Pay BillSCOPE | Provider Update
August 2026
Clinical Matters
This National Immunization Awareness Month, providers can make a difference
August is National Immunization Month, shining a light on the importance of immunizations in providing protection from serious diseases – advancing both individual and public health. However, vaccine hesitancy continues to be a challenge. Healthcare providers are in a unique position to educate patients of all ages.
Individuals who understand the personal and community-wide benefits of immunizations are more likely to vaccinate versus patients who do not understand the value. All healthcare professionals play an important role in slowing down the spread of vaccine hesitancy.
Understanding vaccine hesitancy by populations
The World Health Organization (WHO) defines vaccine hesitancy as “delay in acceptance or refusal of vaccination despite availability of vaccination services.” The populations most likely to be vaccine hesitant include racial/ethnic minorities, low economic status, and less education. However, it is vital to understand every patient's baseline comfort level with vaccines and not make sweeping assumptions.
- Many racial minorities report a lack of trust in the medical system due to systemic inequalities over time. One commonly reported example is the Tuskegee Syphilis Study, an unethical 20th century clinical trial that intentionally withheld syphilis treatment for hundreds of Black men in Alabama. Another common concern involves the lack of minority representation in vaccine clinical trials. Antiracist and culturally competent healthcare is imperative to mitigate vaccine hesitancy.
- Those of a lower economic status and less educated are more likely to fall prey to vaccine misinformation. Some theorize this may be due to lack of understanding where to find reliable information. Healthcare providers can assist in providing reliable sources of information on vaccines, taking advantage of their status as one of the country’s most trusted professions.
The vaccine ‘infodemic’
The WHO defines this ‘infodemic’ as “an overabundance of information - some accurate and some not - that makes it hard for people to find trustworthy sources and reliable guidance when they need it.”
With vast amounts of content available online, all sorts of conflicting information and opinions can overwhelm patients. This misinformation negatively impacts vaccination rates. And more emotionally charged information, including the exaggeration of potential side effects, can lead to conspiracy theory believability.
Taming the ‘infodemic’ has been identified as key to managing vaccination rates. Providers can help by answering questions in a nonjudgmental way.
Common vaccination myths vs. facts
- Myth: Vaccines contain several harmful ingredients.
- Fact: Different ingredients are included to assist with stability, preserving and more at much lower doses than what the average person is exposed to in the environment. No evidence exists that vaccine ingredients cause health risks.
- Myth: Vaccines will cause autism and SIDS.
- Fact: There is currently no clear understanding on the etiology of autism and SIDS, but there is no evidence that links those conditions with vaccinations. A significantly flawed 1998 study raised concerns between the MMR vaccine and autism. That study has since been retracted from the journal it was published in due to bad design and bad science.
- Myth: It is possible to get the disease from the vaccine.
- Fact: Most vaccines are inactivated (killed), meaning contracting the disease is impossible. Out of the live vaccines, a mild case of the disease can take place that can actually be a positive sign the vaccine is working.
The 5C model of vaccine hesitancy
This helpful model was developed as a person-specific method to understand an individual’s vaccine hesitancy.
- Confidence: the individual’s trust in the safety and efficacy of vaccines. Solution: respect, understand, and debunk their concerns in easy-to-understand language.
- Complacency: lack of perception of personal risk and/or disease severity. Solution: educate on the risk of contracting a vaccine-preventable disease and the benefits to the population (herd immunity for those who legitimately cannot get vaccinated).
- Constraints: having access to affordable vaccines in areas where communities gather. Solution: hold a mass vaccination event (ex: at a place of work or school) and help solve external factors that could be impacting access.
- Calculation: the ‘infodemic’ of vaccine misinformation. Solution: understand the emotionally charged nature of this content and why people believe it. Create space for open dialogue to provide education.
- Collective responsibility: understanding the importance of herd immunity (and who it intends to protect). Solution: educate the individual on the immunocompromised who rely on herd immunity to stay healthy and the public health benefits that come from getting vaccinated.
Conclusion
Vaccinations have been extensively studied and shown to be incredibly safe and effective at preventing many serious illnesses. Their benefit far outweighs the potential risks. When speaking with a vaccine-hesitant individual, listen with concern, correct misinformation, and foster informed decision making.
Helpful Resources
- American Association of Family Physicians: Immunizations and vaccines for family physicians
- American Academy of Pediatrics: Immunizations
- CDC: National Immunization Awareness Website
- WHO Infodemic Website
Office Matters
Independent Health: on course for the future; affiliation update
The Western New York health care community has experienced a number of challenges and changes over the last several years, which has implications for providers, patients and payers. These challenges aren’t local: the health care industry is undergoing a profound transformation, driven by rising costs, evolving consumer expectations, and the need for more connected, proactive care.
Like many health plans across the country, Independent Health has had to make product changes, adjust offerings and refine some processes to remain strong and stable well into the future to meet the health care needs of the community. These efforts are trending toward a strong 2026 for Independent Health, and our organization is well positioned to continue delivering on our mission to provide affordable access to quality healthcare while improving the health and well-being of the communities we serve.
As the health care landscape continues to evolve, our leadership team has sought opportunities to align with a like-minded organization to develop broader capabilities and a stronger foundation for long-term sustainability. Last November, we announced plans to affiliate with the MVP Health Care family of companies. MVP is a nationally recognized, not-for-profit health insurer based in Schenectady, caring for members in New York and Vermont.
MVP's expertise
MVP’s operational expertise will help address the challenges facing the entire health care industry and will unlock new opportunities for growth and innovation. Independent Health’s president and chief executive officer, Michael W. Cropp, M.D., shared his vision in a recent Buffalo News article about this pending affiliation.
Affiliation timing
This planned affiliation continues to move through the regulatory review phase, which we expect to be completed in the fourth quarter of this year. During this regulatory review process, both organizations are operating separately.
When the affiliation receives regulatory approval, members, providers, and partners can expect business as usual with no immediate changes to coverage, benefits, our network, reimbursement rates, or local personalized service.
As Independent Health joins the MVP family of companies, providers will benefit from expanded resources, deeper clinical expertise, and a stronger regional network. This affiliation will allow us to scale best-in-class care management programs, invest in advanced technology, and streamline administrative processes—making it easier for providers to deliver high-quality, coordinated care.
Together, we are building more agile, responsive organizations that are committed to strengthening provider relationships, improving patient outcomes, and supporting the evolving needs of our respective provider communities.
Due by Aug. 31: Mandatory training: Independent Health’s Assure Advantage (HMO-SNP) 2026 Model of Care
Independent Health is committed to ensuring its provider network meets all regulatory requirements set forth by the Centers for Medicare & Medicaid Services (CMS) as mandated by 42 CFR§422.101(f)(2)(ii).
It is time for provider staff who see Independent Health Assure Advantage Medicare members on a routine basis to complete the 2026 Annual Model of Care Provider training by August 31, 2026.
Assure Advantage is a Chronic Special Needs Plan (C-SNP), designed for eligible Medicare beneficiaries who have been diagnosed with chronic heart failure and reside in Erie County.
Who must complete the training?
All provider staff who see Medicare patients on a routine basis must complete the training, including care coordination staff, administrative staff, or other clinical or support staff.
How does your practice complete this training?
The 2026 Annual Model of Care Provider Training is conducted online following these steps:
View and/or download the presentation here.
Once your practice/staff have completed the training module, fill out the attestation that accompanies the training presentation or click here to start attestation. Only one attestation per practice is required.
Please complete the attestation by August 31, 2026.
If you have any questions, please contact Provider Relations Monday through Friday from 8 a.m. to 5 p.m. at (716) 631-3282.
Pre-authorization changes effective Oct. 1, 2026
Independent Health regularly evaluates medical services to understand utilization patterns in order to promote clinically appropriate, evidence-based care, and mitigate variability in quality and usage.
As a result of recent assessments, we will make changes to services that require authorization. In some cases, we will begin to require preauthorization; in other cases, we will remove the preauthorization requirement.
We are sending you this notification that includes the following services because your practice/provider has submitted codes related to one or more of these services.
These changes below apply to all lines of business.
Services that will require authorization
We will require pre-authorization on the following services for dates of service on and after October 1, 2026:
- Advanced Infertility / IVF Services
- Cochlear Implants
- Fertility Preservation Services
- Nasal/Sinus Endoscopy Surgery
- Percutaneous Vertebroplasty / Kyphoplasty
- Septorhinoplasty
- Spinal Cord Stimulation/Electrical Stim Devices
- Transplants
Independent Health will deny claims and related charges to the provider liability for lack of pre-authorization/notification. Independent Health members must not be held responsible for the cost of these denied services.
Services that no longer require authorization
Independent Health will no longer require pre-authorization on the following services with dates of service on and after October 1, 2026:
- Electromagnetic Wound therapy
- Pulse Dye Laser
- Therapeutic Radiopharmaceuticals
- Vision Therapy
- Wheelchair Van
Although these services will no longer require pre-authorization, Independent Health expects providers to continue to use evidence-based best practices and their judgment in order to continue appropriate utilization of services. If a pattern of inappropriate use emerges, we will need to consider adding prior authorization back to these services.
Please remember to view our monthly policy updates on a regular basis, and share this information to your staff.
New NCD and LCD Medicare claim edits effective Sept. 1, 2026
One new claim edit sourced from National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) will be activated for our Medicare member claims for dates of service on and after September 1, 2026. Please refer to the list below of NCD and LCD policies.
As a reminder, the “Coding Adherence to Medicare LCDs and NCDs” section of the Participating Provider Reimbursement Manual contains additional information on these edits and includes a comprehensive list of LCDs and NCDs that are used to source the new claim edits.
Monthly Update: Upcoming member engagement campaigns to encourage members to take greater control of their health
Independent Health develops outreach campaigns to members in need of certain preventive services and to help make them aware of our programs and resources to help them maintain or improve their health. Here is a summary of the current outreach campaigns underway.
Preventive Cancer Screening Campaign
This campaign provides education on the importance of preventive cancer screenings and encourages Medicare and State Products members to complete a breast cancer and/or colorectal cancer screening where open gaps exist.
- Target population: Medicare and State Products members whose providers are not part of an IPA (Individual Practice Association)
- Outreach method: Outbound telephone call campaign
- Launch Date: Telephonic outreach will begin in late July and run through August
State Program Member Incentive Campaigns
Independent Health State Program members will have until December 31, 2026, to complete various preventive care visits and screenings to receive an incentive for the following programs:
- Gap in Care Program - State members can earn gift cards for completing various preventive care tests and screenings.
- Non-Utilizer Program - State program 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 program 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.
- Launch Date: May through December
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 began in late April; Email campaign began in May and will continue 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 began in late April; Email campaign is occurring 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 began in late April; Email campaign is occurring 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 began in late April; Email campaign is occurring between May through July.
Health-Related Social Needs Self Screening
This campaign will encourage members to complete a health-related social needs screening, and we will provide referral information for community resources if an area of need is identified.
- Target Population: MediSource Connect (HARP); Essential Plan, Commercial, Mainstream Medicaid subpopulation.
- Outreach Method: Telephonic and email campaigns
- Timeframe: January through December 2026
Osteoporosis Management in Women Who Had a Fracture (OMW) Member Outreach
Independent Health’s Medication Therapy Management (MTM) Pharmacy Team will outreach telephonically to Medicare members who fall into the Osteoporosis Management in Women Who Had a Fracture (OMW) measure. The MTM Pharmacy Team will contact members to provide education on the importance of getting screened for osteoporosis following a fracture, discuss any clinical and medication concerns as well as options for gap closure.
The option of an in-home heel ultrasound with Stall Senior Medical (SSM) will be discussed. If the member is interested, The MTM Pharmacy Team 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 MTM Pharmacy Team 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.
Have you completed the annual Cultural Competency and FWA attestation?
Independent Health is required by state and federal agencies to ensure our participating providers complete this annual compliance training.
All participating practices must attest they have completed each of the following by December 31, 2026:
- Cultural Competency Training: All providers who treat Independent Health’s Commercial and State program members must attest annually that they have completed cultural competency training for all staff who have regular and substantial contact with our members.
Please use the Think Cultural Health training guide. The guide offers two modules: one tailored for health care administrators and the other for health care providers or those providing direct care and services. (Note: although the website indicates that the content is under review for updates, practices may use it to complete the requirements).
- Fraud, Waste & Abuse Training: If you haven’t done so already for 2026, provider groups or practices must complete Fraud, Waste & Abuse (FWA) Training and submit an electronic attestation to confirm each of their staff members have completed this training.
Staff members required to complete this training include physicians, mid-levels, ancillary providers, registered nurses, licensed practical nurses, administrative and office staff, technicians, coders and others.
Who must submit each attestation?
An authorized representative must submit each of the above attestations on behalf of all individuals under a practice’s Tax Identification Number (TIN). Therefore, each individual staff member who completes each training does not need to submit the attestation.
Timing for chart reviews will change for State Programs
Independent Health is required to conduct medical record chart quality reviews to meet New York State (NYS) regulatory requirements and standards for coding accuracy. The purpose of these review is to support supplemental data submission to NYS’s All Payer Data to help ensure members are assigned the correct clinical risk score by New York State. The scope of this review is for Independent Health’s Essential Plan, Child Health Plus, MediSource, and MediSource Connect benefit plans.
This review will not change the medical record or payment received for services rendered.
Change in frequency of reviews
We have been performing these chart reviews on an annual basis; however, due the volume of the charts that need to be reviewed, we will conduct the chart reviews on a quarterly basis beginning August 1 for records from Quarter 1 of 2026. Moving forward, we will review charts according to the following:
- Sept. 1: Second Quarter 2026 records
- Dec. 1: Third Quarter 2026 records
- June 1, 2027: Fourth Quarter 2026 records
Independent Health contracts with Solventum which serves as a Business Associate of Covered Entities as defined by the Health Insurance Portability and Accountability Act (HIPAA), to review medical records on the plan’s behalf.
Please note that your Participating Provider agreement states “Participating Provider agrees that books and records pertinent to Independent Health Members including medical records and charts, encounter data, billings records, and financial data and reports, may be examined and copied at no charge by Independent Health when lawfully requested”.
Solventum is authorized to perform activities involving the use or disclosure of Protected Health Information (PHI) on behalf of Independent Health. Solventum treats patients’ PHI with the highest level of protection and confidentiality. We are working with practices to encourage them to enable Solventum remote secure access into their EMRs to ease the administrative effort on practices.
Pharmacy Updates
Formulary and Policy Changes
Remember to view our up-to-date policies online.
Drug Formulary Changes
View the formulary deletions, effective August 1, 2026:
- Medicare Advantage formulary deletions for the Individual Standard formulary
- Medicare Advantage formulary deletions for the Individual Enhanced & Group formularies
- Pharmacy Benefit Dimensions 3-Tier formulary deletions
- Pharmacy Benefit Dimensions 5-Tier formulary deletions
Access Independent Health's drug formularies here.
Drug Policy Changes
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. Log in to 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
Spotlight
Top Takeaways this Month
Monthly Policy Updates: View them here (Posted as Monthly Policy Updates under the News tab in the secure portal). It is very important to review the monthly updates.
Action required: Cultural Competency and Fraud, Waste & Abuse Mandatory Training and Attestation! Learn more and complete this requirement here.