Wound Care Connect program for Medicare Advantage and Group Retiree members

This communication applies to the Medicare Advantage program from Anthem Blue Cross and Blue Shield (Anthem) in Ohio.

 

Applicable to the following states: 

Medicare Advantage, and Group Retirees  

 

Effective November 1, 2022, Anthem Blue Cross and Blue Shield (Anthem) and myNEXUS* are partnering together to deliver an enhanced wound and ostomy program as part of the existing home health product, with a pilot beginning in the state of Ohio for Medicare Advantage and Group Retiree (GRS) members. Members must be homebound¹ (as defined by Centers for Medicare and Medicaid below) and diagnosed with an eligible, in scope wound and/or ostomy ICD-10 diagnosis code (list available upon request by calling 833-419-4030).

 

The following wound(s) and ostomies are not eligible for the program:

• Stage I pressure injuries
• Non-complicated surgical wounds
• Existing non-complicated ostomies

 

The Wound Care Connect program will leverage an existing national network of contracted, home healthcare providers in Ohio in collaboration with our internal team of certified wound/ostomy nurses and certified wound physician specialists to provide high-quality, in-home care.

 

Additional program components include: 

• Agency clinician access to Wound Treatment Associate (WTA) Training Program (administered by myNEXUS).
• Access to evidence-based clinical care pathwaysto guide the agency clinician in making a complete wound assessment during encounters with the member.
• Access to virtual care conferences between agency clinicians and the myNEXUS expert wound teamto discuss potential problems related to a member’s wound and/or ostomy care.
• Facilitating communication between the agency clinician and ordering provider regarding a member’s progress in wound healing.
• Availability for peer-to-peer reviews between the ordering provider and a certified wound specialist physician to discuss clinical issues related to a member’s care.

 

Goals of the Wound Care Connect program include:

• Improved member satisfaction
• Improved healing times
• Improved member outcomes
• Reduction in hospital admissions and emergency department visits
• Reduced total cost of care

 

How to submit a direct referral to myNEXUS: 

Participating Ohio providers are encouraged to submit direct authorization requests for members who are homebound* and have an eligible, in-scope ICD-10 diagnosis code starting November 1, 2022. Providers can submit authorization requests and associated wound/ostomy images and documentation using NexLync, by navigating to www.myNEXUScare.com and submitting an authorization request for Home Health.  

 

If you are interested in learning more about the myNEXUS’ Wound Care Connect program, contact us by calling our dedicated toll-free number 833-419-4030 or email us at mynwoundcareconnect@mynexuscare.com.

 

1 Homebound definition (per the Medicare Benefit Policy Manual Chapter 7 30.1.1 Patient Confined to the Home): An individual shall be considered confined to the home (homebound) if the following two criteria are met:

Criterion one: The patient must either:

1. Because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence
   or

2. Have a condition such that leaving his or her home is medically contraindicated.

 

If the patient meets one of the criterion one conditions, then the patient must ALSO meet two additional requirements defined in criterion two below.

Criterion two:

1. There must exist a normal inability to leave home;
   and

2. Leaving home must require a considerable and taxing effort.

 

If the patient does in fact leave the home, the patient may nevertheless be considered homebound if the absences from the home are infrequent or for periods of relatively short duration or are attributable to the need to receive healthcare treatment.

 

References:

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c07.pdf.

* myNEXUS is an independent company providing Wound Care Connect program on behalf of Anthem Blue Cross and Blue Shield.
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