Important RMHP Pharmacy Change for 2016

Transcription

1 Fall 2015 Provider Edition Important RMHP Pharmacy Change for 2016 In an effort to control increasing medication costs, RMHP will begin using MedImpact s High Performance pharmacy network beginning January 1, MedImpact is the Pharmacy Benefit Manager (PBM) that RMHP has used to process prescriptions for several years and has an extensive network of providers. Most significantly, the new network does not include Walgreens Pharmacy. Effective January 1, 2016, prescriptions will not process at Walgreens for any RMHP Member. Therefore, RMHP Members who regularly use Walgreens Pharmacy for their prescriptions will need to choose another pharmacy for their medications. Because many Walgreens Pharmacies are located in close proximity to other participating pharmacies, Members may be able to find a new participating pharmacy near them. In anticipation of this change to RMHP s Pharmacy network, we ask that you please begin sending prescriptions to another participating pharmacy of the Member s choosing. RMHP will send notices to all Members informing them of this important change in our Pharmacy Network; please work closely with Members to select a new pharmacy. If you have any questions about the change, please contact your Provider Relations Representative.

2 Are You Ready? The ICD-10 compliance date is October 1, As a final reminder, RMHP will follow the Centers for Medicare and Medicaid Services (CMS) guidelines for ICD-10 compliance. Please visit the link(s) below for further details, as the following information is not a complete list. How does this affect paper and electronic claims? Claims for all services and hospital inpatient procedures performed on or after the compliance deadline of October 1, 2015, must use valid ICD-10 diagnosis and inpatient procedure codes. This does not apply to CPT coding for outpatient procedures. Claims that do not use valid ICD-10 diagnosis and inpatient procedure codes cannot be processed and will be denied. Professional and outpatient claims that span the compliance date of October 1, 2015, must be split by the provider prior to sending the claims for payment or the entire claim will be denied. Inpatient hospital claims are based on date of discharge. If a patient was admitted prior to October 1, 2015, and discharged on or after October 1, 2015, then the entire claim must be coded using valid ICD-10 PCS codes. RMHP will not accept ICD-10 codes and inpatient procedure codes before October 1, 2015, or ICD-9 codes and inpatient procedure codes after October 1, Those claims will be denied. Claims can ONLY include valid ICD-9 OR ICD-10 diagnosis and inpatient procedure codes based on dates of service and cannot contain both sets of codes on the same claim; those claims must be split by the provider or those claims will be denied as consistent with CMS requirements. Many people use the terms billable codes and valid codes interchangeably. A complete list of the 2016 ICD-10-CM valid codes and code titles is posted on the CMS website at Medicare/Coding/ICD10/2016-ICD-10-CM-and-GEMs.html. The codes are listed in tabular order (the order found in the ICD-10-CM code book). This list should assist providers who are unsure as to whether an additional 4th, 5th, 6th or 7th character is needed.* *Source: CMS-AMA-Joint-Announcement.pdf Review our previous Provider Newsletters online and look for the ICD-10 Compliance Corner in those editions: rmhp.org/providers/provider-newsletters.

3 Cultural Diversity Member Materials Translation While all written materials can be made available in any language requested, RMHP has many materials readily available in Spanish, the most commonly requested language other than English by our Membership. All materials developed for Medicaid Prime Members are readily available in Spanish. In addition to the Medicaid Prime materials, the following materials are readily available in Spanish upon request: Authorization to Use or Disclose Specific Information Form Certificate of Dependent Status Form Employee Disenrollment Form Essential Prescription Standalone Application Form Medicare Short Enrollment Change Form Notice of Privacy Practice Instructions Member materials are also available in Braille. RMHP uses an experienced third party vender to translate all written Member materials, including marketing materials for all product lines, into Spanish and other languages as requested. The time frame for the completion of translations is based on the size and language of the document. Generally, a request for translation can be fulfilled in five to ten business days. Service When You Need It RMHP will launch self-service phone option for Providers. RMHP is here to help, and we continue to develop ways for you to get the service you need, when you need it. In addition to the current online Provider Portal and our dedicated Customer Service representatives, we re pleased to announce that a 24/7 self-service phone option to check claim status will soon be available. The system is being set up based on your NPI. From there, you will be able to get claim information with a claim number or Member ID and DOS. Please listen carefully to our telephone prompts as we begin to rollout out enhancements. The Clinical and DME Preauthorization Lists Have Been Updated for 2015 Diagnosis codes were removed from the DME list and any codes that impact the preauthorization requirement on the clinical list have been mapped to ICD 10 codes. Providers will receive notification in the next few weeks. The packets will include the cover letter/summary of changes and a CD with the appropriate preauthorization list for the services each of them provides. The lists are posted to the RMHP web site with links from the member and provider portals.

4 Member Rights and Responsibilities The following text is reproduced from the Member Handbook. This information has been included in the Provider Manual for your information. Please keep these rights and responsibilities in mind when communicating with Members regarding health care decisions. Commercial Members It is your right: To receive information about RMHP and its services, practitioners, and providers. To be treated with respect and with recognition of your dignity and right to privacy. To accept or refuse medical treatment to the extent provided by Colorado state law. To participate in making decisions about your health care. To have candid discussion with providers of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage. To bring complaints to RMHP and/or to the Insurance Commissioner of the State of Colorado. To expect all communications regarding your care to be kept confidential as required by law. It is your responsibility: To choose a Primary Care Physician (PCP), when required by your plan, who will provide or arrange for all your medical care needs. To tell your PCP (if your plan requires you to choose one) about any advance directive regarding your medical care. To follow the plans and instructions for care that have been agreed upon with your health care provider. To assume responsibility for your own healthy well-being. To learn about your RMHP health care benefits, procedures, and limitations. To be cooperative and considerate with health care providers and staff. To inform RMHP Customer Service of your PCP changes. To inform RMHP Customer Service of any Membership changes, such as address change or employment termination (if covered through an RMHP group). To assume responsibility for copayments and costs associated with certain health care services that may apply to your health plan and any non-covered services. To give your health care provider all information needed to provide you appropriate health care.

5 Medicare Part D Prescriber Enrollment Requirements Federal regulation requires virtually all prescribers (including dentists, residents, psychiatrists, nurse practitioners and physician assistants) who prescribe Part D drugs for Medicare beneficiaries to enroll in Medicare. Beginning June 1, 2016, Part D plans will no longer be permitted to cover drugs prescribed by prescribers who are not enrolled in Medicare, except in very limited circumstances. CMS has issued provisional guidance to allow temporary fills after the program s implementation date. Beginning June 1, 2106, RMHP will take the following steps to minimize beneficiary impact: Allow up to a three month provisional fill for each drug prescribed by that provider; Provide written notice to the beneficiary within three business days of adjudication of the provisional fill; and Make reasonable efforts to notify the prescriber of the beneficiary s provisional fill. Once the above steps have been satisfied, RMHP s PBM must reject future claims for the same Member/drug/ prescriber combination. Providers are encouraged to use Enrollment, Chain and Ownership System (PECOS) to submit their enrollment application online. All prescribers should enroll before January 1, 2016, to allow for the processing of applications and to ensure enrollees get their prescriptions. Prescribers may opt-out of part D prescribing by submitting affidavits to their Medicare Administrative Contractors (MACs) before January 1, Quality Improvement Program Rocky Mountain Health Plans (RMHP) maintains our tradition and commitment to constantly looking for ways 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. To obtain a copy of the Quality Improvement Program Description, or to request information about the performance of the Quality Improvement Program, contact Jackie Hudson, Quality Improvement Director, at , ext or jackie.hudson@rmhp.org.

6 HEDIS Time is Coming! Help us help you reduce the HEDIS stress! The patient care and documentation you are doing today will be included in the HEDIS review beginning in February of Please consider the following helpful hints for mastering selected HEDIS measures: Medication Reconciliation Post-Discharge (MRP) Measure Review your office process for follow-up of Medicare Members age 18 years and older who have been recently discharged from an inpatient stay. Are you getting discharge summaries in a timely manner? For those Members that have been hospitalized from January 1 - December 1 of 2015, we will be looking for documentation of a medication reconciliation conducted by a prescribing practitioner, clinical pharmacist, or a registered nurse. The medication reconciliation must occur within 30 days of the discharge date. An outpatient visit is not required but the documentation must be found in the outpatient chart and include the date it was performed. The reconciliation must compare discharge medications with current medications. Examples include: Documentation of current medications with a notation that discharge medications were reviewed or discontinued A note stating there have been no changes to medications since discharge Documentation that the Member is on the same medications as at discharge Notation stating that no medications were prescribed at discharge Comprehensive Diabetes Care (CDC) Measure Do you have a consistent process in your office to have HbA1c tests reviewed and documented in your medical records? When documenting HbA1c tests done in the office, remember to indicate the date the test was done. Make sure lab results and reports are placed in the chart or entered in the EMR. Now is a good time to begin contacting patients that have not had their HbA1c test in 2015 or those who need follow-up due to abnormal results.

7 Adult Body Mass Index (BMI) Assessment (ABA) Measure Think about weight and BMI as new vital sign! Calculate a BMI value at each patient visit. Is your EMR set up to do a BMI percentile for Members under 21? Data collection for this measure can be done administratively through claims data. This will reduce the number of medical record requests for HEDIS. Contact us to learn more about how to code visits for BMI and BMI Percentile. Childhood Immunization Status (CIS) and Immunizations for Adolescents (IMA) Measures Include a review of immunizations at every visit. Access the state registry to obtain information about immunizations the child received outside of your office. Routinely upload your immunizations to the state registry. Are you including the initial Hepatitis B vaccination given at delivery? Annual Well-Child Visits (W15, W34) and Weight Assessment Counseling (WCC) Measures The components of a well-child visit can be documented at any patient visit. A sick visit or a new patient visit is an excellent opportunity to provide needed preventive health services. At least annually, document a health history, a developmental history, and a physical exam. Include a BMI percentile or graph and provide health education and/or anticipatory guidelines appropriate for the child s age. Specifically include education and counseling on nutrition and exercise. Screen time does not count. For questions relating to HEDIS and medical record review, please contact: Maura Cameron HEDIS/CAHPS Manager maura.cameron@rmhp.org

8 PO Box Grand Junction, CO PRSRT STD U.S. Postage Paid Grand Junction, CO Permit No. 243 Steve ErkenBrack President and CEO Kevin R. Fitzgerald, MD Chief Medical Officer Front Range and Eastern Plains Professional Relations: or Western Slope and San Luis Valley Professional Relations: or Please check out our website rmhp.org for recent changes to the RMHP Medicare Part D Drug Formulary Please route this important information to: q Physicians q Office Manager q Billing Office q Receptionist q Other Find Updated Formulary Information Online To review recent changes for new drugs and generics, Rocky Mountain Health Plans has the Formulary Updates online for your convenience. Visit rmhp.org Click on the Providers tab in the taskbar Click on Prescription Drug Services for Providers Scroll down the page and click on Formulary Updates located under Drug Information and Formularies If you would like RMHP to mail you a copy, please call or RockyMtnHealthPlans rmhp.org/blog