes for the Third Quarter of 2025.

View the formulary deletions, effective September 1, 2025:

• Medicare Advantage formulary deletions for individual & group plan members
• Pharmacy Benefit Dimensions 3-Tier formulary deletions
• Pharmacy Benefit Dimensions 5-Tier formulary deletions

Access Independent Health's drug formularies here.

Drug Policy Changes

The policy changes for the Third Quarter of 2025 are now available online. Log in to the provider portal to view the changes. Click on ‘Monthly Policy Updates’ under the News tab once you are logged in.

Search for and view the most current versions of all Independent Health’s drug policies when logged in to our provider portal.

Prime Therapeutics reviews prior authorizations for select oncology and specialty drugs 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.