YOUR PROVIDER NEWSLETTER Introducing

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1 INSIDE THIS ISSUE Medicare Advantage options from Prominence Health Plan... 2 November is Diabetic Eye Disease Awareness Month... 2 Behavioral health coordination of care... 3 Prior Authorization updates... 4 Free flu and pneumonia shots through Northern Nevada Medical Group...5 Prominence pharmacy benefits... 5 CentRx Pharmacy... 6 Make sure your patients know about Advance Directives... 6 Free tobacco cessation support for your patients... 7 Affirmative Statement Regarding Incentives... 7 Important provider network closures in northern Nevada... 7 Coming soon! Open enrollment for the Healthcare Marketplace... 8 YOUR PROVIDER NEWSLETTER Introducing Prominence Health Plan is excited to announce a new partnership with Accolade (accolade.com) to provide our members with their own Accolade Health Assistant, starting in October With Accolade, PHP members will have one person who they can contact for anything related to healthcare. He or she will help with everything from getting a new ID card or decoding a bill, to finding a doctor or understanding treatment options. Since the member talks to the same person or team each time, he or she always gets a personal answer. PHP member support from Accolade BENEFITS AND CLAIMS SUPPORT Eligibility and coverage Billing questions Benefit enrollment options Potential cost savings PROVIDER SEARCHES Doctor, specialist, facility and clinic Other care options Appointment assistance Visit preparation CARE AND CONDITION SUPPORT Health questions and treatment options Medication questions Condition management and lifestyle improvement Behavioral health support PHP provider support While your patients will begin communicating with Accolade regarding claims and benefit questions, there is no change for our provider community. Contracted providers should continue to call Prominence Provider Services at for all inquiries about patient claims, benefits or eligibility. Look for HEDIS Reminder check marks Throughout this newsletter, you may find check marks indicating HEDIS Reminders. These note information about the standards and specifications for HEDIS measures, as well as strategies designed to help practitioners and providers improve the quality of care and service provided to Plan members. Healthcare Effectiveness Data and Information Set (HEDIS) is a set of standardized performance measures designed to facilitate the reliable comparison of managed healthcare plans. Prominence HealthFirst collects and reports HEDIS data annually as part of the Plan s National Committee for Quality Assurance (NCQA) Accreditation process, and in support of quality initiatives and our QualityConnect clinical excellence program. Fall 2015

2 Page 2 Prominence Health Plan Medicare Advantage options from Prominence Health Plan Open Enrollment begins October 15 Medicare Advantage HMO plans are available with prescription drug coverage and can include additional benefits not covered by Medicare. Prominence Health Plan provides an affordable, quality health insurance option to residents of northern Nevada who want a Medicare Advantage HMO Plan with in-network access to local hospitals. The annual Medicare Open Enrollment Period runs October 15 through December 7, Want to know more? 3 Visit prominencehealthplan.com/ medicare 3 Call * *Hours of operation are Monday through Friday, February 15 - September 30, 8 a.m. to 8 p.m.; seven days a week October 1 - February 14, 8 a.m. to 8 p.m. November is Diabetic Eye Disease Awareness Month Diabetic eye disease refers to a group of eye problems that people with diabetes may face as a complication of the disease. People with diabetes are at risk for diabetic retinopathy, cataract and glaucoma. Diabetic retinopathy is the most common diabetic eye disease and a leading cause of blindness in American adults. All people with diabetes, both Type 1 and Type 2, are at risk, which is why everyone with diabetes should get a comprehensive dilated eye exam at least once a year. Between 40 to 45 percent of Americans diagnosed with diabetes have some stage of diabetic retinopathy. During pregnancy, diabetic retinopathy may be a problem for women with diabetes. To protect vision, every pregnant woman with diabetes should have a comprehensive dilated eye exam as soon as possible. Remind your patients that annual diabetic retinal exams are a covered benefit for all Prominence Health Plan HealthFirst HMO and Health Choice PPO members with diabetes.

3 Page 3 Behavioral health coordination of care Studies suggest that collaboration between primary care physicians (PCPs) and behavioral health practitioners result in better care and a higher rate of member satisfaction and outcomes. The National Committee for Quality Assurance (NCQA) also stresses the importance of monitoring the coordination of care between behavioral health practitioners and PCPs. Prominence Health Plan contracts with Magellan Healthcare for behavioral healthcare treatment and services for Prominence HealthFirst HMO and Prominence Health Choice PPO members. Magellan s focus is improving care coordination through collaborative efforts, promoting quality healthcare and improving performance outcomes. Components of the Magellan Medical Integration Strategy include but are not limited to the following: The exchange of information between practitioners and providers Access to and providing information education to PCPs to promote appropriate behavioral health diagnosis, treatment and referrals in primary care Ensuring appropriate use of psychotropic medications Management of treatment access and follow-up for patients with coexisting medical and behavioral disorders One example of how Magellan evaluates continuity and coordination of care activities is through the Magellan Treatment Record Review process. This review process assesses medical record documentation. A behavioral health clinician examines the behavioral health practitioner s treatment records using the Magellan Treatment Record Review Documentation tool. Evidence of coordination of care should be clearly documented in the patient medical record and is evaluated in the following five areas: PCP communication after the patient s initial evaluation PCP communication at the time of a significant change in the patient s status (such as hospitalization) PCP communication after psychiatric evaluation if medications are initiated or treatment/diagnosis indicates medication PCP communication at significant changes in medication (such as a change in drug classification from antidepressant to anti-psychotic) Treatment record reflects continuity and coordination of care between the PCP and: a) psychiatrist, b) ancillary providers, c) treatment programs institutions, d) other behavioral health providers, and/or e) consultants For more information, help and support, please call Magellan Healthcare at for Prominence HealthFirst members or for Prominence Health Choice members. Additional information, self-help tools and other resources are also available online at

4 Page 4 Prominence Health Plan Prior Authorization updates In order to maintain quality and medical management standards, the services provided to our members are continually evaluated. Prominence Health Plan has recently eliminated prior authorization for dermatology care to our HealthFirst HMO members. The health plan will be monitoring claims on a quarterly basis to determine if utilization is appropriate. For benefits, limitations and eligibility, providers should call or Providers may request and receive authorization online via the secure provider portal at As a reminder, below are areas of care where prior authorization is required for both Prominence Health Plan HealthFirst (HMO) and Health Choice (PPO) members with additional services requiring PA for HMO/POS members only at the end. The most current list of prior authorization requirements can always we found on Prior Authorization Required PPO Health Choice and HMO/ POS members Admission to an inpatient or outpatient facility (includes all surgeries; inpatient skilled nursing and acute rehabilitation; does not include OB delivery) Tests including CT, CTA, MRA, MRI, nuclear medicine/cardiac, PET, MUGA; radiation oncology; medical oncology; and spine care (related to neck and back, including surgery, epidurals and trigger point injections) Botox injections Dental care and oral maxillofacial services, temporomandibular joint syndrome (TMJ) services, oral appliances (including sleep apnea appliances) Genetic counseling and testing Hyperbaric oxygen therapy Infusion therapy (outpatient only) Mental health/substance abuse (inpatient and day treatment/ partial hospital and electroconvulsive therapy) Out of network/out of area services Plastic and reconstructive surgery Reproductive endocrinology (artificial insemination services and fertility testing) Transplants and all related services Varicose vein surgery Prior Authorization Required HMO/POS members Durable medical equipment (orthotics, prosthetics more than $500) Nutritional supplements (enteral, parenteral and nutrition; special foods for inherited metabolic disorders) 3-D OB ultrasound All requested services must be medically necessary and are subject to benefit coverage. The member is responsible for checking the summary of benefits for his/her plan or may call Member Services for benefit verification. Choosing a provider that does not participate in a plan s network could result in higher costs or denied claims. Documentation is required for out-of-network exceptions. For continuity and coordination of care, consultative reports are to be provided to other treating providers as needed. Note: Clinical preventive services must meet current US Preventive Services Task Force (USPSTF) Guidelines. For more information, go to

5 Page 5 Free flu and pneumonia shots through Northern Nevada Medical Group Immunization remains an important step in controlling these illnesses. All Prominence Health plan members have access to free flu and pneumonia shots at the 2015 clinics hosted by Northern Nevada Medical Group. Members must present their health plan member ID cards at the time of the immunization. The clinics are for individuals 3 years of age or older. For children 6 months through 35 months, an appointment is required by calling Clinic times and locations Northern Nevada Medical Group 5575 Kietzke Lane, Reno Wednesday, October 21, 5 to 7 p.m. Tuesday, October 27, 5 to 7 p.m. Monday, November 16, 5 to 7 p.m. Monday, November 30, 5 to 7 p.m. Saturday, December 5, 9 to 11 a.m. Northern Nevada Medical Center 2375 E. Prater Way, Sparks Saturday, November 7, 7 to 11 a.m. For more information, call the flu shot hotline at There is no charge for Prominence Health Plan members who present their insurance cards. PHP members can also access flu shots at any participating pharmacy. To find one near you, visit Prominence pharmacy benefits Medicine today is complicated with many prescription drugs available to your patients. To help Prominence Health Plan members get the most out of their pharmacy benefits, it s important for them to understand what is available. To view the most current Formulary Reference Guide and access it online, members can visit Covered pharmaceuticals are classified by generic, preferred brand and non-preferred brand. Additionally, if members have questions regarding their prescription drug plan, they should call the Catamaran Customer Care Department at Catamaran member services representatives are available 24/7 for assistance. FORMULARY UPDATES effective September 1, 2015 Drug Name Tier Status Keytruda Tier 4 Prior authorization required Plegridy TM * Tier 4 Prior authorization required *Quantity limit of 2 pens/syringes in one month and 1 starter pack per year

6 Page 6 Prominence Health Plan CentRx Pharmacy Prescription for convenience Now, residents have full-service pharmacy services available right next to Northern Nevada Medical Center and the NNMC Medical Office Buildings. When they visit the NNMC ER or a doctor practicing in one of the medical offices, the physician can send prescriptions right to CentRx. Patients don t have to leave the campus to get their medications. HERE ARE MORE BENEFITS: A trained, licensed pharmacist Medicare Part D and Prominence Health Plan accepted Over-the-counter drugs and sundry items Easy transfer of prescriptions to a local pharmacy Direct communication with physicians CentRx Pharmacy at NNMC is located in the Vista Medical Terrace in Suite 111. Hours are Monday through Friday, 9 a.m. to 5:30 p.m. For more information, call (Fax: ). Physicians are independent practitioners who are not employees or agents of Northern Nevada Medical Center or Prominence Health Plan. Make sure your patients know about Advance Directives It is important for health plan practitioners who treat patients 18 years and older to be aware of the preferences your patients have regarding Advance Directives and a Living Will or Durable Power of Attorney for their healthcare. If your patient becomes incapacitated, this knowledge could assist you and other treating physicians in their appropriate healthcare-related decision-making. This information should be prominently documented in each of your patient s medical files. An effective approach used by many offices is simple Yes/No questions for the patient to answer on a demographic sheet or a medical history form, such as: Do you have an Advance Directive(s)? Yes No Type of Document: Living Will Durable Power of Attorney for Healthcare Please provide a copy of your Advance Directive to our office for your file. Would you like information about Advance Directives? Yes No To assist you and your office staff, downloadable Advance Directives information and forms can be found on Prominence Health Plan's website at This information is also available in hard copy, upon request, by calling the Prominence Health Plan exclusive practitioner/provider line at or

7 Page 7 Free tobacco cessation support for your patients All Prominence Health Plan members have free access to Tobacco Free Forever, a one-on-one personal phone coaching tobacco cessation program that helps those who smoke or use chewing tobacco quit for good. The program helps participants understand nicotine addiction and recognize their tobacco triggers, create an individualized quit plan and identify a support system. It also teaches behavior modification and stress management techniques in order to prevent a relapse. Members can receive six telephone coaching sessions free of charge and have access to a pharmacy benefit for all prescribed tobacco cessation medications. I just completed two years as a nonsmoker! I never could have done it without your help and support In addition, I used my knowledge to support my boyfriend in finally quitting, too. We re both doing great and use the money that we used to spend on [cigarettes] to go to Mexico twice a year. Thank you! Susan B., Virginia City, Nevada Encourage your patients who smoke to visit www prominencehealthplan.com or call to schedule their free coaching sessions today. Affirmative Statement Regarding Incentives Prominence Health Plan distributes annually An Affirmative Statement Regarding Incentives to all members, employees, practitioners and providers affirming the following: 1. Utilization Management (UM) decision-making is based only on appropriateness of care and services and existence of coverage. 2. The organization does not specifically reward practitioners or other individuals for issuing denials of coverage or service care. 3. Financial incentives for UM decision makers do not encourage decisions that result in under-utilization. For questions about this statement, please call Prominence Health Plan at Important provider network closures in northern Nevada Saint Mary s Medical Group has closed the following Convenient Care Clinics: Spanish Springs Walmart, 5065 Pyramid Lake Highway, Sparks Walmart, 4855 Kietzke Lane, Reno There is no change to Convenient Care services at the following Walmart locations: Carson City, Nevada Gardnerville, Nevada For a complete list of Urgent Care locations, access the Prominence Health Plan website at

8 1510 Meadow Wood Lane Reno, Nevada FPO Coming soon! Open enrollment for the Healthcare Marketplace Enrollment begins November 1, 2015, and goes through January 31, During this time, 2016 Individual and Family Plan coverage will also be available to residents of southern Nevada. Prominence Health Plan will once again feature HMO plans in the federally recognized healthcare marketplace for individuals and families. Northern Nevada residents in Washoe, Storey, Lyon and Douglas counties and Carson City will be eligible to choose from a variety of PHP health plans specifically designed to provide access to an expansive network of physicians and hospitals. And new this year, residents of both Nye and Clark counties will also be able to shop the healthcare exchange for individual and family coverage through Prominence Health Plan. Refer your patients looking for health insurance options to for additional health plan information and online enrollment capabilities. Page 8