health It s Almost HEDIS Time! ROCKY MOUNTAIN

Transcription

1 Care Management Focus Important Pharmacy Update 2018 Medicare Changes Genetic Testing New Resources for Providers Health First Colorado EPSDT Provider Information health ROCKY MOUNTAIN PROVIDER EDITION FALL/WINTER 2017 It s Almost HEDIS Time! Rocky Mountain Health Plans Quality Improvement (QI) department will begin HEDIS data collection and onsite reviews in January, finishing in early May. QI thanks providers in advance for allowing timely access to their offices and providing requested medical records enabling RMHP to meet its HEDIS deadlines.

2 PROVIDER NEWS What to Expect During HEDIS Data Collection RMHP nurses will visit provider offices to collect medical records and perform HEDIS reviews starting in January. Providers also have the option of submitting requested documentation by fax, mailing the records, or allowing RMHP s nurses to access their electronic medical records (EMR) system remotely. Providers interested in learning more about allowing RMHP remote access to their EMR for gathering HEDIS data, should contact QI at before December 31, RMHP will gather information and test the system to determine if data can be gathered securely. Focus on Patients In preparation for the upcoming HEDIS season, QI reminds providers that from now until the end of the year is an important time to focus on closing Member health maintenance gaps. Identify Members who are behind on breast cancer screenings, colorectal cancer screenings, and A1C testing. Encourage these patients to get the recommended screening and testing as needed. Include a copy of these reports in the medical record. Include BMI when recording patients vital signs. Encourage patients with diabetes to have a yearly A1C test, urine microalbumin to monitor for nephropathy, and a yearly dilated or retinal eye exam. If A1C results are >9%, the patient will need additional follow up A1C testing before the end of the year. In child/adolescent well visits document discussions about nutrition and physical activity counseling. Examples include the 5210 Assessment, sports physicals, weight counseling, and notes on current activity levels. Document BMI percentile for patients under 20 years of age and if your office uses BMI growth charts, include a copy in the medical record. Patients up to date on routine screenings and wellness services are taking an active role in their health, and they contribute to favorable HEDIS rates. 2 Rocky Mountain Health

3 2018 Appointment Wait Times Colorado s Division of Insurance defines standards for appointment wait times to ensure patients timely access to health care services. Wait times differ by type of membership. Please use the standards in this table as guidelines for scheduling Members appointments. APPOINTMENT TYPE PRIME CHP+ COMMERCIAL MEDICARE BEHAVIORAL HEALTH Emergent 24/7 24/7 Routine 14 days 7 days Urgent 24/7 24 hours Non-emergent, non-urgent mental health services 14 days 7 days Non-emergent, non-urgent substance abuse disorder 14 days 7 days Prescriber appointments (Psychiatrist) 10 days 10 days Non-prescriber appointments (Psychologist) 10 days 10 days Follow-up routine visit (Psychologist) 30 days 30 days Follow-up routine visit (Psychiatrist) 30 days 30 days MEDICAL Emergent 24/7 24/7 24/7 24/7 Routine 7 days 7 days 7 days 7 days Urgent 48 hours 48 hours 24 hours 24 hours Preventive 30 days 30 days 30 days 30 days Non-urgent, symptomatic 10 days 30 days 7 days 7 days Non-emergent, non-urgent 7 days 30 days 7 days 7 days Prenatal care 7 days 7 days 7 days 7 days High-volume (OB/GYN) 7 days 7 days High-impact (Oncologists) 7 days 7 days Specialty care 60 days 60 days 60 days 60 days After hours phone call Adult, well-care physical exam (annual exam) 45 days 30 days 30 days Child, well-care physical exam (annual Exam) 30 days 30 days 30 days 30 days Rocky Mountain Health 3

4 Important Pharmacy Update On occasion, RMHP must make changes to ensure our Members are receiving the best savings possible. Effective January 1, 2018, RMHP will change to a new PBM, OptumRx,for a more efficient approach to our Members prescription claims. This change means: RMHP Members will receive new ID cards with updated pharmacy information to begin using January 1, Without the information on new ID card, pharmacy claims cannot be processed starting January 1. OptumRx home delivery will become RMHP s new mail order pharmacy provider on January 1, WellDyneRx will no longer be a network pharmacy. Members with open refills at WellDyneRx will receive a letter notifying them their refills will automatically transfer to OptumRx home delivery. Controlled substance medications are not eligible for transfer. Members who have used WellDyneRx since January 1, 2017, will receive communication from RMHP with instructions on how to place future medication orders with OptumRx home delivery. BriovaRx will become RMHP s preferred specialty pharmacy in Kroger Specialty Pharmacy will no longer be in the RMHP network. Specialty drugs are high-cost medications that require special handling, administration, or monitoring. If a Member is using a specialty pharmacy that is not in the RMHP network in 2018, they will receive instructions for transferring their prescription to an in-network pharmacy. Contact information for OptumRx home delivery and BriovaRx will be provided to prescribers in December. Updated Prior Authorization List Available RMHP s Clinical Prior Authorization list was updated October 1, 2017, and posted online. For prior authorization lists and instructions on submitting a prior authorization request go to rmhp.org, I am a Provider, and Provider Resources Quality Improvement Program Rocky Mountain Health Plans maintains its tradition and commitment to constantly seek to improve quality of care and level of service for our Members. The updated Quality Improvement Program Description document will be available this fall and will be included in your provider manual. You may also request information about the performance of the Quality Improvement Program. For a copy of the Quality Improvement Program Description or to request information about the performance of the Quality Improvement Program, contact Maura Cameron, Quality Improvement Director, at (303) or maura.cameron@rmhp.org. 4 Rocky Mountain Health

5 Medicare Changes for 2018 A change to Part D prescription drug coverage from RMHP RMHP Individual Medicare plans will no longer include Part D prescription drug coverage after December 31, Medicare Part D plans, available from private insurance carriers, cover prescription drugs. Now a part of the UnitedHealthcare family, RMHP has invited its Medicare Members to explore Part D coverage from UnitedHealthcare, by visiting or by calling UnitedHealthcare at To avoid a lapse in Part D coverage, Members must enroll in a new Part D plan by December 31, However, because RMHP members are losing Part D coverage involuntarily, they are eligible for a special enrollment period and have until February 28, 2018, to enroll with coverage effective the first day of the month following their enrollment. If RMHP Members do not enroll by February 28, they will be unable to purchase Part D coverage until the next Medicare open enrollment, October 15 through December 7, Affected Members were informed in October that their Part D coverage through RMHP would be ending December 31. PERA group retirees enrolled in RMHP s Medicare plan do not have to take action to enroll in a new prescription drug plan. The RMHP PERA plan will continue to include Part D benefits, underwritten by UnitedHealthcare. Some RMHP Medicare plans not offered in 13 Denver/Metro counties in 2018 RMHP s Green, Thrifty, Standard, and Plus Medicare plans will no longer be offered after December 31, 2017, in Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas, El Paso, Fremont, Jefferson, Larimer, Pueblo, Teller, and Weld counties. RMHP will continue to offer Basic, B Basic, and PERACare plans statewide, including in these 13 Service Area Reduction (SAR) counties. RMHP does not offer Medicare plans in Baca County. The approximately 5,000 affected RMHP Medicare Members were informed in early October that their coverage would be ending December 31, These Members will also receive information on 2018 coverage options in their area. Competitive coverage options from multiple carriers are available in the 13 SAR counties. RMHP Medicare Members affected by these plan closures: Can enroll in 2018 coverage during Medicare s Annual Election Period (AEP), October 15 through December 7, 2017, and avoid a lapse in coverage. Are eligible for a Special Enrollment Period (SEP) because their loss of coverage is involuntary. This SEP gives Members until February 28, 2018, to enroll in new coverage which starts the first of the month following enrollment. Will revert to Original Medicare coverage on January 1, 2018, if they take no action by December 31, To learn more about Medicare Part D coverage from UnitedHealthcare, encourage RMHP Members to visit rmhppartd.org or call Rocky Mountain Health 5

6 PROVIDER NEWS Care Management Focuses on Drug Safety, Complex Cases, and Chronic Conditions Each year the Care Management Department assesses the characteristics of Rocky Mountain Health Plan s (RMHP) membership and develops programs to support needs identified in the review. The following programs, free to RMHP Members, address the most recently identified needs. Drug Safety Program RMHP Members visiting multiple prescribers and using multiple pharmacies to fill controlled medication prescriptions are identified by our Pharmacy department and enrolled in the Drug Safety Program. The program limits these Members to one prescriber and one pharmacy with coverage denied if other prescribers or pharmacies are used. With RMHP s Drug Safety Program: Case managers facilitate appropriate utilization of resources. Adherence to the medication treatment plan is reinforced. Periodic member assessments are performed. Members receive support and education pertinent to their needs. Case managers attend Member appointments with providers as able. Providers can refer an RMHP Member for enrollment in the Drug Safety Program by contacting the Pharmacy Help Desk. Call , fax your request to , or pharmacy.reps@rmhp.org. 6 Rocky Mountain Health

7 Complex Case Management RMHP s Complex Case Management Program uses a team approach to improve the quality of life for Members with complex health needs. Nurses help Members take control of their health care needs and optimize their benefits. Case managers collaborate with the Member s providers, including behavioral health providers. RMHP case managers also have access to community resources to help Members experiencing financial or other challenges because of their health situation. Providers can refer an RMHP Member or contact a case manager to discuss a concern by calling RMHP s referral line at or or by completing a referral at rmhp.org. Click on I am a Provider, and you ll find commonly used forms under Provider Resources. Disease Management RMHP offers a Disease Management Program to educate and provide resources for Members diagnosed with diabetes or congestive heart failure. The Disease Management Program can help: Reduce complications of disease through education and life style changes, Support the Member s treatment plan, and Find additional resources. To refer a patient to RMHP s Disease Management program call or complete an online referral at rmhp.org. Go to I am a Provider, Provider Resources, and Commonly Used Forms. Rocky Mountain Health 7

8 PROVIDER NEWS New Resources Help Providers Navigate the Colorado interchange New Training Resources The Colorado Department of Health Care Policy and Financing (HCPF) has added new resources to its website to help providers and their staff more smoothly navigate with the interchange system, the state s service delivery model. Recently, two new billing resources were developed: Billing Workshops for CMS 1500 and UB-04. Additional resources are planned, so check back frequently to see what s available. Existing and new trainings are in the provider resources section of the department s website at colorado.gov/hcpf/our-providers. As a reminder, HCPF frequently revises the Known Issues Web Page & Updates page (colorado.gov/hcpf/knownissues) with new issues, work arounds, and updates. Regional Field Representatives Now Available Regional Field Representatives are here! The State s fiscal agent and claims system vendor, DXC Technology, now has regional field representatives to assist with training and technical support related to the Colorado interchange. Field representatives can assist providers with specific claims denial questions, PAR questions, portal errors, and provider enrollment questions. Field representatives will begin offering regional provider training sessions in late fall Providers are encouraged to reach out to their regional representative with training topics. Go to colorado.gov/hcpf/regional-provider-support, and click on your county to contact your field representative. 8 Rocky Mountain Health

9 RMHP Prime and CHP+ Members Rights and Responsibilities The following text is reproduced from the Member Handbook. This information has also been included in the Provider Manual for your information. It is your right to: Get information about RMHP services, doctors, and health providers and to get information about your rights and responsibilities Be treated with respect and with recognition of your dignity and right to privacy Accept or refuse medical treatment to the extent provided by Colorado state law and to participate in making decisions about your health care Have open discussion with health care providers about appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage, and presented in a manner appropriate to your condition and ability to understand Make appeals and to bring complaints to RMHP, the Insurance Commissioner of the State of Colorado, or the Department of Health Care Policy and Financing Be furnished health care services in accordance with federal health care regulations for access and availability, care coordination, and quality Freely exercise your rights without being treated differently Be free from the use of physical restraint or being isolated. These methods may not be used to make you cooperate, to punish you, for the ease of the caregiver, or as a way of getting back at you Get family planning services from any Health First Colorado provider, in or out of RMHP s network, with no referral Request and receive your medical records and to have them changed according to federal law Get a second opinion Make recommendations regarding RMHP s rights and responsibilities policy It is your responsibility to: Choose a Primary Care Physician (PCP) for each member of your family and to let that PCP know of any advance directive regarding your medical care Let your PCP direct your care with specialists and other health care providers, except in cases of medical emergencies, urgent care when outside the service area, obstetrical or gynecological care, and eye care Learn about your RMHP health care benefits, procedures, and limitations, and to be cooperative and considerate with health care providers and staff Notify RMHP Customer Service of membership or address changes, marriage, birth of a child, or adoption of a child Take responsibility for copayments and costs for certain health care services and any services that are not covered by Colorado Medicaid Provide the health care provider with all information needed for you to receive appropriate care and to follow the care and instructions agreed upon with your provider Understand your health problems and participate in making treatment goals Tell RMHP about any other insurance you may have, including Medicare File a complaint or grievance; please follow the rules as described in the Appeal and Grievance section of the provided handbook Rocky Mountain Health 9

10 Health First Colorado (Colorado s Medicaid Program) EPSDT Provider Information All children and adolescents age 20 and under who receive care under Health First Colorado have a special benefit called EPSDT. EPSDT stands for Early and Periodic Screening, Diagnosis and Treatment. The goal of EPSDT is to ensure that children and adolescents through age 20 receive age-appropriate screening, preventive services, and treatment services that are medically necessary to correct or ameliorate any identified conditions. EPSDT is key to ensuring that children and adolescents receive appropriate preventive, dental, hearing, vision, mental health, developmental, and specialty services. Referral and transportation/ scheduling services are also available. More information about EPSDT is available at rmhpcommunity.org/epsdt. This link has information about: Recommended periodicity schedule Community resources How to refer to services such as oral health and vision services More information about EPSDT, such as what is covered by RMHP and services available through other Health First Colorado providers Other important services, such as lead toxicity screening Ask RMHP if you have questions about EPSDT or how to get medically-necessary services for children and adolescents covered under Health First Colorado. Go to rmhpcommunity.org/epsdt for more information. Vendor Change in Behavioral Health Services Effective January 1, 2018, Optum Behavioral Health will replace Beacon Health Options as RMHP s behavioral health services vendor for utilization and case management for Medicare, CHP+, and Commercial Members. In preparation for this change, RMHP s online Prior Authorization list has been updated. Details about this change, including contact information for Optum Behavioral Health will be distributed in December. 10 Rocky Mountain Health

11 PROVIDER NEWS Genetic Testing The number of genetic tests available has grown exponentially in recent years, and it s important to keep the following points in mind when ordering tests for RMHP Members. In general, genetic testing requires prior authorization. RMHP uses evicore to prior authorize these tests. Medical geneticists and doctors at evicore continually evaluate the evidence and create and update the policies outlining the criteria for approval. RMHP medical directors give evicore feedback on provider and member concerns. The evicore number for questions regarding genetic testing prior authorization is Copies of the clinical criteria for specific genetic tests and conditions may be requested at resources/pages/providers.aspx. If you do not obtain prior authorization for genetic testing, the claim for the test will not pay, creating administrative costs down the line for the appeals process. Without a prior authorization for a non-network (non-contracted) lab, the claim will not pay, and if on appeal it is found the test does not meet the evicore guidelines, the Member may be responsible for the cost of the testing. This often runs in the thousands of dollars. In general, if you are thinking of ordering genetic testing for risk stratification, it is nearly always a good idea to have the Member see a genetic counselor first. The counselor can determine which genes are most important to order. Although many companies offer multi-gene panel testing for hereditary cancer syndromes, often testing for 10 to 20 genes, these panels may not be paid for if they are not prior authorized. Non-invasive prenatal testing (NIPT) is standard of care. CPT code is generally covered in women with singleton pregnancies. CPT code for microdeletions is not covered at this time. If you order a panel that includes both codes, the claim will reject. Medicare has its own rules about genetic testing. Some are national rules (NCDs), others are regional (LCDs). This is all summed up nicely by UnitedHealthcare in a 27-page.pdf. To find the UnitedHealthcare document, use your favorite search engine and the search terms: UnitedHealthcare Medicare rules for genetic testing. If you have questions about genetic testing, don t hesitate to call Care Management before you draw that blood. It may save your patient some headaches, which are not hereditary and can be avoided. Rocky Mountain Health 11

12 PRSRT STD U.S. Postage Paid Grand Junction, CO Permit No. 243 Steve ErkenBrack President and CEO Kevin R. Fitzgerald, MD Chief Medical Officer PO Box Grand Junction, CO Front Range, Eastern Plains, and San Luis Valley Professional Relations: or Western Slope Professional Relations: or Please route this important information to: Physicians Office Manager Billing Office Receptionist Other UPDATED FORMULARY INFORMATION ONLINE To view periodic formulary changes, including new drugs and generics, visit our website at rmhp.org/i-am-aprovider/provider-resources and scroll down to View Formulary changes. To view the most up-to-date, complete formulary, visit rmhp.org/formulary or call or (TTY: 711) and we will mail you a copy of the @RockyMtnHealthPlans rmhp.org/blog