News Flash. Self Funding Program

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1 FOR NETWORK PROVIDERS OF KAISER PERMANENTE networknews JUNE 2006 Produced by Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. with the Mid-Atlantic Permanente Medical Group, P.C. Kenya Neal, Manager, Provider Relations address: Website address: News Flash Self Funding Program Beginning July 1, 2007, Kaiser Permanente will offer its employer groups the self insured option. This product will mirror our commercial HMO product that you are currently contracted with and will follow the same referral and authorization processes that are being used presently. As a valued member of our provider network we want to insure that you are able to participate in all of our products, so you will soon receive an amendment to your contract which will allow you to see our self insured members. In order to comply with regulatory requirements we are requesting that you complete and return the amendment no later than Friday, June 30, If you have any questions, please contact the Provider Relations Department at As always, we value your participation as we partner together to provide the best medical care in the Mid-Atlantic States! The Mid-Atlantic Permanente Medical Group, P.C E. Jefferson Street Rockville, MD Presorted Standard US Postage PAID Rockville, MD Permit # 4297

2 Top 5 Reasons To Submit Claims Electonically # 5: Maximize the use of your office computers &/or your office network capabilities Get your money s worth from your office computers and/or your office network by submitting claims electronically. Many practice management systems have an electronic claims component included &/or available at minimal cost. #4: Control paper flow and reduce administrative expenses. Electronic claims submission reduces your office s paperwork burden and frees up your staff s time to concentrate on more important tasks providing outstanding service and care to your patients. # 3: EDI simplifies your billing practices. Electronic claim submission streamlines billing. Claims are sent to the clearinghouse with a press of a button, and the clearinghouse takes care of sorting and sending your claims to the carrier. # 2: Minimizes claim rejections Because the clearinghouse edits claims before routing them to carriers for payment, any claims with missing or invalid information can be returned to you for correction in 1 to 2 business days instead of 1 to 2 weeks with paper claim submissions. And the #1 reason you should submit your claims electronically is... Submitting claims electronically minimizes cash flow disruptions! Electronic claims can be processed faster and more efficiently than paper claims, which can result in an increased turn-around time in your claim processing. Experience the benefits of EDI at your practice! Kaiser Permanente has the ability to receive your claims electronically through the WebMD Clearinghouse. The Kaiser Permanente Mid-Atlantic States payor ID is Call the Provider Relations Department at to get started. Coming Soon! National Provider Identifier The Administrative Simplification provisions of the Health Portability and Accountability Act of 1996 require the Dept. of Health and Human Services (HHS) to establish national standards for electronic health care transactions and national identifiers for providers, health plans and employers. The National Provider Identifier (NPI) is a 10 digit numeric identifier that will be used to identify healthcare providers. NPIs will be assigned by a Medicare national entity. This identifier is INTELLIGENCE free. It is a randomly selected number not associated with specialty or unique information about the provider. The purpose of the National Provider Identifier (NPI) is to uniquely identify a health care provider in standard transactions, such as health care claims. The compliance date for mandated use of the NPI in standard transactions is May 23, There are two types of NPIs: 1. Type 1 will be assigned to practitioners 2. Type 2 will be assigned to Ancillary, facilities, DME providers, labs and radiology. It is vital that you obtain your NPI by May 23, 2007, so please use one of the following three ways to apply as soon as possible: 1. A web-based application process is available at cms.hhs.gov 2. A paper application may be submitted to an entity that assigns the NPI (the Enumerator). A copy of the application, including the Enumerator s mailing address, is available at cms.hhs.gov. A copy of the paper application may be obtained by calling the Enumerator at (800) or TTY (800) With provider permission, an organization may submit a request for an NPI on behalf of the provider via an electron file. Kaiser Permanente will need time to update the provider systems, so in August 2007 we will begin collecting NPIs from our contracted providers. Watch for more information. You don t have to wait until August though. Beat the rush and send your NPI in early! [2]

3 FOR PRACTITIONERS Prenatal Care Clinical Guideline Revised The prenatal clinical practice guideline, for use with low risk patients and for the identification of high risk patients, was revised in May, What s new? A Depression Survey has been added to the First Visit/Social & Demographic History. To view the complete document, log on to the Clinical Library at or if you do not have access to the internet, you may call the Provider Service Center (PSC) at , prompt # 2 to request a hard copy. Diabetes And Pregnancy Care Management Preconception Care A preconception consultation visit is recommended for all women with diabetes who desire or are considering pregnancy. Once a viable pregnancy is confirmed, it is recommended that the clinical RN consult with an Obstetrician or MFM specialist as soon as possible (no later than 2 business days) to determine the patient s plan of care. Screening All prenatal patients (except those already diagnosed with diabetes) will be screened between weeks for gestational diabetes using a 1 hour GCT with 50 gram of oral glucose. The exception will be patients who are considered at high risk for diabetes and require earlier screening near the first prenatal visit. Management Blood glucose monitoring of patients with Gestational & Pre-gestational Diabetes All prenatal patients with diabetes receive a nutrition consult within 5 business days. Initiation of an order for insulin or glyburide Usually a MFM specialist, Obstetrician or Endocrinologist will initiate the order Criteria for starting insulin or glyburide Suggested treatment regimes after failure of diabetic diet This is at the discretion of the physician; however, Kaiser Permanente has a list of principles which may be helpful in making the adjustments. Please refer to you Provider Manual to view the entire Diabetes and Pregnancy medical guidelines. Use of HgA1c Postpartum management Antenatal Testing Fetal movement count health notes (# ) for pregnant diabetics at 28 weeks gestation Fetal surveillance for patient with Gestational Diabetes (diet controlled) Lab work see medical guideline for recommended lab work Follow up Patients with gestational diabetes (diet controlled) Patients with poorly controlled gestational diabetes (diet controlled) Documentation Should be electronically entered For further recommendations on Treating Patients on Insulin or Oral Hypoglycemic agents, and Referral Guidelines, please visit the Kaiser Permanente Provider Website at www. providers.kp.org to view the clinical guideline in its entirety. If you do not have access to the internet or would like to request a hard copy of this guideline, or any other clinical recommendation guideline, you may contact the Provider Service Center (PSC) at , prompt # 2. [3]

4 FOR PRACTITIONERS The following is based on 2004 National Cervical Cancer Screening Guideline, and is for Clinician use in the Mid-Atlantic States. This is not a Kaiser Permanente driven change, but Cervical Cancer Screening Guidelines rather a medical community, science-based improvement that is similar to guidelines of the American College of Obstetricians and Gynecologists, and the American Cancer Society. Who? Population When? Screening Interval Method? Cytology +/- Hpv What Test? ASYMPTOMATIC, AVERAGE RISK WOMEN Age 21, or 3 years after 1st sexual intercourse to age 29 3 years (screen if >30 months. has elapsed) Cytology with reflexive high risk HPV testing IF PAP=ASC-US* Age with intact uterus 3 years (screen if >30 months has elapsed) Cytology and high risk HPV Age >65 w/ 3 consecutive normal results, & no abnormal results in 10 years No further screening recommended All ages, S/P Total Hysterectomy for benign condition, & normal cytology hx No further screening recommended WOMEN AT INCREASED RISK Patients who have been treated for CIN 2/3* 6 & 24 months following treatment * Positive cytology or high risk HPV: Evaluate by colposcopy Cytology & high risk HPV * Normal cytology & neg. high risk HPV: Return to Q 3 year screening All ages, S/P Total Hysterectomy for benign condition, w/ hx of CIN 2/3* Three consecutive, annual, negative vaginal smears prior to discontinuation of screening Cytology only Women who are immunosuppressed or HIV positive Annually Cytology only * All abnormal results will be managed by OB/GYN department [4]

5 FOR OFFICE MANAGERS Claim Processing Enhancements Recently, you may have noticed the following new claim denial codes. These enhancements were implemented to confirm adherence and generally accepted guidelines (e.g., the AMA CPT Code Book, CMS/CMS correct Coding Initiative). It is our goal to provide Kaiser Permanente Participating Providers and their staffs with the latest information on our claim process procedures. If you have any questions regarding these new claims system enhancements, you may call all Provider Relations at Reason Code EOB Code Reason Type Reason Description X0002 TB NC Deny, outpatient consult billed w/dos <6 months X0003 TC NC Deny, confirmatory consult billed w/dos <6 months X0004 TD NC Deny, initial consult billed > max time period X0005 TE NC Deny, consult billed by PCP X0006 TF NC Deny, new patient code billed within past 3 years X0007 TG NC Deny, E&M billed within procedure follow-up period not payable X0008 TH NC Deny, supplies billed same day as surgery X0009 TI NC Deny, procedure identified as unbundled X0010 TJ NC Deny, anesthesia code billed by a non-anesthesiologist X0011 TK NC Deny, not billed on Sunday/Federal holiday or after hours X0012 TL NC Deny, procedure code not consistent with gender X0013 TM NC Deny, procedure code not generally covered X0014 TN NC Deny, unlisted CPT code X0015 TO NC Deny, duplicate claim service X0016 TP NC Deny, modifier required X0017 TQ NC Deny, procedure billed does not require service of assistant surgeon X0019 TS NC Deny, deleted or expired HCPCS or CPT code X0020 TT NC Deny, add-on billed w/o primary procedure X0021 TU NC Deny, bilateral billed inappropriately X0022 TV NC Deny, incorrect bilateral modifier X0023 TW NC Deny, base code billed with quantity >1 X0024 TX NC Deny, diagnosis not consistent with gender X0025 TY NC Deny, always unbundled [5]

6 FOR OFFICE MANAGERS Specialty Referral Guidelines The MAPMG/KPMAS Specialty Care Guidelines are regionally developed referral and authorization guidelines used to support primary and specialty care practitioners in the care of patients with selected conditions. These guidelines are produced based on medical evidence available at the time of guideline development. In addition, expert opinion of subject matter experts in the specific field of specialty may be sought in the guideline development process. Development and Implementation of Specialty Referral Guidelines Specialty Referral Guidelines are developed, reviewed, &/or revised by the MAPMG/KPMAS UM Team, under the leadership of the UM Physician Director of Referrals and in collaboration with the MAPMG primary and specialty care service chiefs and other practitioners and specialists. The development of Specialty Referral Guideline is based on information obtained through literature review, information obtained from the Kaiser Permanente Interregional New Technologies Committee (INTC), and/or in consultation with MAPMG primary and specialty care service chiefs and other practitioners and specialists. All specialty referral guidelines are then reviewed and approved by the KPMAS regional committees, and filed with the State of Maryland through the Maryland Insurance Administration. The Role of Utilization Management Provider Service Center The Provider Service Center (PSC) is a 24-hour, 7 day/week telephonic Utilization Management and Referral Management Service Center, designed to assist MAPMG practitioners, community-based practitioners, affiliate providers, KPMAS staff, and vendor staff in coordinating health care services for KPMAS members. The Provider Service Center provides telephone support for utilization and referral management to physicians and staff. You can reach PSC at and select prompt # 3 to speak with a staff member. The PSC staff can assist you with the following: Information regarding utilization management processes The status of a referral or an authorization Request for copies of criteria/guidelines which are utilized for decision making Questions regarding a benefit denial decision Question regarding notification that a service you requested for a member was denied (select prompt 4) If you do not have access to the internet, or would like to request hard copies of any specialty referral guidelines or utilization management criteria, please contact the Provider Service Center (PSC) at , prompt # 2. How do I reach the Utilization Management Physician regarding denial decisions? UM Physicians can be reached by calling the Provider Service Center at , prompt # 4. If you need to speak with the UM physician after normal business hours, page the on-call UM physician at or We Value Your Input! Satisfaction Surveys were mailed to community providers in April, This survey will allow Kaiser Permanente to assess your user satisfaction with the KP HealthConnect Online Affiliate ( Your responses will enable us to improve services through the KP HealthConnect Online Affiliate and our Community Provider website. This is your opportunity to be heard so please take time to complete and return the survey today! The return address is listed on page one of the survey. We at Kaiser Permanente are listening and your input is very important to us. If you would like to request additional copies of the survey, or if you have any other questions, please contact Provider Relations at (877) [6]