ProviderNews. Security Health Plan introducing Smart Cost Advisor transparency tools SPRING

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1 SPRING Security Health Plan introducing Smart Cost Advisor transparency tools Security Health Plan is committed to helping you give your patients what they want from their health care. Your patients and employer groups alike are asking for help in controlling their costs and knowing how much health services will cost before they receive them. That s why Security Health Plan is working with Change Healthcare to launch Smart Cost Advisor, which will give your patients price transparency tools. The first phase of Smart Cost Advisor is available now. Healthcare University educates members about health insurance and how to use it. It uses online videos, games and other resources to provide interactive, enjoyable education on a variety of health insurance topics including how certain benefits work and the online marketplace. Healthcare University is available at and through the Security Health Online member portal. The second phase of Smart Cost Advisor, which will launch soon, has components called Cost Lookup and Ways to Save, that will introduce members to steps they can take to save money on health care expenses, such as switching medications or choosing a lower-cost provider for a particular service based on long-term claims data. Ways to Save will make post-service recommendations on what members can do differently to save money in the future based on their claims. Cost Lookup will allow members with or without recent medical services to search and compare expected costs before receiving care. Members will be able to review nearly 1,200 of the most common prescription medications and more than 270 of the most common medical services. Through our secure member portal only registered members will be able to view these price comparisons. Some of the common medical services members will be able to compare include: Knee and hip replacement Imaging Office visits Colonoscopies In addition to pricing, Smart Cost Advisor will allow patients to compare provider and facility quality ratings. We want to ensure that the quality data we use accurately reflects regional data. Because of this, we will roll out the quality-comparison feature during a later phase. Members will be able to see: Overall quality ratings Provider credentials Provider affiliations 2014 We will obey HIPAA rules and restrict access for this information to members 18 and older. In addition, members will not be able to view information for dependents older than 11. We also will ensure that providers found via Cost Lookup are specific to a member s health plan, network and geographic area. We will provide more information on our price transparency tools as we approach their go-live dates. In the meantime, direct any questions to the Provider Assistance Line at or (04/14) 2014 Security Health Plan of Wisconsin, Inc.

2 SPRING 2014 Explaining vision services coverage for ACA-compliant plans The Affordable Care Act (ACA) requires insurance carriers to provide vision coverage, but gives those carriers flexibility in how coverage is administered. Security Health Plan s vision coverage for members under its ACA-compliant plans is noted here for your reference. Eye exams covered Adult: One routine eye exam every two years including dilation/refraction, if professionally indicated If diabetic, one routine exam annually Child: One routine eye exam per year including dilation/refraction Examples of covered eyewear include: Glasses For enrolled dependents younger than 19, one pair of glasses including lenses and frames per year limited to a selection of glasses approved by Security Health Plan. Contact Security Health Plan for more information* Single-vision lenses Conventional (lined) bifocal or trifocal lenses Lenticular lenses Frames Ultraviolet protective coatings, polycarbonate lenses, blended segment lenses, standard or premium progressive lenses, intermediate vision lenses, photochromic glass lenses, polarized lenses, standard anti-reflective coatings, premium anti-reflective coatings, ultra anti-reflective coatings and hi-index lenses Contact lenses For enrolled dependents younger than 19, one pair every calendar year in lieu of eyeglasses* Also covered Standard intraocular lens after cataract surgery First standard external lens (contacts or glasses) after cataract surgery Not covered Eyewear for adults 19 and older Vision therapy (eye exercises training/ orthoptics) and visual tracking training Refractive eye (LASIK) surgery and other ocular procedures to improve refraction Vision correcting intraocular lens after cataract surgery Preparation or fitting eyeglasses or contact lenses and related fees Eyeglass or contact lenses except as defined above * Important - please note: Members, 18 years and younger, have coverage for only one prescription per benefit year of either glasses OR contact lenses. They do not receive coverage for a pair of glasses and contact lenses. Coverage of glasses OR contacts for members 18 years and younger are limited to the first claim received for one complete pair of glasses (including glasses frames and lenses) OR the first claim received for contact lenses, per benefit year. Security Health Plan will reimburse only for the first received claim for glasses OR contact lenses. During the claim adjudication process, the first prescription (glasses or contact lenses) that is processed will apply the limit count. If you have questions regarding this information, please contact your Provider Relations/Contract Manager at , extension

3 We will apply reasonable and customary fee limits Security Health Plan wants our members continue to receive the best value and that our network providers are their first choice for care. As a result, we will soon apply reasonable and customary fee limits to non-network provider submitted charges. If a non-network provider s charges exceed our reasonable and customary fee limits, our members will incur higher costs for that non-network provider s services because we don t have agreements for fee limits with non-network providers. Changes coming to pharmacy benefits These costs, regardless of any referral or prior authorization, would be in addition to any applicable deductibles, coinsurance and copayments, and would not accumulate to a member s out-of-pocket limits. This will emphasize to your patients the benefits of visiting you, our network providers. We will emphasize this information to our members and employer groups through policy documents and upcoming letters. It s important that providers know about this. If you have questions regarding usual and customary fee limits call the Provider Assistance Line at Security Health Plan will soon make changes to the way we manage our members pharmacy benefits. Here s some important information providers need to know: If any of your patients currently receive specialty medications through Briova Specialty Pharmacy, we will contact them to help them transfer their prescriptions to Amber Specialty Pharmacy. Your patients may continue to use Marshfield Clinic Specialty Pharmacy. Security Health Plan will use a new company for mail order prescriptions. If your patients receive mail order prescriptions through Catamaran Home Delivery, we will contact them to help them transfer their prescriptions to MedVantx. We believe these changes will help us serve our members better: Make sure they receive the best pharmacy service available Keep their current drugs covered Will not change their prescription copayment amounts Allow them to keep using their neighborhood pharmacy including all the major chains If you have any questions about these changes, call the Security Health Plan Pharmacy Department at between 8 a.m. and 5 p.m. Monday through Friday. You also may call the Provider Assistance Line at NCQA Excellent Accreditation affirmed Security Health Plan has received another 3-year Accreditation from the National Committee for Quality Assurance (NCQA). This achievement reaffirms the Plan s Excellent Accreditation status for its commercial, Medicare and Medicaid programs. NCQA President Margaret E. O Kane said Excellent Accreditation is only awarded to those plans that meet or exceed NCQA s rigorous requirements for consumer protection and quality improvement and deliver excellent clinical care. Security Health Plan Chief Administrative Officer Steve Youso said the status reflects the high quality work of the Plan s network providers and employees. Thank you to all of our provider partners, including Marshfield Clinic, Ministry Health Care, Aspirus, UW Health, Meriter, Group Health Cooperative, Essentia Health and all others in our growing network, Youso said. Your dedication to care for our members is a significant reason we have achieved Excellent Accreditation from NCQA for 12 consecutive years.

4 PLEASE SHARE WITH YOUR APPROPRIATE CLINIC PERSONNEL SPRING 2014 Hot Topics Important: To ensure that your questions are answered by the appropriate person, we have created new addresses. Please use one of the following addresses that best fit your questions: Benefit or Eligibility or General Inquiries: Subrogation/Workers Compensation: Claim Inquiries: COB Inquiries: Diagnostic coding accuracy is necessary to promote accurate determination of a patient s risk factor score for Hierarchal Condition Category (HCC) coding. Hierarchal Condition Category coding and cancer Coding of a cancer diagnosis can be tricky. Most active cancer diagnoses are associated with a HCC code. An active cancer is: A cancer that is receiving current treatment, or A cancer for which treatment is not pursued Current treatment includes surgery, radiation, chemotherapy or oral medications (even if maintained long term, as is often the case in breast or prostate cancer). Coding guidelines for cancer state that, when a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to the site and there is no evidence of any existing primary malignancy, a V10, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy. A personal history of cancer is not associated with a HCC code. Additional information about HCC coding is available on the Security Health Plan website at: We re pleased to report that the initial round of testing with several of our network providers for professional claims through ICD-10 coding has been successful. More than 99 percent of the claims tested accurately, with both ICD-9 and ICD-10 coding resulting in identical pricing. Initial ICD-10 testing successful With the transition to ICD-10 delayed until no earlier than October 1, 2015, the Plan will pause most of its scheduled testing with providers. Dave Marksteiner, Director of Information Systems, said Security Health Plan will continue to monitor CMS and industry guidance and likely will restart testing with providers early in He added that Security Health Plan would be open to test ICD-10 sooner if requested by a provider. Visit our website regularly for updates at We can help with information and answers to your questions. Contact our Provider Relations and Contracting Department at or by at shpprd@securityhealth.org.

5 Hot Topics Verify member eligibility and network Bonus plan aligned with 2014 state performance targets Important information regarding clinical practice guidelines In order for a member to receive benefits, they should seek care from an in-network health care provider. Security Health Plan offers different networks of providers based on the product members have purchased. Security Health Plan s ACA compliant Reliance or Select products offer our Exclusive Provider Organization (EPO) network of providers. This network is made up of primarily the following provider groups; Marshfield Clinic, Ministry Medical Group, and HSHS Medical Group. Some of our members are confused about their provider network and have sought care from providers who are not a part of this network. This has led to unexpected out-of-pocket costs related to the services they ve received and increased patient responsibility denials to providers. To prevent this from happening, please verify that you are an in-network provider for the Security Health Plan product that the member whom is seeking care has purchased. This information is available on the provider portal by searching a member s eligibility. A letter has been mailed to members instructing them to verify the network of providers they have access to for medical care. Security Health Plan has announced the incentive measures selected for its 2014 BadgerCare Plus Pay for Performance program. Incentive measures are HEDIS measures selected to align with wellness and disease performance targets identified for health plans by the Wisconsin Department of Health Services. When a participating practice meets the minimum 80 percent HealthCheck compliance rate, the practice will be eligible for incentives to be paid in The provider goals for 2014 Pay for Performance are: Antidepressant Medication Management (Continuation) 41 percent (because the measurement year runs from May 1, 2014, through April 30, 2015, this measure will first be included in the 2015 measurement goals with payment in 2016) Breast Cancer Screening 59 percent Childhood Immunization Status 82 percent Initiation and Engagement of AODA Treatment 18 percent (note: the incentive payment is for the engagement portion of this measure only) Comprehensive Diabetes Care/HbA1c Testing 88 percent Security Health Plan s clinical practice guidelines are the foundation of our disease management programs and clinical quality outcome measures. We have adopted evidence-based guidelines developed by the Institute for Clinical Systems Improvement (ICSI). Clinical practice guidelines are available for the chronic conditions of diabetes, asthma, depression, ADHD, cardiovascular conditions, COPD, and nicotine dependence. Health care guidelines are also available for preventive services for adults and for children and adolescents, as well as prenatal and postpartum care. Recently revised guidelines include: Lipid Management in Adults All guidelines may be accessed from our website at When you visit our website, click on Providers, then Provider tools and resources. You can request a paper copy of any of these health care guidelines by calling You can save time and find answers to most of your questions on our website The Provider Portal features instructions and tutorials on Eligibility and Benefits, Claim Status, Prior Authorization and Authorization Look-up, and Checking Coverage Schedule of Benefits. You ll find these tutorials on the Announcements page under Provider Portal Education Materials. If you need assistance navigating Security Health Online or need to talk with someone about a related matter, please call

6 1515 North Saint Joseph Avenue P.O. Box 8000 Marshfield, WI Nonprofit Org. U.S. Postage PAID Security Health Plan of Wisconsin, Inc. and Hot Topics FEATURED INSIDE Transparency tools Explaining vision benefits UCR explanation Pharmacy change ICD-10 update Lipid management BadgerCare Pay for HCC coding and cancer Performance targets NCQA accreditation Provider News: Security health Plan s Provider News is intended to keep providers in our network current with the latest developments in group and direct pay, Medicare, Medicaid and other managed care programs. You can view an electronic version of the newsletter at If there is a topic you would like addressed in Provider News, please contact Terry Anderson, editor, at

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