Effective Today: Changes to Medical Benefit Drug Matrix and Commercial Medical Preferred Drug List
Please be aware we have made changes to the Medical Benefit Drug Matrix and the Commercial Medical Preferred Drug List, effective today, July 1, 2025. The updated documents are viewable on our website for your convenience on our Authorization Matricies webpage.
Please take a moment to familiarize yourself with these updates to help maintain seamless patient care and accurate billing practices. If you have any questions, feel free to reach out to our provider support team.
Credentialing Webpage!
Hometown Health now has a Provider Credentialing webpage dedicated to assisting our provider partners in the credentialing and re-credentialing process! The Provider Credentialing webpage includes:
* Provider rights and responsibilities.
* FAQ with common credentialing questions.
* Provider Forms and Important Links.
* How to join Hometown Health’s Medical Affairs Committee!
The Provider Credentialing webpage is a great resource to understand Hometown Health’s credentialing requirements and onboarding process! Visit the Provider Credentialing webpage here.
Hometown Health Medical Affairs Committee – Building Partnerships with Hometown
Speaking of the Medical Affairs Committee, we have a couple openings for new members! The statewide physician committee consists of providers across a variety of specialty types who review physician applicants to the Hometown Health network to determine participation based on the Hometown Health Standards of Participation. For more information or to get involved, please visit: Medical Affairs Committee | Hometown Health
Fall Prevention Resource Webpage for Seniors
A new Fall Prevention Resource webpage aimed at preventing falls among seniors is now available on the Senior Care Plus website. The Fall Prevention Resource page includes:
* Educational resources such as downloadable guides on strength and balance exercises.
* A music playlist to encourage physical activity.
* A two-minute video featuring Dr. Derek Beenfeldt, Hometown Health’s Chief Medical Officer, who shares practical tips for fall prevention.
* Non-slip sock giveaway information.
Senior Care Plus members who watch the video can earn a one-time $5 Healthy Rewards. These fall prevention resources are designed to empower seniors to take proactive steps in safeguarding their health and maintaining independence! For more information, please visit the Fall Prevention Resource webpage here.
Important Reminders for Provider Partners
Reminder: Complete Your Provider Data Attestation!
Important Notice: Claims may be denied when required directory attestations have not been completed
Since January 1, 2022, the No Surprises Act has required providers and facilities to attest to their demographic details every 90 days. To avoid being removed from the directory and/or receiving claim denials, complete your attestation today!
Hometown Health has partnered with Quest Analytics’ BetterDoctor to collect your quarterly provider data attestations. There are two options to attest:
* Attest via the BetterDoctor portal using the secure access code you receive from Quest Analytics’ BetterDoctor via email, fax, and/or direct mail each quarter.
OR
* Attest via roster if your organization includes 20 or more practitioners at multiple service locations. Please send your quarterly roster to rosters@questanalytics.com.
It’s important Hometown Health has an accurate email address for your office on file as this is the easiest way for you to attest. If you’d like to update your email address with us, please reach out to HTHProviderrelations@hometownhealth.com.
Our goal is to ensure members can access the care they need when and where they need it. That starts with accurate provider information which helps us keep our directory up to date, allowing our members to find the right care without unnecessary barriers. Thank you for your vital partnership in making quality care accessible.
Medicare/Medicaid Duals Plan Reminder
As a reminder, when billing for medical services under the Extensive Duals Plan with Senior Care Plus, please ensure you collect both Medicaid and Medicare information for these members. With Dual Plans, if there is any member cost share, remember to bill Medicaid directly, as members should not be billed for services under this plan.
Thank you for your understanding and partnership!
To help providers and members access covered services more efficiently, Hometown Health encourages the use of its online provider directory at www.hometownhealth.com to find participating providers.
Reminder: Referral and Authorization Responsibilities
Hometown Health would like to remind all referring providers of their responsibility to direct members to in-network providers whenever possible. Referrals to non-contracted providers may result in unexpected out-of-pocket costs and delays in care, which can negatively impact the member’s experience.
Additionally, it is the provider’s responsibility to obtain necessary authorizations and referrals when directing members to specialists or services, including lab work, sleep studies and genetic testing.
Key Points to Remember:
* Authorization Matrices are available on the provider page of HometownHealth.com and the EpicCare Link portal homepage.
* As outlined in your provider service agreement, you must refer patients only to contracted providers within the Hometown Health network.
* Referrals made to out-of-network providers may lead to unexpected out-of-pocket costs for members.
* If a referral to an out-of-network provider is needed, submit a referral through either EpicCare Link or via fax so it can be reviewed. If it is determined that the referral to the out-of-network provider is warranted, our Health Utilization Management team will submit the request to Contracting to coordinate a letter of agreement (LOA).
If Hometown Health receives an appeal for out-of-network services that were denied for no prior authorization:
* The referring provider is responsible for coordinating a payment resolution with the out-of-network provider.
* This payment resolution must address the member’s out-of-pocket costs and be completed within ten (10) business days of notification per our Administrative Guidelines.
We appreciate your continued partnership in ensuring our members receive high-quality, cost-effective care.
Documentation of Cancer According to ICD-10 Coding Guidelines
It is appropriate to code cancer as active during the timeframe between the initial diagnosis and the completion of treatment (either by excision; or by completion of chemotherapy and/or radiation therapy). Untreated cancer that is being monitored (watchful waiting) should be coded as active.
After completion of treatment, it is appropriate to use a ‘history of malignant neoplasm’ code [Z85.-]
*It is important to remember that the use of quantifying language such as, “Rule out, probable, possible or consistent with” cannot be coded as active cancer in the office setting.
The following ICD 10 CM coding guidelines will be helpful in deciding which codes are appropriate:
* When a primary malignancy has been excised but further treatment, such as an additional surgery for the malignancy, radiation therapy or chemotherapy is directed to that site, the primary malignancy code should be used until treatment is completed.
*When a primary malignancy has been previously excised or eradicated from its site, there is no further treatment (of the malignancy) directed to that site, and there is no evidence of any existing primary malignancy at that site, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy.
*Any mention of extension, invasion, or metastasis to another site is coded as a secondary malignant neoplasm to that site.
* Follow-up codes are used to explain continuing surveillance following completed treatment of a disease, condition, or injury. They imply that the condition has been fully treated and no longer exists.
* Follow-up codes may be used in conjunction with history codes to provide the full picture of the healed condition and its treatment. The follow-up code is sequenced first, followed by the history code.
*Z08 Encounter for follow-up examination after completed treatment for malignant neoplasm.
*Z85 – Personal history of malignant neoplasm.
* Should a condition be found to have recurred on the follow-up visit, then the diagnosis code for the condition should be assigned in place of the follow-up code.
*Leukemia is the only exception, as this condition has specified ‘in-remission’ codes.
Member’s Rights and Responsibilities
Just a reminder: you can find information about Member Rights and Responsibilities in the Administrative Guidelines. At Hometown Health, a member is someone who meets all the eligibility rules in the Evidence of Coverage and whose enrollment form has been accepted by Hometown Health Plan.
The Administrative Guidelines list requirements for members, the process for dismissing a member, and a statement of member rights and responsibilities. Please visit Hometown-Health-Administrative-Guidelines-06012025.pdf for more information!
Tips and Tricks for Timely Turn Arounds
EDI Attachment Implementation Update:
With the new process for submitting 275 files/attachments, providers must now include a PWK segment with an Attachment Control Number in the related 837 claim file. This ensures the attachment—which must also include the same control number—correctly links to the matching claim.
The PWK segment notifies Hometown Health that an attachment is expected and allows us to process it appropriately.
Please note, providers must submit the 837 claim file first before sending the 275 attachment file. This ensures the claim, along with the PWK segment and control number, is already in the system so the attachment can be matched correctly. If the 275 is submitted before the 837, the attachment will not be linked to a claim and will fail to load into Tapestry.
Hometown Health will only accept solicited 275 attachments—those that correspond directly with a submitted claim. If a provider submits unsolicited 275 attachments (not tied to a claim), Optum will reject the submission because there is no claim to match the attachment against.
Service Level Auth Updates – Streamlined Process for Improved Visibility
Epic has recently implemented some updates designed to improve visibility and make it easier for our community providers to distinguish between a referral and an authorization.
We anticipate this enhancement will streamline the process and reduce any confusion moving forward.
You should now notice that the referral number in EpicCare Link will display its status as “authorized.” When we approve it, a new number will be issued, which will be the actual authorization number and that number will be displayed on the approval letter as the reference number. Within EpicCare Link, the Referral may show as “authorized,” however, it is important to open the referral and confirm the status to ensure it has been “authorized” and not “pending review.”
If you have any questions, please feel free to reach out to your Provider Services Representative!
Helpful Hints to Improve Turnaround Times with Credentialing!
One of the most common issues our credentialing team encounters when reviewing applications and supporting documents relates to Professional Liability (Malpractice) Insurance. Hometown Health requires all practitioners to maintain current coverage of at least $1 million per occurrence and $3 million aggregate, provided by an insurance carrier authorized to operate in the state where the practitioner is licensed and practices.
Please note, coverage under the Federal Tort Claims Act or NRS 41.038 with a statutory cap of NRS 41.035 is acceptable. Hometown Health requires a copy of the Certificate of Insurance (COI) for each policy listed on the credentialing application. Each COI must include the practitioner’s name or be accompanied by a letter on company letterhead confirming that the provider is covered under the policy. Please visit the credentialing webpage for addition information on Professional Liability (Malpractice) Insurance: Provider Credentialing | Hometown Health.
