CONNECTIONS A. Promoting continuity of care during behavioral health treatment. Year-End Provider Incentive Program to Improve Member Health Outcomes

Transcription

1 CONNECTIONS A Transition to Optum : Promoting continuity of care during behavioral health treatment Beginning January 1, 2018, we will offer behavioral health services to health plan members through Optum. Optum s delivery of care model is based on a whole-life case management approach that provides varying types and intensities of support, intervention, and clinical collaboration depending on where members reside on the overall wellness spectrum. This care coordination approach extends beyond invites you to participate in the 2017 Year-End Provider Incentive Program to Improve Member Health Outcomes, which includes a supplemental payment opportunity for each eligible service provided from October 1, 2017, through December 31, How do I participate? Identify members on your panel who require one or more of the eligible services in this program. Eligible members may be identified through the Prestige Analytics Tool (PAT). Your Provider Network Management Account Executive can help you sign up for access to the tool. traditional behavioral health case management to be more inclusive, identifying and supporting members before they have a behavioral health event, while they are in treatment, and after treatment to maintain their recovery. The Optum model also leverages case managers who liaise between members families and/ or caregivers and their medical providers to align treatment Schedule appointments with the identified members and provide the required eligible services from October 1, 2017, through December 31, 2017, and submit a claim for each encounter. Submit the eligible services you provided by including the appropriate Current Procedural Terminology (CPT) codes and following your normal claim submission procedures. Supplemental reimbursement of $25 is available for each eligible service provided: Breast Cancer Screening (BCS). Adults Access to Preventive/ Ambulatory Health Services (AAP). Provider s Link to goals to more effectively close care gaps. This includes working with our network physical health providers to review current treatment and progress towards recovery goals. To learn more about Optum s delivery of care model, please visit or call Year-End Provider Incentive Program to Improve Member Health Outcomes Children and Adolescents Access to Primary Care Practitioners (CAP). Adolescent Well-Care Visits (AWC). Comprehensive Diabetes Care (CDC). If you have questions about this program, please contact your Provider Network Management Account Executive or Provider Services at We thank you for your participation in the Prestige Health Choice provider network and for your continued commitment to our members ISSUE 4 Articles in this edition 2018 Provider Satisfaction Survey coming in Q1 Transition to Optum : Promoting continuity of care during behavioral health treatment Year-End Provider Incentive Program to Improve Member Health Outcomes Introducing the Let Us Know program Provider Appeals department will review provider complaints New List of HCPCS codes updates prior authorization requirements over-the-counter repellent coverage Help your patients earn rewards for healthy behaviors, including mammograms How our Utilization Management program works for providers Drug formulary resources available for Prestige Health Choice Flu season is here! mobile app now available in Haitian Creole Compliance Corner: Federal False Claims Act Care Now SM family planning program Risk management: Issues for patients after discharge Clinical practice guidelines help guide members' treatment HEALTH CHOICE Leading the Way to Quality Care

2 Introducing the Let Us Know program The Let Us Know program is a partnership between Prestige Health Choice and the provider community, to collaborate in the engagement and management of our chronically ill members. We have support teams and tools available to assist in the identification, outreach, and education of our members, as well as clinical resources, targeted for providers, for their care management. There are three ways to let us know about chronically ill members. Contact our Rapid Response and Outreach Team. They are here to support you. The team addresses the urgent needs of our members and supports providers and their staff. The Rapid Response and Outreach Team consists of registered nurses and Care Connectors who are trained to assist members in investigating and overcoming barriers to achieving their health care goals. Call , Monday through Friday, from 8 a.m. to 6:30 p.m., or fax a member intervention request form, available at www. prestigehealthchoice.com, to Use the Availity care gap report. When checking member eligibility, your office will receive popup alerts that indicate members who are at risk due to missing or overdue preventive services or underutilization or absence of disease-specific controller medication. Run a care gap query report and contact the Rapid Response and Outreach Team to request outreach to a member. Refer a patient to the Complex Care Management program. Complex Care Management is a voluntary program focused on prevention, education, lifestyle choices, and adherence to treatment plans. It is designed to support your plan of care for patients with chronic diseases, such as asthma, diabetes, or coronary artery disease. Members receive educational materials and, if identified as high risk, will be assigned to a Care Manager for one-on-one education and follow-up. For more information, or to refer a patient to the Complex Care Management program, call Provider Appeals department will review provider complaints The Complaint department will now be known as the Provider Appeals department. The Provider Appeals department reviews provider appeals related to denied and underpaid claims, denied authorizations, and administrative complaints. How to contact the department: Call: once an appeal has been filed. Write:, Provider Appeals Department, P.O. Box 7366, London, KY Fax: Online: Download our provider appeal form at resources/provider-appeal-form.pdf New List of HCPCS codes updates prior authorization requirements A comprehensive list of Healthcare Common Procedure Coding System (HCPCS) codes for medications that require prior authorization has been developed to replace previous authorization requirements, including for infusion or injectable medications with charged amounts of $250 or greater per line item when administered in an outpatient setting. The HCPCS list and the changes to prior authorization will be effective December 8, To submit medication requests containing an HCPCS code that requires prior authorization, fax the request to the PerformRx Prior Authorization team at For any questions, call PerformRx at The HCPCS codes list and the latest request forms are available on the provider prior authorization page of the Prestige Health Choice website at Connections A Provider s Link to the Health Plan

3 Prestige Health Choice over-thecounter insect repellent coverage As a reminder, covers over-the-counter (OTC) insect repellents as detailed below. A prescription from the member s health care provider is not required. Approved over-the-counter purchases for members are limited to a maximum of $50 per year, per household. The following products are part of Prestige Health Choice s expanded OTC benefits list. Product name Ounces UPC OFF! Family Care 2.5 oz OFF! Deep Woods 4 oz OFF! Deep Woods 6 oz Help your patients earn rewards for healthy behaviors, including mammograms OFF! Active 6 oz Cutter Skinsations 6 oz Cutter Backwoods 6 oz Repel Sportsmen 6.5 oz Repel Sportsmen Max Formula 6.5 oz follows guidelines set forth by the American College of Physicians recommending annual mammograms for women ages members can earn a $10 reward for completing a mammogram. Prior authorization is not required. Please encourage your patients to schedule and complete their mammograms. Members can also earn up to $50 in rewards for completing additional Prestige Health Choice Healthy Behaviors program screenings. There is no limit to how many screenings a member can complete. For a complete list of Healthy Behaviors program incentives and associated forms, please visit Inc.

4 How our Utilization Management program works for providers s Utilization Management (UM) staff (i.e., nurses, Medical Directors, and pharmacists) regularly reviews the medical appropriateness of services for which authorization is requested. Approval or denial of coverage for requested services are based on medical necessity, eligibility for outpatient and inpatient services, and benefit guidelines. The medical necessity review is performed using: Nationally accepted medical guidelines. Medical information, including Medicaid benefits and supporting clinical information. does not reward health care providers for denying, limiting, or delaying benefits or health care services. Financial incentives for UM decision-makers do not encourage decisions that result in underutilization. Drug formulary resources available for Formulary detail s comprehensive formulary may be accessed on our website at provider/itn/find-provider/ index.aspx by clicking Preferred Drug List (formulary). This links to the searchable preferred drug list (PDL) on the Agency for Health Care Administration s (AHCA) website. This searchable formulary provides details regarding age limits, prior authorization requirements, and other coverage requirements. On our site, you may also find a link to the Summary of drug limitations, which provides all quantity and age limits for applicable drugs. The formulary is generic friendly. Unless otherwise specified, if a generic equivalent is available for a brand name medication, claims processing rules will require that the generic equivalent be dispensed, or the medication will not be covered. When a non-pdl (nonpreferred) agent or an agent that has an associated edit is inadvertently prescribed, prescribers and pharmacists are encouraged to work together to convert to a preferred formulary agent when appropriate. Clinical edits Various clinical edits, including prior authorization and age limits, are included on the formulary for specific medications. Prior authorization forms and criteria can be accessed from our website at provider/itn/find-provider/ index.aspx. As part of the prior authorization process, providers must complete a prior authorization request form. The form must be fully completed and submitted with all appropriate documentation (medical history, previous therapies tried, additional rationale) which may help us process the request. Incomplete forms or missing documentation may delay or prevent a request from being processed. Current prior authorization forms may be downloaded at provider/itn/find-provider/ index.aspx. The forms are available under the heading Pharmacy Prior Authorization or by clicking AHCA s pharmacy prior authorization forms, which links to the forms located on AHCA s website. PerformRx provides pharmacy benefit management services to. You may fax prior authorization requests to PerformRx at You may call Provider Services at for assistance. For pharmacy questions, call the Pharmacy Help Desk at , 24 hours a day, seven days a week. Upon approval of a specialty authorization, you may forward the corresponding prescription to PerformSpecialty via fax at for prompt service. You can contact them by phone at Formulary changes The AHCA PDL and Changes Summary Report, which lists changes made to the PDL as a result of the last AHCA Pharmaceutical and Therapeutics Committee meeting, may be accessed from the Prestige Health Choice website at www. prestigehealthchoice.com/ provider/itn/find-provider/ index.aspx or on AHCA's website at ahca.myflorida.com/ medicaid/prescribed_drug/ pharm_thera/fmpdl.shtml. Connections A Provider s Link to the Health Plan

5 Continued Drug formulary resources available for In the event that there is a formulary change, various types of communications may be utilized to communicate the change, including letters, fax blasts, web documents, and provider alerts. Any necessary communication will be completed as early as possible, prior to the implementation of a change. Most direct communications will be the result of a negative formulary change, such as removal of a medication from the formulary or the addition of a clinical edit. Medical exception process As mandated by AHCA, all agents included in the Prestige Health Choice formulary are represented on the AHCA PDL applicable to fee-for-service Florida Medicaid. In the event a non-preferred agent is most clinically and therapeutically appropriate for a member, the prior authorization process allows for a coverage determination. Non-PDL formulary agents may be available through the prior authorization process. Typically, if formulary criteria have been met and the preferred formulary agents have failed or are not medically appropriate, then a non-preferred agent may be considered for coverage. Again, all supporting documentation must be submitted for us to consider covering a nonpreferred agent. Carve-out medications A portion of the pharmacy benefit for Medicaid beneficiaries is carved out by the State of Florida. Medications such as anti-hemophilic factors, Spinraza, and Exondys 51 are covered under the fee-forservice portion of the benefit. Instead of billing Prestige Health Choice for these medications, the pharmacy must bill fee-forservice Medicaid (Magellan Rx Management SM ). Pharmacies will be alerted in a rejection message if they submit a claim to Prestige Health Choice for a carve-out medication. The Magellan Rx Management Clinical Call Center can be reached at for claims questions associated with these medications. You can also find additional information on AHCA s website at ahca. myflorida.com/medicaid/ Policy_and_Quality/Quality/ fee-for-service/hemophilia. shtml. Flu season is here! The flu season is here. Remind patients to get flu shots covered by at no cost to members. Many of the pharmacies in the network can administer the flu vaccine. Members can locate a participating pharmacy online at Also offered at no cost are adult pneumonia and shingles vaccines Inc.

6 mobile app now available in Haitian Creole The application is now being offered in English, Spanish, and Haitian Creole. This free mobile app for members is available for download to ios and Android devices. The app provides members with fast, secure, and easy mobile access to important health plan information, including: Member ID card Members can quickly display, , or fax their member ID cards. Primary care provider (PCP) information Members can access their PCPs contact information, and a oneclick call feature allows members to call their PCPs directly from the app. Searchable provider and facility directory Members Compliance Corner can use the directory to find participating providers, hospitals, urgent care centers, and pharmacies. The mobile app is available under the app name PHC Mobile in the Google Play Store or Apple App Store. If you have any questions, please contact Provider Services at Federal False Claims Act The federal False Claims Act (FCA) is a long-standing and broadly written federal statute designed to both ferret out and punish persons and companies that defraud government programs, such as Medicaid and Medicare. The federal government uses the FCA as an important tool in combating health care fraud. For example, the U.S. Department of Justice reported that it recovered more than $4.7 billion in settlements and judgments from civil cases involving fraud and false claims against the government in fiscal year The FCA establishes liability for any person who knowingly presents or causes to be presented a false or fraudulent claim to the government for payment. Examples of false claims include: Making false statements regarding a claim for payment. Falsifying information in the medical record. Double-billing for items or services. Billing for services not performed or items not provided. If you have any questions about the FCA, please reach out to the Prestige Health Choice Compliance team at PHCCompliance@ prestigehealthchoice.com. Care Now SM family planning program has partnered with Stellar Rx to bring you the XpeDose unit, which will include long-acting reversible contraception. The unit will allow your office to dispense at the point of service, with no expense to you. Patients don t need to take a prescription to a pharmacy. Your office will simply transmit prescription information to Stellar Rx. Stellar Rx maintains your office s system. Contact Stellar Rx at to offer the Care Now program to your patients today. Connections A Provider s Link to the Health Plan

7 Risk management: Issues for patients after discharge Safe discharge and transition of care for all patients should be a common goal for all providers. Patients discharged from the hospital can often find themselves at risk of an adverse event due to some common systematic problems in care transitions. Nearly 20 percent of patients experience adverse events within three weeks of discharge, nearly three-quarters of which could be prevented or ameliorated. Adverse drug events, hospitalacquired infections, and procedural complications rank among the most common post-discharge complications. Discontinuity between inpatient and outpatient providers is often a cause, as traditional communication, including dictated discharge summaries, may be missing essential information and do not always reach outpatient providers in a timely manner. Failure to enlist appropriate resources to help patients with the transition from hospital to home or another health care setting may leave patients vulnerable. Preventing adverse events after discharge Providers should address several areas to help ensure safe care transitions. Always cross-check a patient's medications to ensure that no regularly ongoing medications have been stopped and that any new prescriptions are safe and would not lead to dangerous drug interactions. Accurate and prompt discharge communication should be provided to outpatient providers. This includes information on medication changes, pending tests and studies, and any other follow-up needs. Patients, and their families, must also understand their diagnoses, any follow-up needs, and whom to contact with questions or problems after they have been discharged. If you have any questions on guidelines for discharging a member or transferring them from one facility to another, please call Prestige Health Choice Utilization and Medical Management at Source: Clinical practice guidelines help guide members' treatment makes clinical practice guidelines available as a reference for providers. These clinical practice guidelines represent professional standards, supported by scientific evidence and research. These guidelines are intended to inform, not replace, a provider s clinical judgment. The provider remains responsible for determining clinically appropriate treatment for each individual. The guidelines can be found at provider/itn/resources/clinical/ guidelines.aspx. Fraud Tip Hotline: , 24 hours a day, seven days a week. Secure and confidential. You may remain anonymous. PRES_ Inc.

8 HEALTH CHOICE Leading the Way to Quality Care Kew Gardens Ave. Suite 200 Palm Beach Gardens, FL CONNECTIONS A Provider s Link to 2018 Provider Satisfaction Survey coming in Q1 In an ongoing effort to meet the needs of our providers and measure provider satisfaction with our health plan, we will be launching our annual Provider Satisfaction Survey during the first quarter of This survey is designed to gain your insight into our health plan s overall engagement levels, along with benchmarking our progress against last year s survey results to reveal strengths as well as areas for improvement. Look for the survey via mail or telephone. Your feedback is crucial to assessing our progress over the last year and renews our commitment to leading the way to quality care.