During member visits Synagis (palivizumab)

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1 Fall/Winter 2015 During member visits Synagis (palivizumab) Respiratory syncytial virus (RSV) season begins as early as September and runs through April. Synagis (palivizumab) is a monoclonal antibody indicated for the prevention of RSV. The American Academy of Pediatrics (AAP) recommends a maximum of five (15 mg/kg) monthly doses of palivizumab during the RSV season for high-risk infants who were born before 29 weeks, 0 days gestation, have chronic lung disease (CLD) of prematurity or have hemodynamically significant heart disease. Updated indications for prophylaxis can be found in the July 2014 AAP Policy Statement and on our provider website at unicare.com. Table of contents During member visits 1. Synagis (palivizumab) Business operations 2. Annual Quality Improvement Summary 3. New Reimbursement Policy: Distinct Procedural Services (Modifiers 59, XE, XP, XS, XU) The Synagis prior authorization form can be found on provider website at unicare.com. Only one request is needed for each patient throughout the RSV season. In a case where higher dosage is necessary due to weight gain, documentation of the patient s new weight must be provided. In most cases, Express Scripts, Inc. is the preferred provider for Synagis requests. However, some markets prefer other vendors. Please check with your local Customer Care representative or our Provider Services team at for specific details on how to obtain Synagis. You can also find additional drug information at unicare.com. UWVPEC November 2015

2 Annual Quality Improvement Summary Business operations The results are in UniCare Health Plan of West Virginia, Inc. (UniCare) is pleased to present the annual Quality Improvement summary of clinical performance and service satisfaction. Throughout the year, we evaluate data trends related to how our members receive health care and preventive care services, and compare that data to national practice guidelines. We also recognize that collaboration with our network providers and their office staff and managers is the key to quality performance of our health plan. Thank you for participating in our network, for providing quality health care to our members and for your cooperation in our annual review process. The National Committee for Quality Assurance (NCQA) is a private, nonprofit group committed to improving health care. We have achieved Accreditation status from NCQA. This status is for health plans which meet or exceed NCQA s standards for service and quality. Clinical performance and service satisfaction are based upon results from: Medicaid Healthcare Effectiveness Data and Information Set (HEDIS ) 2015 A national program developed by the NCQA to measure how effectively health plans and providers deliver preventive care. Consumer Assessment of Healthcare Providers and Systems (CAHPS) 2015 These surveys evaluate member satisfaction as well as care and services received during the previous six months; a random sample of UniCare plan members answered questions about their doctors and the health plan. Improving HEDIS scores is a team effort We have a comprehensive plan to improve our HEDIS measures through member outreach, provider outreach, case management and data collection, but we also need your help. Collaboration with our providers is the key to quality improvement. HEDIS The HEDIS report below is provided as a service for you, our network providers, as a reference tool. We compare HEDIS 2015 measures against 2014 performance data. We produce this report to share key findings regarding our quality improvement activities and progress toward meeting our goal to reach the Quality Compass Medicaid National Average plus five percent. HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).

3 The graph below denotes the rate of UniCare members who received services for the following HEDIS measures: Data obtained from the NCQA 2014 Quality Compass Medicaid National Average Adolescent well child (AWC) The percentage of enrolled members 12 to 21 years of age who had at least one comprehensive well-care visit with a PCP or an OB/GYN. Well child 3, 4, 5, 6 (W34) The percentage of members three to six years of age who had one or more well child visits with a PCP during the measurement year. Adolescent immunizations (IMA) The percentage of adolescents 13 years of age who had one dose of meningococcal vaccine and one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) or one tetanus, diphtheria toxoids vaccine (Td) by their 13th birthday. Diabetes eye exam (DRE) The percentage of members with diabetes who had a screening for diabetes retinal disease. Screening must include a retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year or a negative for retinopathy eye exam in the year prior.

4 HBA1C diabetes test The percentage of members with diabetes who had at least one HGBA1C in the report year. Postpartum care The percentage of members who have given birth and who had a postpartum exam on or between 21 and 56 days after delivery. Adult body mass index assessment (ABA) The percentage of members 18 to 74 years of age who had an outpatient visit and whose body mass index (BMI) was documented during the measurement year or the year prior to the measurement year UniCare has a comprehensive plan to improve the above HEDIS measures through member outreach, case management and data collection. But we need your help. Collaboration with our providers is the key to quality improvement. We have developed a program called Quality & Access to Care Incentive (QACI). This incentive program rewards providers for providing quality care and for being available to our members. QACI major points: The program rewards providers up to $3.50 per member per month, who meet the following: Access to care: $0.25 per member per month, each measure After hours availability Appointment availability Quality of care: You can choose six of the 10 HEDIS measures listed below and paid at $0.50 per member per month for each measure. 1. W34 Well child visits in the 3rd, 4th, 5th and 6th years of life 2. PPC Postpartum care 3. AWC Adolescent well care visits 4. IMA (#1) Adolescent immunizations (combo #1) 5. MMA Medication management for people with asthma (75% or more total compliance) 6. CDC Comprehensive diabetes care retinal eye exams 7. CDC Comprehensive diabetes care medical attention for nephropathy 8. CDC Comprehensive diabetes care HbA1c testing 9. MPM Annual monitoring for patients on persistent medications 10. ABA Adult BMI assessment The QACI incentive is paid quarterly, except for the two access measures. These measures are audited in September and will be included in the fourth quarter payment.

5 Providers must have a minimum of 10 UniCare members assigned to their panel at all times during each measurement quarter to participate in the quality of care portion of the program. No panel minimum is required for providers to participate in the access measures portion of the program Consumer Assessment of Healthcare Providers and Systems In an effort to serve our members better, we conduct a member satisfaction survey each year. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) tool asks our members to rate their experience with their doctors and/or specialists and with the health plan within the previous six months. We rate our CAHPS performance by measuring against benchmarks set by the National Committee for Quality Assurance (NCQA). The graph below and the one on the following page denote a summary of results from the 2015 UniCare CAHPS CONSUMER ASSESSMENT OF HEALTHCARE PROVIDERS AND SYSTEMS - ADULTS UniCare CAHPS Score 2015 NCQA Benchmark 75th Percentile Smoking Cessation How Well Doctors Communicate Getting Needed Care Customer Service CAHPS is a registered trademark of the Agency for Healthcare Research and Quality.

6 98 CONSUMER ASSESSMENT OF HEALTHCARE PROVIDERS AND SYTEMS - CHILDREN UniCare CAHPS Score 2015 NCQA Benchmark 75th Percentile How Well Doctors Communicate Getting Needed Care Customer Services How are we doing? Member ratings for our customer service reflect high satisfaction. Overall, UniCare members are generally satisfied with the care and services they receive from their providers and their health plan. The survey results show that we can improve, especially with our child population and continue to strive to exceed the national benchmarks. UniCare strives to reach the highest percentile benchmark set by the NCQA. Like NCQA, we are dedicated to improving health care quality. UniCare also offers providers the opportunity to participate on committees aimed at improving services and clinical outcomes for our members. These activities include the review of policies, procedures and clinical practice guidelines. Additionally, participant providers have the ability to advise the health plan administration in any aspect of health plan policy or operation affecting network providers or members. If you would like to participate in the medical advisory committee or the credentialing subcommittee, please call Provider Services at Thank you for your commitment and the care you give to our members your patients. We hope you find the above reports to be beneficial.

7 New Reimbursement Policy: Distinct Procedural Services (Modifiers 59, XE, XP, XS, XU) These policies serve as a guide to assist you in accurate claim submissions and to outline the basis for reimbursement if the service is covered by a member s UniCare benefit plan. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. Proper billing and submission guidelines are required along with the use of industry-standard, compliant codes on all claim submissions. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, we strive to minimize these variations. For more information on these and other UniCare Reimbursement Policies, visit our website at Distinct Procedural Services (Modifiers 59, XE, XP, XS, XU) (Policy , originally effective 08/24/2015) UniCare allows reimbursement for a procedure or service that is distinct or independent from other service(s) performed on the same day by the same provider when billed with Modifier 59, XE, XP, XS or XU unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. Modifier 59 should be used when a more descriptive modifier, like an XE, XP, XS, or XU, collectively referred to as X{EPSU} is not available. The X{EPSU} modifiers are more selective versions of Modifier 59; it would be incorrect to include both modifiers on the same claim line. Modifier Description 59 Used to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures or services that are not normally reported together, but are appropriate under the circumstances XE Separate Encounter, used to indicate a service that is distinct because it occurred during a separate encounter XP Separate Practitioner, used to indicate a service is distinct because it was performed by a different practitioner XS Separate Structure, used to indicate a service is distinct because it was performed on a separate organ/structure XU Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual components of the main service For additional information about Distinct Procedural Services (Modifiers 59, XE, XP, XS, XU), please refer to the policyat Your continued feedback is critical to our success. If you have questions, Medicaid providers can call You may also call your local UniCare representative.