HAP Midwest Health Plan, Inc. Provider Newsletter October 2015

Transcription

1 HAP Midwest Health Plan, Inc. Provider Newsletter October 2015 Medical Director s Report Dr. Mark Tucker Attention Providers, Please see the document link below regarding the latest ICD10 updates from the Michigan Department of Health and Human Services (MDHHS). Thank you! Provider Messaging_Oct 1_2015.pdf PASSIVE ENROLLMENT FOR MI HEALTH LINK IS JULY, AUGUST AND SEPTEMBER. People may be eligible for MI Health Link if they: Are age 21 or over Are eligible for full benefits under both Medicare and Medicaid Are not enrolled in hospice People enrolled in PACE & MI Choice are eligible but must leave these programs before joining MI Health Link People with a spend down are not eligible for MI Health Link(this is an exclusion listed under eligibility criteria) People in a nursing home are eligible & must continue to pay their patient pay amount to the nursing home Benefits of MI Health Link: No co-pays or deductibles for in-network services, including medications One health plan to manage all Medicare & Medicaid covered services

2 One card to access all services Person-centered care with a focus on supports for community living, in addition to doctor-driven medicine Access to a 24/7 Nurse Advise Line to answer questions Each enrollee will have a care coordinator who will: o Work with them to create a personal care plan based on the enrollee s goals o Answer questions & make sure that health care issues get the attention they deserve o Connect people to supports & services needed to be healthy & live where they want Each enrollee will have access to an Integrated Care Team that will: o Include doctors, providers, & anyone else they would like to include o Work with them to identify goals & preferences for care & services Covered Services: All health care services covered by Medicare & Medicaid including: o Medications without co-pays o Dental & vision services o Equipment & medical supplies o Physicians & specialists o Emergency & urgent care o Hospital stays & surgeries o Diagnostic testing & lab services o Nursing home services o Home health services o Transportation for medical emergencies & medical appointments o Long Term Supports & Services (LTSS) Personal care Equipment to help with activities of daily living Chore services Home modifications Adult day program Private duty and/or preventive nursing services Respite Home delivered meals Community transition services Fiscal intermediary services Personal emergency response system Nursing home care

3 Behavioral Health Services to individuals who have a mental illness, intellectual/developmental disability or substance use disorder. Services are accessed through the Prepaid Inpatient Health Plans (PIHP), Macomb County Community Mental Health or Detroit Wayne Mental Health Authority Examples of Medically necessary services o Individual, group and/or family therapy & medication review o Community living supports (meal preparation, laundry, chores, food shopping) o Substance use disorder services (assessment, treatment planning, stagebased interventions, referral & placement) Enrollment Periods: Opt-in enrollment o Eligible beneficiaries can enroll by calling MIENROLLS at not earlier than April 1, 2015 o Services start no earlier than May 1, 2015 Passive enrollment of eligible individuals if they do not opt-out o People will receive notices 60 days & 30 days before they are passively enrolled o Services start no earlier than July 1, 2015 What happens after enrollment: Enrollees will receive their ID card showing their PCP information Enrollees will receive their member materials with HAP Midwest s customer service phone number for assistance with any questions they may have or for any services they may need. Enrollees will receive an initial screening by Michigan Enrolls or ICO contracted provider Enrollees will receive a Level I Assessment by ICO contracted provider If needed, enrollees will also receive a Level II Assessment by ICO contracted provider Each enrollee will help develop his or her own Individual Integrated Care & Supports Plan (IICSP) Individual Integrated Care and Supports Plan Each enrollee will help develop his own care and supports plan with their Care Coordinator (ICO or contracted provider) & will choose the people to participate in the process o Selected family, friends, and providers

4 o Invited integrated care team members Follows a person-centered planning process Is completed within 90 days of enrollment start date Is the single plan that coordinates care for all services & providers & includes the PIHP & LTSS service plans Plan for addressing concerns & goals, as well as measures for achieving them Identifies specific providers, supports & services including amount, scope & duration Lists the person responsible & time lines for specific interventions, monitoring & reassessment The IICSP contains o Enrollee s preferences for care, support and services o Enrollee s prioritized list of concerns, goals, objectives and strengths o Screening and assessment results Ongoing Coordination Care Coordinators will maintain ongoing relationships with enrollees to assure o Assessments and care plans are revisited and updated periodically o Questions and concerns are answered and addressed o Health issues get the attention they deserve Questions Providers may have Q: Whom do I bill? A: You will continue to bill HAP Midwest Health Plan as you always have Q: How do I indicate the claim is for a MI Health Link member on my paper claim? A: Always indicate on top right corner of the CS 1500 and UB04 that the claim is addressed to HAP Midwest MI Health Link Q: what member ID should I use to bill for MI Health Link member A: Just like the HAP Midwest Advantage member you must use the 11 digit Member ID number on the member s HAP Midwest ID card Q: How will I be paid? A: You will be reimbursed the Medicare fee schedule rate applicable to the service provided. Q: How do I contract with HAP Midwest Health Plan for the MI Health Link Plan? A: A MI Health Link addendum was sent to you last summer. This addendum adds you to the MI Health Link provider network Resources

5 Healthy Michigan Plan Health Risk Assessment Completion Instructions Healthy Michigan Plan members are encouraged to complete an annual Health Risk Assessment (HRA) during their first PCP visit. This visit should be scheduled within 60 days of enrollment. Members are mailed the HRA with their welcome packet. The HRA also can be found on the HAP Midwest Health Plan website: hap.org/midwest Sections 1-3 of the Health Risk Assessment form may be completed by the member. If Sections 1-3 have not already been completed, have the member complete it during their office visit. PCP s will need to complete Section 4. Fill in the Member s Results, select a Healthy Behavior in discussion with the member and complete the Primary Care Provider Attestation. All three parts of section 4 must be filled out for the attestation to be considered complete. HRA Submission and Incentives HAP Midwest Health Plan has implemented an incentive for providers who complete and return the Health Risk Assessment. Upon completion of the HRA PCP s must: Give the member a copy of their completed Health Risk Assessment Return all 4 pages of the completed & signed HRA via fax to (313) Bill the HRA completion using CPT code on a CMS1500 and submit it to HAP Midwest Health Plan-Claims Department CPT Procedure code will be processed by the claims department, reimbursed at a $0.00 fee, the transaction will be on the Remittance Advice and submitted to the Michigan Department of Community Health as an encounter The $25 HRA completion incentive will be paid as part of the Pay for Performance (P4P) bonus program If you have any questions, please contact your provider service representative. Linda Abdelghani (313) Nehya Ahmed (313) Brian Flemming (313) Healthy Michigan Plan Health Risk Assessment Online Training HMP HRA online training is now available for providers and office staff at Click Healthy Michigan Plan Provider Information and then Health Risk Assessment to access the training. Select the courses.mihealth.org and choose course ID H0200.

6 Healthy Michigan Plan Beneficiary Notification of Copays at the Point of Service Healthy Michigan Plan members enrolled in Medicaid Health Plans have a copay obligation for certain services. These copays will not be paid at the point of service, but will be paid to the health plan through a MI Health Account. Per a regulation from the Center for Medicare & Medicaid Services (CMS), the Healthy Michigan Plan members are to be informed at the time of service as to the copay obligation even though they are not paying the copay at the time of service. The document titled, Information about Healthy Michigan Plan Copays which outlines potential copay requirements for Healthy Michigan Plan enrollees and can be used for compliance with this regulation can be found online at or hap.org/midwest Please distribute the copay notice to all HMP members at the point of service. Please contact your provider representative if you have any questions. Thank you for your assistance. Community Resources: is the health and human service equivalent of to give or get help spearheaded by United Way is a free, easy-to-remember telephone number that connects people with resources that improve their lives. The call specialists are available 24 hours a day, 7 a days a week, and are ready to provide information about a wide range of community services including health care, job training, childcare, mortgage foreclosure assistance and more is available in all of the HAP Midwest Health Plan service area, including Wayne, Washtenaw, Oakland, Macomb, St. Clair, and Livingston counties. Anyone can ask a call specialist about resources for: Rent/Utility Assistance Food Legal Assistance Shelter Support Groups, and more Help your patients get in touch with community resources by telling them about 2-1-1! For more information go to: ACETAMINOPHEN OVERUTILIZATION Due to a growing number of serious liver injury cases caused by unintentional acetaminophen (APAP) overdoses, The Food and Drug Administration (FDA) is increasing awareness that the maximum daily dose of APAP should not exceed four (4) grams in healthy adults. Many individuals use more than 4 grams of acetaminophen each day without knowing.

7 Factors that may contribute to APAP overutilization: The availability of APAP in many prescription combination medications, and in single-agent and combination over-the-counter (OTC) products Lack of patient knowledge and/or awareness Patients seeing multiple prescribers who are unaware of what is in the medications the other practitioners have prescribed for the patient The use of multiple pharmacies Acetaminophen overutilization is the leading factor in cases of unintentional acute liver failure in the United States. While some patient populations are already at a higher risk for liver damage, awareness to the total amount of acetaminophen consumed is paramount in reducing the incidence of liver damage caused by the overuse of acetaminophen. ANALGESICS WITHOUT ACETAMINOPHEN Tramadol Oxycodone immediate release Methadone Hydromorphone Morphine immediate or extended release ANALGESICS WITH ACETAMINOPHEN Codeine with Acetaminophen (Tylenol w/codeine #2, #3, #4) Oxycodone with Acetaminophen (Percocet, Endocet, Tylox, Roxicet) Hydrocodone with Acetaminophen (Vicodin, Hycet, Lorcet, Norco) MAXIMUM ACETAMINOPHEN UTILIZATION Acetaminophen strength Maximum tablets / day Maximum tablets / month (mg) If you have any questions regarding Acetaminophen Utilization, please contact our Director of Pharmacy, Brian Peltz at (313) HAP MIDWEST HEALTH PLAN S WEBSITE Be sure to visit HAP Midwest Health Plan s website at hap.org/midwest On HAP Midwest Health Plan s website, providers will find the following information: PCP Member eligibility lists Quick Reference Guide that tells you when you need referrals and authorizations Obtain authorization via Clear Coverage How to request an appeal and the appeals process Privacy Notice on how we use member information Free educational programs for our members Every other Month provider newsletters

8 HAP Midwest Health Plan s QI program, QI plan and annual evaluation Pharmacy information, including the formulary and preferred drug list MHP s entire Provider Administrative manual, (this includes our preventive health and clinical guidelines, policies and procedures on confidentiality, member s rights and responsibilities, medical record documentation, fraud/abuse/false claims, safety information on area hospitals, our formulary, formulary updates and pharmacy procedures, affirmative statement regarding UM decision making, etc.) This web site also includes information for our members such as our free educational programs, our policies and procedures and even the entire membership guide/handbook that tells the members what their MHP benefits are! Hope you visit our website. If you would like a hard copy of any of the information on our website or have any questions or comments please contact the Provider Representatives: Linda Abdelghani (313) , Brian Flemming (313) or Nehya Ahmed (313) HAP MIDWEST HEALTH PLAN PROVIDER PORTAL REGISTRATION To better serve you, please make sure you have registered on to our provider portal by logging on to hap.org/midwest and click on registration. All HAP Midwest Health Plan Providers must FIRST register as a Provider Administrator (owner of the tax id) and then create a new user id and password in order to access our Provider Portal. Once a Provider Admin has successfully registered (obtaining access to all areas) an will be sent confirming the registration has been successful. Then Provider users (office managers, biller users and referral coordinators) can register as Provider Users selecting access to only what is necessary for their role. Once a Provider User has successfully registered (obtaining access to selected or all areas) an will be sent to the Provider Administrator confirming the provider users registration and selection. *Please note the same rules apply to the Biller Agency Administrator (3 rd party billing agency). The Provider Admin must register first to open all approval for The Billing Agency Administrator as well as the provider users. If you should have any questions Please contact your Provider Services Representative Linda Abdelghani (313) , Brian Flemming (313) or Nehya Ahmed (313) ENTER AUTHORIZATRION ONLINE Authorization online is available to improve the prior authorization process for our providers. Clear Coverage is available to our entire network. HAP Midwest Health Plan (HAP Midwest Health Plan) has implemented Clear Coverage, a web- based application that can be accessed by logging on to our website hap.org/midwest and entering your user id and password. As a HAP Midwest Health Plan provider, you can enter a prior authorization service request and receive automatic authorization for some specific services. With Clear

9 Coverage, you can provide clinical information, upload medical records as needed, view authorization status, and print proof of authorization. It is our expectation that automating this process will improve access to necessary specialty care to our beneficiaries and save valuable time for you and your office staff. HAP Midwest Health Plan, is offering training on how to use Clear Coverage. For more information on training please contact you Provider Representative Linda Abdelghani (313) , Nehya Ahmed (313) , or Brian Flemming (313) NOTICE OF PRIVACY PRACTICES HAP Midwest Health Plan Notice of Privacy Practices tells you how we use and protect member information. Since your office also accesses member information, you need to also keep member information secure and private. This notice is included in the member handbook, annually in the member newsletter and is posted on our website. Please review the Notice of Privacy Practices found on our web site at Remember- Treat member information as if it was your personal information! If you have any questions, please call (313) Medicaid Member Billing Policy: State and federal regulations prohibit health care providers from billing HAP Midwest Medicaid members for services provided to them except under limited circumstances. HAP Midwest monitors this activity based on reports of billing or complaints from members. We will communicate with our providers to resolve any member billing issues and that includes notification of excessive member complaints and education regarding appropriate practices. Failure to comply with regulations after intervention may result in HAP Midwest reporting the provider to MDHHS for non compliance and potential termination of provider's agreement with HAP Midwest. Regulations on Billing Medicaid Members: Federal regulations as well as your executed contract with HAP Midwest, prohibit providers from billing members except in very limited situations. To bill a member all of the following must have occurred: Provider has submitted a Prior Authorization request to HAP Midwest and HAP Midwest has denied the Prior Authorization request; and After receipt of denial and prior to rendering the services the provider has notified the member, in writing, of the financial liability to the member should member elect to proceed with the services; and The written notification must be specific to the services to be provided, and clearly states the member is financially responsible for the specific service. A general patient liability statement signed by all patients at your practice does not meet this requirement; and

10 The written notification must be signed and dated by the member; date must be prior to date of service. In compliance with federal and state requirements, HAP Midwest Medicaid members cannot be billed for missed appointments. HAP Midwest encourages members to keep scheduled appointments and call to cancel, if needed. HAP Midwest provides transportation for many doctor s visits to help ensure our members make it to needed medical appointments. Please call our Customer Service Department at if you are concerned about HAP Midwest members who miss appointments. Providers should call Provider Services for guidance to determine if billing members for any services is appropriate. You can reach Provider Services by calling prompt 2 for Providers, prompt 3 for the Provider Services Department and any provider services representative can assist you. LANGUAGE INTERPRETATION SERVICES HAP Midwest Health Plan has language interpretation services available for all members and providers in both written and oral communication. HAP Midwest Health Plan employs bilingual speaking staff that speaks English, Arabic, and Spanish. HAP Midwest Health Plan also contracts with a vendor to assist when communicating with non-english speaking persons. Please contact the Customer Services department at (888) for assistance. MEDICAID AND MICHILD ACCESS As a reminder, Medicaid and MIChild members may receive services at Federally Qualified Health Centers (FQHC), Rural Health Centers (RHC), Tribal Health Centers (THC), and Child and Adolescent Health Centers (CAHC). A list of these centers is available by calling your Provider Representative. Prior authorization is NOT required for in network FQHC, RHC, THC and CACH. If a member wishes to visit one of these facilities that are out of network, they must receive a prior authorization. As a reminder, women who want to see an OB/GYN doctor for a well-woman check-up or for pregnancy can make an appointment with any OB/GYN within MHP s network, without a PCP referral. If you need help finding an OB/GYN for your member, call customer service at (888) Your members under 18 years old may see any pediatrician in MHP s network for wellchild visits without a PCP referral. If you need help finding a Pediatrician for your member, call Customer Service at (888) MICHILD PROGRAM MIChild recipients are ineligible for the VFC Program. The Provider should bill their usual/customary charge for these services and will be reimbursed as FFS. Any questions regarding this matter please contact your Provider Representative in the Provider Services Department.

11 MCIR, VFC, and REPORTING COMMUNICABLE DISEASES MCIR: You are required to report all vaccines to MCIR. MCIR (formerly the Michigan Childhood Immunization Registry) is now the Michigan Care Improvement Registry. As per your contract with HAP Midwest Medicaid and per Public Act 91 of 2006, it is required that all immunization providers report childhood immunizations (those administered to persons born 1/1/1994 to present) to the MCIR. If you need information on reporting or access please contact (888) Information on MCIR is easily found on their web site at MCIR can also assist you in improving your immunization rates by using MCIR to run batch reports and monthly immunization recall letters. Vaccines for Children (VFC): As a Medicaid provider, you are required to get your vaccines through the VFC program. The Alliance for Immunization in Michigan (AIM) tool kits include information on VFC and MCIR as well as catch up schedules, storage information, vaccine information sheets and much, much more!. Contact your local health department if you have questions about the VFC program. The AIM tool kit can be found at Reporting Communicable Diseases: You are required by State law to report all communicable diseases to the local health department. The Alliance for Immunization in Michigan Provider Tool Kit includes a helpful brochure titled Table of Reportable Diseases in Michigan. If you need an additional copy of this or any other information found in the AIM kit, it is found on the website at HEALTH SERVICES: Member Appeals HAP Midwest Health Plan recognizes that participating providers may choose to exercise their right to appeal a utilization management decision. The appeals process is established to facilitate this right. If a provider disagrees with a utilization management decision the provider may file an appeal. The provider must make the appeal in writing to the HAP Midwest Health Plan Medical Director. HAP Midwest Health Plan will accept verbal appeals only in emergent situations. If the HAP Midwest Health Plan Medical Director cannot reverse the adverse determination: o A physician not involved in the initial denial will review the case. o The physician reviewer will be of the same specialty of the requesting physician with similar credentials and licensure. o The appeal will be resolved within 15 calendar days (up to 30 calendar days total for all levels of appeal) of the request for appeal. When the request for urgent care is denied by the HAP Midwest Health Plan Medical Director, HAP Midwest Health Plan gives members and practitioners confirmation of the

12 decisions within 72 hours of receipt of the request. Verbal notification is given within 72 hours of receipt of the appeal request, with written notification within 3 calendar days. Case Management HAP Midwest Health Plan has a telephonic case management program. Case Management Services include: Education on current disease process Coordination of services Referral to community agencies Support with adherence to plan of care Claims, utilization reports, discharge planners and utilization review staff, disease management, providers and member/caregiver self-referral, may identify members who may benefit from case management services. The program is voluntary and requires the involvement of the member or caregiver. The case manager will assess the needs of the member, develop a plan of care with the member and health team, establish mutual goals, and implement interventions designed to reach Health Services Registered Nurse will set up a specific care plan. The RN will contact members via phone to discuss goals and the plan to attain the goal. Please contact HAP Midwest Health Plan Health Services Department (313) to initiate an evaluation for case management services. Screening for Depression Primary Care practitioners play an important role in screening for and treating depression. HAP Midwest Health Plan recommends the use of PHQ-9 Questionnaire as a depression screening tool. The Tool is available online as part of the MacArthur Initiative on Depression & Primary Care at Dartmouth and Duke at: primarycare.org/clinicians/toolkits/materials/forms/phq9/. You will find useful information and a Depression Management Tool Kit on their website that includes the following: Recognition and Diagnostic Information Patient Education Materials Treatment Information Monitoring and Follow-up Information Bibliography

13 Please remember to screen for depression in asthmatic, diabetic and post-partum patients and refer patients for behavioral health services if needed. You can find behavioral health providers in the HAP Midwest Health Plan Provider Directory which is online at hap.org/midwest. If you have questions about the depression screening tool, please call the Health Management department at (313) FREE GLUCOMETER PROGRAM HAP Midwest Health Plan provides glucometers FREE of charge to our diabetic members. The form that must be completed in order for members to receive the FREE glucometer is available on the Provider section of the website at: hap.org/midwest The glucometer can be shipped to your office for the member to pick up, or mailed directly to the member s home. Because diabetic supplies (i.e. alcohol swabs, lancets, and test strips) are billed under the prescription drug benefit, your patient will need a prescription to take to the pharmacy for those items. If you have questions regarding this program, please call Customer Service at (888) REPORTING FRAUD, WASTE AND ABUSE If you suspect fraud or abuse, contact HAP Midwest Health Plan s Compliance Officer: HAP Midwest Health Plan Compliance Officer 4700 Schaefer Road, Suite #340 Dearborn, MI Toll Free: (866) For Medicaid: call Toll Free MI-Fraud ( ) On line at In writing: Office of Inspector General, PO Box 3047 Lansing, Michigan For Medicare: contact the OIG:(Member fraud) , and (Provider fraud) Reporting may be done anonymously to MDCH, OIG and HAP Midwest Health Plan. The False Claims Act: prohibits the knowing submission of false or fraudulent claims for payment to the federal or State government, the knowing use of a false record or statement to obtain payment on a false or fraudulent claim, or a conspiracy to defraud the federal or state government by having a false claim allowed or paid. Whistleblower Protection: It is the policy of Midwest that no employee who makes a report of alleged wrongdoing will be subjected to reprisal, harassment, retribution, discipline or discrimination by Midwest or any of its employees based on having made the report.

14 Providers can access web based training for the FWA Medicare Learning Network (MLN) Training Module on the CMS website at: MLN/MLNProducts/index.html?redirect=?MLNProducts HEALTH MANAGEMENT MQIC Mobile App The Michigan Quality Improvement Consortium (MQIC) now features an app for all Android and ios smartphones that features evidence based clinical practice guidelines and useful tools. Download the application to be up-to-date on the most recent announcements and news. There are different categories you may select from on the home screen that are best suited for your practice. ROSEBUD Pregnancy Education Program HAP Midwest Health Plan would like to remind you of our telephonic case management and education program for pregnant members and their infants. ROSEBUD is staffed by nurses who specialize in perinatal care and case management. The Perinatal Case Management program targets women at risk for complications during pregnancy. The program supports the healthcare provider s plan of care as well as provides ongoing education to the expectant mother and her family. You may refer members to this program, by calling the Health Management Department at (313) You may also fill out the Notification of Pregnancy form and fax it to (248) , Attention: Health Management Department. Thank you for your assistance! The Notification of Pregnancy form can be found on our website at hap.org/midwest Smoking Cessation Program HAP Midwest Health Plan s Smoking Cessation Program can help members quit smoking. This is a telephone health coaching program. The program includes proactive phone calls by a dedicated health coach over a 12 month period. Health coaches offer strategies to increase self-efficacy, identify barriers to change, and provide techniques to cope with and overcome barriers. For more information on our Smoking Cessation Program or to refer any of your patients to the program, call the Michigan Tobacco Quitline at QUIT NOW ( ).

15 Disease Management Diabetes Program: When enrolled, members will receive information on how to take care of their diabetes. Call (313) to refer your patient into this program. After joining, the member will be sent information on what diabetes is, how to control blood sugar, taking medications the right way, exercising, eating right, eye and foot care and other important information. Asthma Program: When enrolled, members will receive educational information in the mail. To refer your patient into this program, call (313) After joining, the member will be sent information on asthma triggers, use of medications,, an asthma action plan to complete with PCP, information on stopping smoking, and much more. Hypertension Program: When enrolled, members will receive educational information in the mail. To refer your patient into this program, call (313) After joining, the member will be sent information on lowering blood pressure, healthy diet and exercise, and medication adherence. Quality Management Clinical and Preventive Health Guidelines HAP Midwest s Clinical and Preventive Health Guidelines include: Adolescent Health Advance Care Planning Asthma Attention-Deficit/Hyperactivity Disorder Back Pain Bronchitis Cancer Cerebral Palsy Cystic Fibrosis Depression Diabetes Heart Failure Hypercholesterolemia Hypertension Kidney Disease Office Based Surgery Osteoarthritis Osteoporosis Otitis Media Overweight and Obesity Pharyngitis Pregnancy Pregnancy Prevention Preventive Services Sickle Cell Disease Substance Use Tobacco Control Venous Thrombosis

16 These guidelines are found on our website at hap.org/midwest. Please review these guidelines. These guidelines are developed based on nationally recognized sources each guideline lists the sources. These guidelines were endorsed by the Medical Directors of the Michigan Quality Improvement Consortium (MQIC) and/or the Michigan Association of Health Plans Medical Directors. You can also find the guidelines along with physician tools on the MQIC website at There has been a change in the HEDIS measure for Body Mass Index (BMI). Effective January 1, 2015, NCQA has mandated that all patients ages now have a BMI percentile. This means that in order to be compliant the member must have a height, weight and BMI percentile documented in the medical record. Please notify your staff and make this change immediately. As a reminder: It s nearing back to school time and immunizations are important!!! When rendering school physicals don t forget the BMI percentile and graph, nutritional and exercise counseling as well as anticipatory guidelines. Please note the physical activity requirement to indicate that notation of anticipatory guidance related solely to safety (e.g., wears helmet or water safety) without specific mention of physical activity recommendations does not meet compliance criteria. Lead Screening: It s not only about lead in paint but lead found in many items including pipes in older homes, playground water fountains, playgrounds, toys, and imported items from different countries such as China. Many of these items can be found in Dollar stores. Lead screening is vital!! Michigan State law states that all Medicaid-enrolled children, between the age of 12 and 24 months or 36 and 72 months if not tested previously, must have a blood lead test. NO EXCEPTIONS OR WAIVERS EXIST! The HEDIS lead screening measure requires that children receive a blood lead screening on or before their second birthday. Medical record documentation needs to include the DOS and the result of the blood lead screen. PCP offices may also enter the results of blood lead screening into MCIR to reduce onsite medical record review. Page 16 of 21

17 Helpful HEDIS tips HEDIS BMI Measures: HEDIS has two BMI measures, Adult BMI Assessment and Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents. Adult BMI Assessment looks at those members that have had a BMI documented in the medical record in 2014 or Documentation in the record must include the following in order to count towards a HEDIS hit: Date of BMI Weight BMI Value Weight Assessment and counseling for Nutrition and Physical Activity for Children/Adolescents looks at children ages 3-17 years of age who had a visit in 2015 and has had the following documented in their medical records. All components must be documented to count towards a HEDIS hit. BMI percentile calculated or plotted on a growth chart (dated and calculated) o Height and Weight Counseling for Nutrition or Anticipatory Guidance was given regarding it. Counseling for Physical Activity during a visit or Anticipatory Guidance was given regarding it. Per NCQA HEDIS specifications - the following notations or examples of documentation does not meet criteria and does not count as compliant: Notation of anticipatory guidance related solely to safety (e.g., wears helmet or water safety) without specific mention of physical activity recommendations. Notation of cleared for gym class alone without documentation of a discussion. Notation of health education or anticipatory guidance without specific mention of physical activity. Notation solely related to screen time (computer or television) without specific mention of physical activity. PCP offices may also enter the child s height and weight into MCIR which will calculate the BMI and BMI percentile, which is required for HEDIS reporting. MCIR also allows providers to check a box stating nutrition and activity was addressed. By entering these findings into MCIR, this will allow HAP Midwest Health Plan to capture the data and help reduce onsite medical record review at PCP offices. Page 17 of 21

18 Below is the HEDIS Annual Comparison 2015 chart Report Year NCQA NCQA NCQA Elig Measure 50th % 75th% 90th% Pop Prevention and Screening Childhood Immunizations (CIS) Combo #2 85.4% 77.6% 79.6% 75.2% 79.7% 83.3% 1965 *Combo #3 79.1% 74.7% 73.8% 72.3% 77.8% 80.9% 1965 Lead Screening (LSC) 77.4% 74.7% 77.6% 70.9% 80.8% 85.8% 1965 Immunizations for Adolescents (IMA) Combo #1 85.6% 88.7% 87.1% 71.3% 80.9% 86.5% 1896 Human Papillomavirus Vaccine for Female Adolescents 19.0% 22.3% 23.4% 19.2% 23.6% 28.9% 928 *Breast Cancer Screening (BCS) 57.5% 58.9% 56.4% 57.4% 65.1% 71.4% 1761 *Cervical Cancer Screening (CCS) 71.3% 66.4% 65.2% 64.3% 71.3% 63.0% 6168 Chlamydia Screening in Women (CHL) yrs old 61.5% 59.5% 59.5% 51.6% 58.4% 65.4% yrs old 71.2% 69.7% 67.4% 63.3% 69.2% 72.6% 865 *Combined Rate 64.8% 63.2% 62.4% 55.0% 62.6% 67.2% 2323 Adult BMI Assessment 75.7% 81.3% 85.2% 78.8% 85.1% 90.8% Weight Assessment & Counseling for Nutrition & Physical Activity in Children & Adolescents BMI 69.8% 65.9% 75.7% 57.4% 73.7% 82.5% Counseling for Nutrition 65.5% 64.7% 69.3% 60.6% 69.2% 77.5% Counseling for Physical Activity 60.6% 61.3% 63.3% 51.2% 60.8% 69.8% Respiratory Conditions *Appropriate Testing for Children w/pharyngitis (CWP) 62.3% 50.2% 65.5% 68.5% 78.0% 83.7% 1371 *Appropriate Treatment for Children w/uri (URI) 85.9% 88.2% 88.4% 86.1% 91.2% 94.4% 3098 *Avoidance of Antibiotics in Adults w/acute Bronchitis (AAB) 20.8% 36.2% 34.7% 30.5% 38.7% 35.4% 634 Use of Approp. Meds for Asthma (ASM) Age 5-11 (beginning 2012) 97.0% 82.8% 84.4% 91.1% 93.6% 95.2% 275 Age (beginning 2012) 97.9% 76.0% 79.4% 87.3% 89.5% 93.0% 248 Age (beginning 2012) 99.1% 67.0% 69.5% 75.9% 80.4% 84.5% 344 Age (beginning 2012) 100.0% 49.6% 62.4% 75.9% 80.4% 84.5% 117 *Combined rate 98.0% 71.5% 75.3% 84.9% 87.2% 91.4% 984 *Use of Spirometry Testing for Diagnosis of COPD (SPR) 32.3% 38.5% 34.7% 29.9% 36.7% 42.4% 274 Cardiovascular Conditions *Controlling High Blood Pressure (CBP) 67.9% 55.7% 66.2% 56.2% 63.8% 69.8% 3601 Persistant Beta Blocker Tx after Heart Attack (PBH) 96.3% 82.9% 97.3% 86.4% 91.2% 94.7% 37 Diabetes Comprehensive Diabetes Care (CDC) *HbA1c testing 92.7% 81.3% 87.0% 83.9% 87.6% 91.7% 2586 *Poor HbA1C control (lower=better care) 35.0% 44.5% 36.6% 44.8% 53.8% 60.8% 2586 *Eye Exam 61.5% 62.3% 57.6% 54.2% 63.1% 68.0% 2586 *Monitoring for Nephropathy 97.8% 84.0% 81.9% 80.1% 83.1% 86.9% 2586 BP Control <140/ % 62.9% 73.9% 61.3% 70.1% 75.2% 2586 BP Control <130/80 (<140/80 after 2011) 46.7% 40.0% 1.9% 39.4% 45.5% 53.2% 2586 Muscular Skeletal Conditions *Imaging Studies for Low Back Pain (LBP) 82.1% 80.7% 79.6% 75.3% 78.6% 84.0% 849 Behavioral Health *Antidepressant Medication Mgt. (AMM) *Effective Acute Treatment 54.1% 50.0% 51.8% 49.7% 54.4% 60.9% 587 *Effective Continuation Treat 39.3% 34.5% 33.4% 33.9% 38.3% 44.6% 587 Page 18 of 21

19 *Follow up Care for Children with ADHD (ADD) *Initiation phase 38.2% 33.7% 32.8% 41.1% 47.0% 53.0% 470 *Continuation phase 50.4% 36.8% 35.1% 49.5% 57.6% 63.1% NCQA NCQA NCQA Elig Measure Pop Access/Availabiity of Care Adult Access to Primary Care Practitioner (AAP) Age % 81.6% 80.6% 83.2% 86.2% 88.5% Age % 88.9% 88.8% 88.8% 91.0% 92.3% 6498 Age % 82.3% 92.5% 88.4% 90.7% 92.6% 321 Child Access to Primary Care Practitioner (CAP) Age months 98.6% 96.0% 94.5% 97.0% 97.9% 98.5% 1861 Age 25 mos. - 6yrs 94.3% 86.0% 86.1% 89.1% 91.7% 93.6% 8467 Age 7-11 yrs 94.2% 90.7% 89.5% 91.2% 93.5% 95.2% 6730 Age yrs 94.0% 88.2% 88.2% 90.0% 92.2% 94.4% 9649 *Prenatal/Postpartum Care (PPC) *Timely Prenatal Care 95.9% 78.8% 87.8% 84.3% 89.6% 93.1% 1975 *Postpartum Care 73.2% 58.8% 62.5% 62.8% 69.5% 74.0% 1975 Use of Services Freq of Prenatal Care (FPC) >80% of visits 80.1% 55.7% 62.3% 60.1% 71.3% 78.4% 1975 Well Child Visits in 1st 15 months (W15) Zero visits 0.0% 0.0% 3.4% 1.5% 2.6% 4.1% or more visits 86.4% 64.2% 59.6% 62.9% 69.8% 76.9% 1591 Well-Child Visits in yrs 3,4,5,6 (W34) 83.0% 72.8% 75.9% 71.8% 77.3% 82.7% 6908 Adolescent Well-Care Visits (AWC) 65.9% 61.1% 54.3% 48.5% 59.2% 65.6% CAHPS - Adult Survey *Getting Needed Care 78.2% 78.6% 80.1% Q14 Easy to get care believed necessary 79.2% 83.1% 84.1% Q25 Easy to get appt w/specialist 77.1% 74.1% 76.1% *Getting Care Quickly 80.6% 82.4% 81.0% Q4 Getting care as soon as needed 81.5% 83.5% 82.3% Q6 Getting appt as soon as needed 79.8% 81.4% 79.8% *How Well Doctors Communicate 89.4% 88.2% 88.2% Q17 Explain things in a way you could understand 89.9% 91.5% 88.1% Q18 Listen carefully to you 89.6% 87.4% 88.4% Q19 Show respect for what you had to say 91.5% 90.4% 90.0% Q20 Spend enough time w/you 86.7% 83.5% 86.4% *Customer Service 83.2% 84.3% 84.8% Q31 Got information or help needed 77.5% 81.6% 77.9% Q 32 Treated you with courtesy & respect 88.8% 86.9% 91.6% Shared Decision Making 51.1% 52.8% 80.2% Q 10 Dr. talked about reasons you might want to take a medicine ( a lot) 52.1% 50.0% 92.5% Q 10 Dr. talked about reasons you might want to take a medicine (some) 32.5% 33.3% Q 11 Dr. asked which choice was best for you 75.0% Q 11 Dr. talked about reasons you might not want to take a medicine ( a lot) 26.3% 25.9% 69.2% Q 11 Dr. talked about reasons you might not want to take a medicine (some) 28.1% 30.9% Q 8 Health Promotion & Education 76.8% 73.8% 75.6% Q 20 Coordination of Care 74.9% 79.9% 75.4% Page 19 of 21

20 *Q13 Rating your Health Care 69.2% 73.8% 72.8% *Q23 Rating of Personal Doctor 79.4% 78.7% 78.2% *Q27 Rating of Specialist 76.6% 79.4% 78.8% *Q35 Rating of Health Plan 71.7% 74.4% 77.6% Smoking Cessation Q37 Smoke Every Day and Some Days NA NA NA *Q38 Advised to Quit Smoking 78.1% 80.2% 81.3% Q39 Discuss Smoke Cessation-Medications 47.8% 50.3% 50.5% Q40 Discuss Smoke Cessation-Strategies 39.8% 44.9% 45.9% * NCQA Accreditation points awarded based on results for this measure NCQA Percentiles P25 P50 P75 P90 WIN CANDY: Your office will have the chance each month to win a free box of candy. All you have to do is answer the questions toward the last page of the newsletter and fax the page to us at If your answers are correct, the candy will be mailed to your office. If you do not answer the questions correctly, you will not receive the candy. So keep up the good work and keep responding. If you re not participating, you should. It s quick and easy and all you have to do is read the newsletter and answer the questions. Congratulations to those offices who responded correctly. We hope you are enjoying the candy! ANSWERSTO THE AUGUST CANDY CONTEST True: Authorizations can now be done online via Clear Coverage by logging on to our Provider Portal and entering our user id and password. 2. Effective July 1, 2015, The MI Health Link Plan is coming to Macomb and Wayne Counties. 3. True: Healthy Michigan Plan members are encouraged to complete an annual Health Risk Assessment (HRA) during their first PCP visit. This visit should be scheduled within 60 days of enrollment. Members are mailed the HRA with their welcome packet. The HRA also can be found on the HAP Midwest Health Plan website: hap.org/midwest 4. What are the Helpful HEDIS Measure tips: Page 20 of 21

21 OCTOBER CANDY CONTEST Effective on or after a valid ICD-10 code is required for dates of services. 2. True or False: After October 1, 2015, if a claim does not have a valid ICD-10 or ICD Qualifier it may reject. 3. True or False: Your organization utilizes a 4010 HIPPA format and relies on a Billing Vendor to convert codes to the proper 5010 HIPPA format. However, your Vendor can not covert the codes properly and is not prepared and therefore, may reject. 4. True or False: Can your organization be tested with MDHHS for success? Print Name: From the office of Doctor: Office Site Name: Office Address: Phone Number: Fax back to us at (248) Page 21 of 21