HealthPro News. A monthly publication for participating HMSA health care providers, facilities, and their staff. ADMINISTRATION & NEWS

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1 HealthPro News A monthly publication for participating HMSA health care providers, facilities, and their staff. December 2014 ADMINISTRATION & NEWS What s Inside Pharmacy 2 Coding & Claims 3 Plans 4 Programs 6 Policy News 6 Calendar 9 iexchange: The Online Prior Authorization and QUEST Integration Referral Tool On January 1, 2015, a new online prior authorization and referral feature called iexchange will be available to you via the Hawaii Health Information Network (HHIN) or Cozeva. Aerial iexchange is a two-way communications platform to create, update, and process prior authorization and referral transactions. iexchange provides the following benefits: Real time entries Get the Request ID (also referred to as the auth ID) once the request has been submitted. Real time approvals Get immediate responses based on information entered. Online status of preauthorization and referral requests Your staff may check the status of requests that have been submitted. Submission of documents You can attach relevant information from your patient s medical records with the request. Acceptable file types include digital images (e.g., jpg), pdf, and Word documents. Savings Reduce time and expense associated with paper, telephone, and fax processes. iexchange will accept prior authorization requests for all HMSA member plans except FEP. To access this new feature, the following system requirements must be met: Access to HHIN or Cozeva. - For help logging on to HHIN, call on Oahu or 1 (800) toll-free on the Neighbor Islands. - For help logging on to Cozeva, call 1 (888) toll-free, Monday through Friday, 8 a.m. 5 p.m. Hawaii time. Internet browsers: Mozilla Firefox, Safari, or Internet Explorer ( ). To learn about opportunities to train on iexchange, PSInquiries@ hmsa.com. Hawai i Medical Service Association 818 Keeaumoku St. (808) P.O. Box 860 Honolulu, HI hmsa.com hhin.hmsa.com Provider Resource Center hmsa.com/portal/provider An Independent Licensee of the Blue Cross and Blue Shield Association

2 2 HealthPro News - Health Care Providers, Facilities, and Staff December 2014 Use HMSA s Electronic Transactions Save time and money with these electronic services: HHIN: Verify member eligibility, benefits, and claim status. eclaims: Submit claims online. For more information, contact the ETS Outreach team at on Oahu or at ETSOutreach@hmsa.com. Tiered Copayments for HMSA s 2015 ACA HMO Plans Beginning January 1, 2015, many of HMSA s Affordable Care Act (ACA)- compliant HMO plans will have tiered copayments for physician visits. Members will have a difference in copayments for physician visits rendered by a PCP versus a specialist; specialist visits will have a higher copayment than PCP visits. Please verify benefits before your patients visits so that you can collect the correct copayment. PHARMACY Nexium: Medicare Part D Formulary Nexium (esomeprazole) will remain a tier 3 (preferred brand) medication in This is a correction of information previously posted on our website. Nexium: Commercial Formulary Effective January 1, 2015, Nexium will move from a tier 2 (preferred brand) drug to a tier 3 (other brand) drug AND require a step therapy trial with a generic proton pump inhibitor first. First-step generic agents include lansoprazole (generic Prevacid), omeprazole (generic Prilosec), pantoprazole (generic Protonix), and rabeprazole (generic Aciphex). Your patients who continue using Nexium without trying a generic agent first will be required to pay in full for their medication. Insulin Tier Change In the October 2014 HealthPro News, we provided a matrix showing a tier change for insulin products effective January 1, However, we will not be moving forward with this change. We apologize for any confusion or inconvenience this may have caused.

3 3 HealthPro News - Health Care Providers, Facilities, and Staff December 2014 CODING & CLAIMS Submitting Documentation with Claims There are times when HMSA needs supporting documentation to process a claim. In these cases, supporting documentation must be attached to the specific claim that it supports. You can t submit one set of supporting documentation for a group of claims. You can submit either one multi-page claim with one set of attachments or individual claims with supporting documentation attached to each claim. We can t accept multiple separate claims with one set of supporting documents. Office Urine Drug Screening Tests HMSA conducts post-payment reviews to ensure that claims are submitted and processed according to the right coding guidelines and policies. Recently, we found that some providers are submitting incorrect CPT or HCPCS codes on claims for urine drug screenings in the office setting with multiplexed screening kits (or cassettes, cups, etc.). HMSA will recoup payments made for claims with incorrect codes. Since 2011, the CPT book published by the American Medical Association (AMA) has stated, For qualitative analysis by multiplexed screening kit for multiple drugs or drug classes, use CPT The definition says the code should be billed once for each procedure: CPT 80104: Drug screen, qualitative, multiple drug classes other than chromatographic method, each procedure. Medicare Advantage plans follow CMS guidelines, which only allow HCPCS code G0434 to be billed when using multiplexed screening kit. The G0434 should be billed as one unit when reported: HCPCS G0434: Drug screen, other than chromatographic, any number of drug classes, by CLIA waived test or moderate complexity test, per patient encounter. Please refer to the following CMS link: cms.gov/outreach-and-education/medicare-learning-network-mln/ MLNMattersArticles/downloads/SE1105.pdf. Based on these definitions, CPT code and HCPCS G0434 are equivalent and should be reported as one unit each. HMSA s non-medicare plans accept both codes. This is a reminder that when your office performs urine drug screening tests using multiplexed screening kits (or cassettes, cups, etc.), the appropriate code to bill is either CPT or G0434 for one unit. In addition, remember to bill the QW modifier when tests performed in the provider s office are FDA-approved waived tests under the Clinical Laboratory Improvement Amendments (CLIA). Based on CLIA Law and Regulation requirements, when rendering lab services in the office setting, the appropriate CLIA certification documentation should be available in your office. NOTE: will be terminating on December 31, Effective January 1, 2015, a new code should be used to report the office urine drug screening tests: CPT code 80300: Drug screening, any number of drug classes from Drug Class Lists A, any number of non- TLC devices or procedures, capable of being read by direct optical observation, including instrumented-assisted when performed, per date of services. CPT code should be billed as one unit per patient, per day. Commercial QUEST Medicare

4 4 HealthPro News - Health Care Providers, Facilities, and Staff December 2014 PLANS QUEST Integration The new benefit year begins January 1, 2015, and brings a new plan, QUEST Integration, which combines the QUEST population and the QUEST Expanded Access (QExA) population into a single plan. There s no change to the benefits that were available to these members under their previous QUEST or QExA plan. Members who opted to change plans for the new benefit year will have a seamless transition of care from the previous plan to the new plan. Any treatment plan approved by the previous plan may continue during the transition until the treatment plan is completed or the new PCP has had an opportunity to review the treatment plan. New HMSA membership cards will be sent to all members. Members are now classified into three categories as noted under the Benefit field on their new HMSA card. NON-ABD: These are members who are not aged, blind, or disabled. They were previously QUEST members and continue to be eligible for regular QUEST benefits for adults and children. Member Name KEIKI K QUEST Member ID XLQ Effective Date Benefit RXBIN RXPCN ADV 11/05/14 NON-ABD RXGRP RX3987 QUEST INTEGRATION Birth Date 08/05/07 Sex M PCP KIMO U MAHALO MD Network BIG ISLAND FAMILY PRACTICE PCP Phone (808) PCP Effective Date 9/16/14 TPL1 HMSA HEALTH PLAN HI TPL2 EPSDT Member: This is your QUEST identification card. Present it to the provider of health care when you receive services. Please call HMSA if you have questions regarding your benefits. Providers: This is a QUEST member. QUEST is the state of Hawaii Medicaid Managed Care Program. Payment of benefits will be based on the patient s eligibility at the time services are received. For pharmacy services rendered in Hawaii, mail claims to: Pharmacy Claims, P.O. Box 52116, Phoenix, Arizona For all other services rendered in Hawaii, mail claims to: The HMSA Plan for QUEST Members - Claims, P.O. Box 3520, Honolulu, HI Services rendered out-of-state, mail claims to: The local Blue Cross/Blue Shield of the service area. hmsa.com 24 Call Center and Nurseline Oahu Toll-free 1 (800) Blue Cross Blue Shield of Hawai i 818 Keeaumoku St. Honolulu, HI An Independent Licensee of the Blue Cross and Blue Shield Association ABD: These are members who are aged, blind, or disabled. They were previously QUEST Expanded Access (QExA) members and continue to be eligible for regular QUEST benefits as well as the expanded benefits under their previous QExA plan. Member Name KIMO K QUEST Member ID XLQ Effective Date Benefit RXBIN RXPCN ADV 11/05/14 ABD RXGRP RX3987 QUEST INTEGRATION Birth Date 07/04/86 Sex M PCP KIMO U MAHALO MD Network BIG ISLAND FAMILY PRACTICE PCP Phone (808) PCP Effective Date 9/16/14 TPL1 TPL2 Member: This is your QUEST identification card. Present it to the provider of health care when you receive services. Please call HMSA if you have questions regarding your benefits. Providers: This is a QUEST member. QUEST is the state of Hawaii Medicaid Managed Care Program. Payment of benefits will be based on the patient s eligibility at the time services are received. For pharmacy services rendered in Hawaii, mail claims to: Pharmacy Claims, P.O. Box 52116, Phoenix, Arizona For all other services rendered in Hawaii, mail claims to: The HMSA Plan for QUEST Members - Claims, P.O. Box 3520, Honolulu, HI Services rendered out-of-state, mail claims to: The local Blue Cross/Blue Shield of the service area. hmsa.com 24 Call Center and Nurseline Oahu Toll-free 1 (800) Blue Cross Blue Shield of Hawai i 818 Keeaumoku St. Honolulu, HI An Independent Licensee of the Blue Cross and Blue Shield Association

5 5 HealthPro News - Health Care Providers, Facilities, and Staff December 2014 PLANS (CONTINUED) ABD and LTSS: These are ABD members who are eligible for the same medical benefits as the ABD population and long-term supports and services (LTSS), including non-medical services such as expanded adult residential care home, community care foster family home, personal assistance, and other services that support a medical condition. Member Name KIMI K QUEST Member ID XLQ Effective Date Benefit RXBIN RXPCN ADV 11/05/14 ABD and LTSS RXGRP RX3987 QUEST INTEGRATION Birth Date 03/05/87 Sex F PCP KIMO U MAHALO MD Network BIG ISLAND FAMILY PRACTICE PCP Phone (808) PCP Effective Date 9/16/14 TPL1 HMSA HEALTH PLAN HI TPL2 Member: This is your QUEST identification card. Present it to the provider of health care when you receive services. Please call HMSA if you have questions regarding your benefits. Providers: This is a QUEST member. QUEST is the state of Hawaii Medicaid Managed Care Program. Payment of benefits will be based on the patient s eligibility at the time services are received. For pharmacy services rendered in Hawaii, mail claims to: Pharmacy Claims, P.O. Box 52116, Phoenix, Arizona For all other services rendered in Hawaii, mail claims to: The HMSA Plan for QUEST Members - Claims, P.O. Box 3520, Honolulu, HI Services rendered out-of-state, mail claims to: The local Blue Cross/Blue Shield of the service area. hmsa.com 24 Call Center and Nurseline Oahu Toll-free 1 (800) Blue Cross Blue Shield of Hawai i 818 Keeaumoku St. Honolulu, HI An Independent Licensee of the Blue Cross and Blue Shield Association Please verify QUEST Integration enrollment at each visit. You should confirm eligibility and note which QUEST Integration plan they are enrolled in, as well as PCP information. You can continue to confirm HMSA QUEST Integration eligibility by using HHIN or calling QUEST Integration Provider Service at on Oahu or 1 (800) toll-free on the Neighbor Islands. If you re registered with the state s online system, you can also access the Med-QUEST eligibility website. Thank you for your past partnership with HMSA s QUEST plan. We look forward to your continued collaboration in the new QUEST Integration plan. QUEST Integration Informational Session Available Online The QUEST Integration Informational Session held November 19, 2014, is available online to view at your convenience. To view the session, visit the HMSA Provider Resource Center. Multiple ER Visits on the Same Day When the same patient is seen in the emergency room at different times on the same day, be sure to provide the visit times. Otherwise, one of the visits will be denied as a duplicate claim. On paper claim submissions, use the remarks form locator 80 to indicate that the patient was seen twice on the same day and include the time for the billed visit. On electronic claims, use the notes field to provide the information. Well-woman Visits As a reminder, women may self-refer to a women s health specialist for well-woman exams. No referral is needed unless the visit will be to a specialist on an island other than the member s island of residence. Commercial QUEST Medicare

6 6 HealthPro News - Health Care Providers, Facilities, and Staff December 2014 PROGRAMS Aloha Kidney Aloha Kidney is a program created by local nephrologist and HMSA Medical Director Ramona Wong, M.D., as a community outreach effort. The two components of the program are kidney disease education and chronic kidney disease navigation. The goal of this program is to help patients understand how to slow the loss of kidney function, reduce CV risks, explore all options if kidneys fail, and prepare in time to smooth any transitions, enabling them to make informed choices and work better with their doctors. Dr. Wong personally provides kidney disease education through an ongoing series of six free classes, two hours each, for patients and their families. She provides chronic kidney disease navigation as a free service to doctors and their office staff, and chronic kidney disease patients and their families when patients need help getting to the next step aligned with their life goals. HMSA has become a co-sponsor of Aloha Kidney, collaborating with Dr. Wong to expand awareness of and access to these educational sessions. HMSA hired Ku'ulei Alama Francis, R.N., who has years of experience in CCU, ICU, palliative care, hospice, and CKD/ESRD disease management. She ll work with Dr. Wong as an additional chronic kidney disease navigator for HMSA members. The process is simple. Any patient with a GFR<60 or proteinuria can call on Oahu to register for classes. Aloha Kidney classes are currently offered in three locations on Oahu and via the Web to Neighbor Island residents. Providers who want individualized chronic kidney disease navigation for a patient who s having a difficult time can also call. It s our hope that you, your patients with chronic kidney disease, and their families will benefit from the expertise offered by this collective effort. Call on Oahu to request brochures, services, or more information. POLICY NEWS Medical policies are at hmsa.com/prc0004. For copies, call Provider Services at on Oahu or 1 (800) toll-free on the Neighbor Islands. Expanded Coverage of Polysomnography/Sleep Studies HMSA will soon be covering polysomnography in the home setting. The draft policy is available for review at hmsa. com/prc0005 and becomes effective March 1, This broader coverage of polysomnography is for members who do not have contradictions to a home study, such as high blood pressure, heart disease, history of stroke, other breathing disorders, etc. Facility-based studies are available as previously published.

7 7 HealthPro News - Health Care Providers, Facilities, and Staff December 2014 POLICY NEWS (CONTINUED) Provider Input Solicited for Annual Policy Review December HMSA s medical directors welcome comments and suggestions from participating providers about medical policies that are undergoing annual review. We re soliciting input for these policies: Anesthesia for Gastrointestinal Endoscopies. Bio-Engineered Skin and Soft Tissue Substitutes. Blepharoplasty and Repair of Blepharoptosis. Bortezomib (Velcade). Computerized Corneal Topography. Cosmetic and Reconstructive Surgery and Services. Endovascular Procedures for Intracranial Arterial Disease. Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes. Implantable Ventricular Assist Devices and Total Artificial Hearts. Intrastromal Corneal Ring Segments for Keratoconus. Panniculectomy/Abdominoplasty. Photodynamic Therapy for the Treatment of Actinic Keratoses and Other Skin Lesions. Reduction Mammaplasty. Repetitive Transcranial Magnetic Stimulation for Treatment of Refractory Depression. Spinal Cord Stimulators for Pain Management. Transcatheter Closure of Patent Foramen Ovale for Stroke Prevention. Transcatheter Pulmonary Valve Implantation. Transcutaneous Electrical Nerve Stimulation (TENS). Treatment of Varicose Veins. Uterine Artery Embolization to Treat Fibroids. Go to hmsa.com/prc0005 to read these policies. Please include supportive citation source material when submitting comments to help medical directors evaluate the comment or proposed change. We can t guarantee that any specific proposed change will be included in the final policy. Our policies rely on the use of evidence-based medicine, typically from peer-reviewed literature. You may comment by to medical_policy@hmsa.com or by fax to on Oahu. Comments are due by December 31, New Policy Drafts Online for Review Drafts of new medical policies are posted online for your review. Please visit hmsa.com/prc0005 in the Provider E-Library for drafts of policies that may affect your practice. Please comment by the due date indicated to medical_policy@hmsa.com or by fax to on Oahu. Questions? Call Provider Services at on Oahu or 1 (800) toll-free on the Neighbor Islands. Commercial QUEST Medicare

8 8 HealthPro News - Health Care Providers, Facilities, and Staff December 2014 POLICY NEWS (CONTINUED) Annual Review of Medical Policies The following policies have undergone review and have been updated in the Provider E-Library at hmsa.com/prc0006; printed copies are available on request. Allogeneic Hematopoietic Stem-Cell Transplantation for Genetic Diseases and Acquired Anemias. Biological Agents for the Treatment of Plaque Psoriasis. Biomarkers (Novel) in Risk Assessment and Management of Cardiovascular Disease. Bone Mineral Density. Carotid Artery Stenting. Colorectal Cancer Screening. Continuous Glucose Monitoring System. Erythropoiesis Stimulating Agents (ESA). High Frequency Chest Wall Oscillation Devices. Home Infusion Pain Management Therapy. Negative Pressure Wound Therapy (NPWT). Never Events and Hospital Acquired Conditions. Pulse Oximeters for Children. 90-Day Notice for Policy Changes The following policies have been updated and are effective March 1, Revisions can be found at the accompanying URL. Colonoscopy: The criteria/guidelines and references. hmsa.com/portal/provider/zav_pel.aa.col.301.htm Endovascular Procedures (Angioplasty and/or Stenting) for Intracranial Arterial Disease (Atherosclerosis and Aneurysms): The description, criteria/guidelines, administrative guidelines, and references. hmsa.com/portal/provider/zav_pel.aa.end.100.htm Immune Globulin Therapy: The criteria/guidelines and references. hmsa.com/portal/provider/zav_pel.aa.int.701.htm Insulin Pumps External: The criteria/guidelines and references. hmsa.com/portal/provider/zav_pel.aa.ins.501.htm Intensity Modulated Radiation Therapy (IMRT): The criteria/guidelines, administrative guidelines, and references. hmsa.com/portal/provider/zav_pel.aa.int.201.htm Polysomnography and Sleep Studies: The criteria/guidelines, limitations/exclusions, administrative guidelines, and references. hmsa.com/portal/provider/zav_pel.aa.pol.501.htm Readmissions and Transfers: The administrative guidelines and references. hmsa.com/portal/provider/zav_pel.aa.rea.401.htm New Policies The following policy goes into effect December 1, Ledipasvir/Sofosbuvir (Harvoni) for Treatment of Hepatitis C. Precertification is required through CVS/Caremark. We encourage you to read the criteria. Please refer to the current medical policies online for more information, including precertification requirements, at hmsa.com/prc0006.

9 9 HealthPro News - Health Care Providers, Facilities, and Staff December 2014 CALENDAR Hawaii State License Renewal Reminder Hawaii state licenses for physical therapists (PT) and occupational therapists (OT) will expire on December 31, We encourage you to renew your license as soon as possible. We ve been advised that there s a time lag between renewing a license and posting the renewal on the state s licensing website, which we reference for current licensure. To update our records, we ask that PTs and OTs submit a copy of their renewed license to HMSA s Credentialing Unit by one of the following methods: Fax to on Oahu. to ps-credunit@hmsa.com. Standard mail: HMSA Attn: Credentialing Unit, Room 550C P.O. Box 860 Honolulu, HI If we can t confirm that you renewed your state license, we re required to terminate your HMSA credentialing status. This may result in HMSA being unable to make payments for your services effective January 1, If you have questions, please call the Credentialing Unit at on Oahu or 1 (800) , ext. 5010, toll-free on the Neighbor Islands. Well-Being Workshops The workshops listed below are available to HMSA members at no cost. These informative sessions are presented by Healthways health educators and can help your patients improve their health and well-being. For more information, refer your patients to hmsa.com/wellness-programs/workshops or have them call 1 (855) toll-free to register. Goodbye, Diet! Hello, Health! Learn how to reach your weight-loss goals with good nutrition, regular exercise, and other healthy behaviors. 12/5, 4:30 5:30 p.m. HMSA Honolulu Exercise: the Magic Bullet Learn fun and convenient ways to be more active. 12/6, 9:30 10:30 a.m. Kaimuki Plaza, Kaimana Room Season s Eatings Discover strategies to maintain your health and weight during the tempting holiday season. 12/12, a.m. HMSA Pearl City Music & Health Christmas Special Music, singing, and laughter are just plain good for us. Find out why and recapture those moments that make Christmas memorable. 12/13, 9:30 10:30 a.m. Kaimuki Plaza, Kaimana Room

10 10 HealthPro News - Health Care Providers, Facilities, and Staff December 2014 CALENDAR (CONTINUED) Community Classes Walk With a Doc on Hawaii Island Meet up, rain or shine, for some beneficial, lowimpact exercise. Walk includes a brief warm-up/stretch and an informative talk from a community doctor or medical student. First-time walkers get a free T-shirt and pedometer. For more information, see wwadbigisland.org. Every Sunday, 8 a.m. Liliuokalani Gardens, Hilo Health & Education at Queen s The Queen s Medical Center, Women s Health Center Classroom. Genetics Class: Learn about prenatal genetic screening and tests to check the health of your baby. Call for times and information. Free. Lamaze Class: Sundays, 1 4 p.m. Get birthing techniques from a Lamaze-certified instructor in this birth-partner-focused class. $150 per couple for five sessions. Lymphedema/Breast Cancer Clinic: First and third Thursdays, 11:30 a.m. 12:30 p.m. Learn exercises to prevent lymphedema (swelling of the arms). Free. Mammogram and Cervical Cancer Screening: Every other Friday, 8 a.m. noon. Free for women who are ages 50 64, uninsured or underinsured, or low income. Call for times and eligibility information. Adult Fitness at Queen s The Queen s Medical Center, Women s Health Center Classroom. Six classes for $66. Call to register. Pilates and Yoga with Fitness Cue: Mondays, noon 1 p.m. Strengthen and lengthen muscles and improve spinal health and alignment. Instructor: Li Si Yang. Bollywood and Beyond: Tuesdays, 4:30 5:30 p.m. Perform upbeat and expressive movements from around the world. Instructor: Willow Chang. Journey to Fitness Pyramid: Wednesdays, noon 1 p.m. Learn corrective exercises and five principles of good health and fitness. Instructor: Li Si Yang. Kickboxing Fitness: Thursdays, 6 7 p.m. Tone your body using mitts, kick pads, and standing heavy bags. Instructor: Mineyo Shimojo. Jazzercise: Fridays, noon 1 p.m. Dance-based cardio and strength training. Instructor: Sheri Yamashita.