Network Updates. THC Successfully Implements New Medical Management Tool Authorization Numbers Change

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1 Network Updates March/April 2015 Totally Connected.. THC Successfully Implements New Medical Management Tool Authorization Numbers Change THC is pleased to announce the successful launch of our new medical management tool. Like any implementation, there are some changes that we must adapt to, so we appreciate your patience during this phase-in time. Additionally, this implementation has resulted in some process changes you need to be aware of: 1. Viewing authorizations in the portal. The UM department will continue to clinically review services that require a prior authorization and enter the decision for approval into our new Medical Management tool. Then there is a short lag time for the information to download into the portal for viewing by the provider. Therefore, if there is an urgent request and the authorization isn t available in the portal, please contact our UM department for the information. This should not affect any services that are authorized in advance of the service date. Reminder: Determinations for urgent requests will be processed within 72 hours; Routine requests will be processed within 14 calendar days. 2. Authorization numbers will look different. The new system will allow for a distinction between inpatient admissions and outpatient referrals: A) Inpatient admissions will have an authorization number that begins with the letter A followed by 12 digits (several are leading zeros). The A signifies the service is inpatient and has been reviewed clinically by THC. B) Outpatient services that require clinical review and approval by THC (such as bunion surgery, blepharoplasty) will have a referral number that begins with the letter R. The R signifies that the service has been reviewed clinically by THC. Currently, referrals entered into the portal by the PCP will be available for immediate viewing by the PCP and specialist; and the configuration of the referral authorization number remains unchanged. You can tell the distinction as there is no alpha character preceding the authorization. Therefore, any service that requires prior authorization that does not have an authorization number beginning with an alpha A or R has not been appropriately approved and should be considered ineligible. Claims will be denied for lack of authorization if the appropriate authorization has not been obtained. To review the list of services that require prior authorization or referral, go to > Provider Page > Referral & Prior Authorizations > Authorization Grid. Our Mission: To be the industry leader in providing quality, cost effective health care for our members

2 Quality Improvement Quality Improvement Program Total Health Care s (THC) Quality Improvement Program (Quality Assessment and Performance Improvement Program) is based on the principles of continuous quality improvement. The QI Program s purpose is to provide a framework that enables THC to ensure Plan members have access to and receive high quality health care and preventive services that promote wellness. It is designed to meet state and federal requirements and is structured to meet accreditation standards. The QI Program applies to all Total Health Care product lines. Annually, Total Health Care evaluates its quality improvement activities and updates the program as necessary. A yearly work plan is developed that reflects specific objectives, activities and performance measurements for improving the quality and safety of clinical care, the quality of service, and member s experience. Upon request, THC will provide information to members and practitioners about the QI Program, including a description of the QI Program, and a report on the Plan s progress toward achievement of annual goals. Information about the Program is also available on THC s website Click on the Providers tile - under the More Information tile click on the Documents and Additional Info link, then Quality Improvement. Clinical Practice Guidelines Total Health Care s Quality Improvement Committee is continually focused on offering evidencebased recommendations to improve positive health outcomes. The following CPG developed by MQIC (Michigan Quality Improvement Consortium) has been approved for use by our Quality Improvement Committee: Diagnosis and Management of Adults with Chronic Kidney Disease Access to this and other approved MQIC Guidelines is available on the THC website, wwwthcmi.com > Provider page > Clinical Resources. UM decision-making criteria is available to practitioners upon request. Call 844-THC-DOCS to request this information. Page 2

3 Pro-HEDIS Tool ProHEDIS ~ Online HEDIS reporting Tool The 2015 HEDIS gaps in care measures are expected to be released in mid-april. Data will be refreshed with performance data based on claims received in THC is working to incorporate performance data received from electronic registry and lab feeds within the coming months. In the interim, providers can use the tool to obtain patient-level detail on needed measures, and selfreport measures in the portal. Please note, all self-reported measures MUST be accompanied by documentation that can be uploaded into the tool using a PDF, or faxed. Without documentation, self-reported information will not count towards your report card. For training on the tool, please contact your Provider Relations representative. See page 11 to determine your assigned representative. Find a doctor You can search for a participating doctor in the THC network using the Find a Doctor tool at / find-a-doctor. Enter a ZIP code and type a provider s name or specialty and click Search. For more specific criteria or facility service line requests, such as therapy or diagnostic & imaging, click on Advanced Search, select Professional or Facility, enter your zip code and click Submit. You can print any of your results by clicking on the PDF icon. Page 3

4 Quality Improvement Adding Members to Closed PCP Panel Effective April 1, 2015 Primary Care Physicians with closed patient panels will no longer be allowed to selectively add new patients to their closed patient panel. The past practice of arbitrarily selecting to add members is discriminatory and will no longer be allowed. THC will consider individual circumstances if a practice can substantiate that a new THC member had a past active history with the practice. It is advantageous to open your PCP panel if you have less than 300 members. An open patient panel is needed to participate in our 2015 P4P program. Call your Provider Relations Representative if you have any questions. Physicians must have an open panel no later than June 30, Member Engagement & Access As a participating provider with THC, we need to work together to best service the needs of our patients. THC is committed to ensuring our members have access to the right care at the right place and in a timely manner, which is defined as within 30 days for a routine office appointment or well visit, within 7 days for a routine non-urgent but symptomatic appointment and within 24 hours for an urgent need. Additionally, Healthy Michigan members need to be appointed with their PCP for the first visit within 60 days of enrollment, and seen within 150 days. PCP offices should access and review eligibility rosters (available through the Provider Portal) every month to determine newly assigned patients and reach out to them to come into the office for a visit. We ideally want all our members to obtain an initial assessment of their health status within 90 days of enrollment with the plan. Establishing the doctor-patient relationship is essential to health management and encouraging patients to take responsibility for their own health. However, we recognize that not all members will take that initiative, so we ask that you put forth your best efforts to reach out to your assigned members. So, what s the pay off? Improved HEDIS Scores Increased Pay for Performance Dollars Improved Patient Satisfaction Increased Revenue Contact your Provider Relations Representative today if you have questions or need help assessing this information.

5 Medical Record Documentation THC is providing information about the requirements of medical record documentation to help physicians ensure what they are billing on their claims is supported in the medical record. THC has seen many examples of unsubstantiated codes based on medical record documentation. This information is submitted as a help aid and should in in no way be interpreted that THC is telling physicians how to bill their claims. Principals of Documentation What is documentation and why it s important? Medical record documentation is required to record pertinent facts, findings and observations about an individual s health history including past and present illnesses, examinations, tests, treatments and outcomes. The medical record chronologically documents the care of the patient and is an important element contributing to high quality care. The medical record facilitates: The ability of the physician and other healthcare professionals to evaluate and plan the patient s immediate treatment, and to monitor his/her healthcare over time Communication and continuity of care among physicians and other healthcare professionals involved in the patient s care Accurate and timely claims review and payment Appropriate utilization review and quality of care evaluations Collection of data that may be useful for research and education Serves as a legal document that describes a course of treatment (Excerpt from the 1995 Documentation Guidelines for Evaluation and Management Services) Components of Good Documentation A medical record contains many components including the following: patient registration form, consent to treat, HIPAA notice, medical history, medication list, problem list, preventive screenings, encounter form, practitioner orders, consultation reports, operative notes, nursing notes, laboratory reports, immunization records and discharge planning. Many providers document the visit on a patient encounter form or a progress note. A common technique used to document the visit is called SOAP: Subjective, Objective, Assessment and Plan. This method may also be referred to as MEAT: Monitor, Evaluate, Assess and Treat. Subjective Includes reason for the visit, review of patient s history of present illness, past social and family history and review of systems. Objective Includes the provider s findings from the exam Assessment Includes the thought process of the provider after reviewing patient s symptoms. Includes diagnosing patient and documenting significant findings, signs and/or symptoms Plan - Plan of care to treat a patient s condition including tests, treatments, procedures, directions given to patient, consultations and follow up. Continued on page 3 Page 5

6 Medical Record Documentation continued Other key documentation requirements include: 1. Medical record entries should be accurately dated and signed by the person providing the service. A licensed Provider must co-sign any documentation performed by a non-licensed provider or other personnel (medical assistant, nurse..) 2. Entries should be made in black ink in a paper chart and must be legible 3. All pages of the medical record must contain the Patient s name and date 4. Medical records may be dictated, handwritten, recorded on a form or entered into an Electronic Health Record system. Dictated records must include date of dictation and date of transcription. 5. All signatures must be legible. A signature log or attestation statement may be used to identify an illegible signature. 6. Date and time must be documented on progress notes and procedures 7. All orders must be signed by Licensed Provider prior to services being rendered. Late signatures may not be accepted if record is audited. If an order for a test/procedure is unsigned, it may be supported if intent to order test(s) is documented in the Progress notes. 8. If signature is missing from order and the intent is not derived from the progress notes, the unsigned order will be treated as though it was not received. 9. Service(s) must be reasonable and necessary 10. Indicate Late Entry for out of sequence entries 11. Do not black out any entries. If there is a mistake, draw a line through the error and initial and date. For Electronic Health Records, a reliable means to clearly identify the original content and modified content, date and authorship is required. 12. Do not cut and paste notes from one record to another. All entries are unique to patient. Selecting appropriate Diagnosis and Procedure Codes from the Medical Record ICD-9 and ICD-10 coding instructions are listed in the front of the Coding manual. Section IV provides guidance for selecting appropriate diagnosis codes for Outpatient Hospital and Physician Office settings. Guidelines indicate that Providers should select diagnosis codes that describe the reason for the encounter. If a diagnosis cannot be determined, code the signs and symptoms. A provider may include additional codes that describe co-existing conditions that are being treated during the encounter. Do not code conditions that were previously treated and no longer exist. However, do use a history code if it has an impact on the current condition or influences treatment. A provider may report chronic diseases that are treated on an on-going basis. Total Health Care requires chronic conditions to be reviewed by provider each year and reported on a claim. Diagnosis codes and CPT-4 codes can be billed if they are documented in the medical record as being treated and are medically necessary.

7 Evaluation and Management (E & M) Documentation Evaluation and Management (E/M) service guidelines are in the CPT-4 manual at the beginning of the E/M section. There are several categories of E/M codes based on place of service and type of patient (new or established). Each category is further defined by the level of E/M. The levels of E/M services encompass the wide variations in skill, effort, time, responsibility and medical knowledge required for the prevention or diagnosis and treatment of illness or injury and the promotion of optimal health. (Excerpt from the 2015 E/M guidelines in the CPT-4 manual) Medicare publishes an Evaluation and Management Services Guide that includes more detail in selecting an E/M level and provides two variations of guidelines: 1995 guidelines and 1997 guidelines. The 1997 guidelines are more detailed than the 1995 guidelines. There are specific differences in documenting the History of Present Illness and the Physical Exam. Providers should consistently use one version for their guidelines. E/M documentation includes seven components: History Medical Record Documentation continued Examination Medical decision making Counseling The first three components, History, Examination and Medical decision making are key components used to select the level of E/M code. The other components contribute to selecting an E/M level by providing more detail about the service and medical decision making. If a provider spends more than 50% of their time counseling and coordinating care with patient and/or family face to face, then time shall be considered the key or controlling factor to qualify for a particular level of E/M service. Documentation of History Accurately recording a patient s history is an important part in selecting the appropriate E/M level. There are four key elements that comprise a patient s history: Chief Complaint (CC) reason for encounter Coordination of care Nature of presenting problem Time History of Present Illness (HPI) development of the patient s current problem Review of Systems (ROS) review of body systems directly related to problem Past Family and/or Social History (PFSH) related to illness and disease History of Present Illness, Review of Systems and Past Family and/or Social History are defined further by the level of detail documented. This level of detail is dependent on clinical judgment and the chief complaint. This detail is used to assist providers in choosing the Type of History. This detail is covered in the E/M Guidelines found on the CMS website. See chart below: Type of History Chief Complaint HPI ROS PFSH Problem Focused Required Brief N/A N/A Expanded Problem Required Brief Problem Pertinent N/A Focused Detailed Required Extended Extended Pertinent Comprehensive Required Extended Complete Complete

8 Medical Record Documentation continued Documentation of Examination A provider examines the body areas and organ system(s) that are identified in the history of present illness. There are four Examination types: a. Problem Focused limited exam of the problem area b. Expanded Problem Focused exam of problem area and other symptomatic organ systems c. Detailed exam of problem area and other symptomatic organ systems (multiple systems) d. Comprehensive complete exam of organ system or multisystem exam 1995 Guidelines are not as specific as the 1997 Guidelines. The 1997 Guidelines have specific details about reviewing key body areas and organ systems. Both guidelines recommend that specific abnormal and relevant negative findings of the affected or symptomatic body area(s) or organ system(s) should be documented in detail as should any findings for asymptomatic body area(s) or organ system (s). Documentation of Medical Decision Making Medical Decision Making is the thought process conducted by a physician using his/her training, experience and expertise to determine what the problem is and how best to treat the condition. The following elements contribute to medical decision making: a. The number of possible diagnoses and management options b. The quantify of medical records that must be reviewed c. The number of tests that should be ordered d. The risk of complications, the rate of sickness(morbidity) or the risk of death (mortality) e. Impact of condition on patient s health f. Severity of presenting problem There are four categories for medical decision making based on the elements listed above: a. Straightforward minimal decision making required zero to one element above b. Low Complexity decision making includes two to three of the elements above c. Moderate Complexity Several of the elements above d. High Complexity Many of the elements above To assign an E/M level code, read the specific instructions in the CPT-4 manual to determine the number of elements required to assign the level. Many E/M codes require all three elements to select the code (History, Examination and Medical Decision Making) or two out of the three elements. The code selection is based on meeting or exceeding the levels of the key components. 1. Check code description to determine whether 2 or 3 elements must be met 2. Review the documentation and match it to the level descriptions for each component 3. Determine the highest level met (equal to or more than the requirements) 4. Compare the levels of each key component and choose the highest level of code for which all key components have been met.

9 Medical Record Documentation continued Example: Setting: Office Visit (three of three components must be met) Chief Complaint: New patient presents with runny nose, coughing and headache HPI- No fever, No meds, No allergies PFSH Family history Asthma (mother), COPD & Lung Cancer (Grandfather), Patient smokes ½ pack per day but is trying to quit. ROS BP 120/86, R-18, P-80, Eyes- inspects conjuctivae/lids, EAC/TMs inspected, Nasal mucosa/turbinates, Neck no masses, Lungs CTAB, good resp effort, Cardio-CTA. MDM Sinusitis, R Given Z-Pak, Information on smoking cessation given History Expanded Problem Focus Exam Expanded Problem Focus MDM Moderate CPT Select This code requires an expanded problem focus history and exam and straightforward decision making. The history and exam meet the requirements for Expanded Problem Focus but the medical decision making is Moderate and meets or exceeds the requirement for the code. Therefore is the appropriate level. By using the SOAP note technique, E/M level selection should be easily achieved. Documentation takes effort but is very important to care for the patient appropriately and to ensure the physician receives adequate reimbursement and safeguards against audits and legal issues. There are many resources to learn about documentation improvement. Please visit the websites of these organizations to search for more information: CMS, AAPC, AHIMA, AMA and organizations for certain specialties. Billing Medicaid Recipients for Medicare/Medicaid Dual Eligible Members THC is receiving many calls from Medicaid recipients stating that they are being billed by providers for Medicare/ Medicaid services. The following is Medicaid policy concerning the processing and payment of Medicare Crossover claims. Providers are responsible for establishing internal billing procedures to ensure that Medicaid recipients are not being inappropriately billed for Medicare/Medicaid services. Please note that Medicaid does not necessarily pay the full Medicare deductible and co-insurance on a claim. Providers may not balance-bill recipients in these instances. Dual eligible are recipients who have Medicare and Medicaid coverage. Medicaid will reimburse the provider an amount up to the full amount of Medicare s statement of liability for co-insurance and deductible for the beneficiary. For claims in which Medicare s reimbursement exceeds the maximum allowable by Medicaid, Medicaid will zero pay the claim. This means that the claim Explanation of Payment will have a $0 shown in the payment column. This claim is considered paid in full and the provider may not seek additional remuneration from the recipient. Per Medicaid guidelines, Total Health Care will pay up to the Medicare deductible and coinsurance on Medicare approved claims for beneficiaries receiving both Medicare and Medicaid, provided the procedure is covered by Medicaid. Medicaid will reimburse the provider an amount up to the full amount of Medicare s statement of liability for coinsurance and deductible as long as it does not exceed Medicaid s allowable reimbursement for the service. Total Health Care will zero pay the claim/claim line when Medicare s reimbursement exceeds the maximum allowable by Medicaid. For more information regarding the prohibition on balance-billing Qualified Medicare Beneficiaries (QMB) for Medicare cost-sharing, including deductible, coinsurance, and copayments please visit

10 Pharmacy Updates Drug Prior Authorization Criteria THC s Pharmacy Department ensures that drugs provided to members are medically necessary and appropriate. Under the direction of the Medical Director, Pharmacy staff consistently applies THC written criteria when making benefit and medical necessity determinations. The criteria are based on facts and nationally accepted standards. Coverage denials are made by a board certified physician. Prior Authorization Criteria for prescription drugs is available to providers upon request by contacting the Pharmacy Department in writing or by calling THC at , press extension Pharmacy Access to Staff Pharmacy staff are available Monday through Friday during normal business hours from 8:30-5:00 to answer questions and provide information on Prior Authorization requests. Communications received after normal business hours via phone, or fax, are responded to the next business day. Communications received after midnight on Monday through Friday are responded to on the same business day. Pharmaceutical Management Procedures THC s Drug formularies and Prior Authorization forms are available on THC s website at Each formulary includes a list of covered drugs that may include restrictions and preferences, limits or quotas, generic substitution, step therapy, prior authorization and notes the tiering level of a drug. An explanation of all restrictions is noted on each drug formulary. THC s Pharmacy & Therapeutics Committee meets quarterly. Formulary updates are available on the website and providers are notified via , when changes are made. Drug formularies and pharmaceutical management procedures are available to providers upon request by contacting the Pharmacy Department in writing or by calling THC at , press extension Drug Exception/Prior Authorization You may requests a Drug Exception or Prior Authorization if the use of other formulary agents is contraindicated in the member, if a member has failed current formulary options as listed in the Therapeutic Drug Formulary or the continued use of current formulary options would be of no clinical benefit for the member. An exception or prior authorization form is available on THC s website at and may be submitted with clinical information to THC s Pharmacy Benefit Manager, EnvisionRx Options by faxing the information to EnvisionRx Options is available 24 hours a day at Diabetic Supplies Total Health Care contracted with J&B Medical Supply to manage distribution of diabetic supplies. For questions about diabetic supplies, contact J&B Medical Supply at

11 Pharmacy Updates Drug Formulary Updates Effective April 2015 MIChild / MIChild- CSHCS Formulary Affected Medicaid/ 3- Medication Update CSHCS Commercial Tier Duloxetine 20mg, Added with Quantity Limit (QL) of 30mg, and 60mg one capsule daily. Escitalopram 5mg Added with QL of one and one-half and 10mg tablet daily. Escitalopram 20mg Added with QL of one tablet daily. Celecoxib 100mg and 200mg Fluvoxamine ER 100mg and ER 150mg Paroxetine ER Pristiq Venlafaxine ER (Tablets) Clomipramine 25mg, 50mg, and 75mg Desipramine Tablets Hydromorphone ER Tablets Oxycodone 5mg (Capsules) Oxycodone 5mg, 15mg and 30mg tablets Morphine Sulfate 30mg Morphine Sulfate ER 30mg, 60mg, and 100mg Percocet 5mg Percocet 7.5mg and 10mg Tylenol with Codeine Added with QL of one capsule daily. Removed (Fluvoxamine IR is covered). Removed (Paroxetine IR is covered). Removed (Venlafaxaine capsules are covered.) Removed (capsules are covered). Removed (formulary Tricyclic antidepressants therapy). Removed (formulary Tricyclic antidepressants therapy). Removed (Hydromorphone IR is covered) Removed (tablets are covered). Quantity Limit of six tablets daily. Quantity Limit of six tablets daily. Quantity Limit of three tablets daily. Quantity Limit of three tablets daily. Quantity Limit of six tablets daily. Quantity Limit of thirteen tablets daily. Hydrocodone Quantity Limit of twelve tablets daily. 5mg/325mg Hydrocodone 7.5mg / 325mg Quantity Limit of six tablets daily. QHP (Exchange) Please call the Total Health Care Pharmacy Department at , extension 3300 for any claims processing questions. You may view the complete drug formularies on THC s website at

12 Get Ready Now With less than a year to go before the October 1, 2015, compliance date, now is the time to get ready. Whether you re a provider, payer, or other health care entity, it s important to prepare for ICD-10 now. Visit the CMS ICD-10 website to learn how to make a plan that fits your needs. By working together, we can make a successful ICD-10 transition. Benefits of ICD-10 Foundational to advancing health care, the ICD-10 code set will replace ICD-9 codes for both diagnosis and inpatient procedures. Among its benefits, ICD-10: Better captures details about chronic illnesses, identifying underlying causes, complications of disease, and conditions that contribute to complexity of a disease Serves as a building block that allows for greater specificity and standardized data to better support patient care and improve disease management Improves data for peer comparison and utilization benchmarking and better documentation of patient complexity and level of care to support reimbursement for care provided Enhances public health surveillance and reporting as well as quality measurement and reporting with robust detail for research and data analysis Using ICD-10, doctors can capture much more detail, meaning they can better understand important information about the patient s health. And by enabling more detailed patient history coding, ICD-10 can help to better coordinate a patient s care across providers and over time. CMS Resources Can Help You Get Ready To help you prepare for ICD-10, CMS recently released two new Medscape videos and an expert column. Available on the CMS ICD-10 website, these resources provide guidance about the transition to ICD-10 with a focus on small practices. Continuing medical education (CME) and nursing continuing education (CE) credits are available to health care professionals who complete the learning modules. Anyone who completes the modules can receive a certificate of completion. The Road to 10 Tool, also available through the CMS ICD-10 website, gives an overview of ICD-10 and answers frequently asked questions. The tool is designed to help small practices jumpstart their transitions. Providers can build an ICD-10 action plan and review tailored clinical scenarios to learn more about how ICD-10 affects their practice. Want more information about ICD-10? Visit the CMS ICD-10 website for the latest news and resources to help you prepare for the October 1, 2015, compliance date. Sign up for CMS ICD-10 Industry Updates and follow us on Twitter.

13 Total Health Care Team Clinical Operations Robyn Arrington, MD Medical Director Linda Alexander, RN Chief Clinical Officer Valeon Waller, RN Manager, Case Management Anita Nesby-Flowers, RN Clinical Coordinator Nancy Williams, RN Quality Kyle Hill Performance Improvement Administrator Pharmacy Karen Bunio Pharmacy Dept Claims LaDawn Wyatt Claims Manager Provider Network Services Susan Ryan Manager Anita Wallace Provider Relations Representatives Networks: Oakwood UOP Independent Physician Practices A-M Monroe Allied Physicians Pamela Long Provider Relations Representatives Networks: Beaumont St John Providence United Physicians OPNS PMC Shelley Clark Provider Relations Representatives Networks: DMC PHO Greater Macomb Olympia OSP Wayne State University Physicians Group Independent Physician Practices N-Z Judith Idris Provider Relations Christina Pittinato Credentialing Maryanne Adam Network Analyst Gary Francis Network Development Page 13