PMR Provides Valuable On-time Patient Information

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1 PMR Provides Valuable On-time Patient Information Related article, page 2 Univera Healthcare s goal is to provide you with tools that will assist you in the delivery of quality medical care to our valued members. The Patient Management Reminder (PMR) is an excellent on-time reminder system that better enables your staff and patients keep up to date with preventive and chronic illness measures of care. The PMR is available exclusively in Western New York to Univera Healthcare s Primary Care Physicians and Pediatricians who have Medent software and is an excellent source for helping you to improve your ability to earn panel model incen- Univera Healthcare, The American Diabetes Association, National Committee for Quality Assurance (NCQA) and NovoNordisc have teamed up to enable physicians identified as exceptional providers of diabetic care to earn recognition for their performance. NovoNordisc and our organization will provide funding for physicians who wish to apply for the Diabetes INSIDE THIS ISSUE FALL 2005 A Message from the CMO 2 Pharmacy News 3 Office-Staff Connection 5-6 Getting Your Patients to Quit 7 Fun 2B Fit 8 tives, improve your quality measures and streamline the process by which you prepare for our HEDIS data collection. It also enables us to gather the most up-to-date information for our birthday card preventive screening reminders that are sent to our members. A 2-page PMR is faxed daily for each patient on your office-visit schedule. It includes our clinical guidelines and information about the following: Preventive Health Smoking status PAP smear Mammogram Physician Recognition Program including assistance with the abstraction of medical records necessary for submission with the application. Funding will be considered for any Primary Care Physician with a minimum of 30 diabetic patients who have been diagnosed and are under his or her care for at least 12 months. Recognition is awarded based on the following standards: Glycated Hemoglobin (A1C) Control Blood Pressure Control Eye Examinations Smoking Status and Cessation Advice or Treatment Lipid Profile and Control Nephropathy Assessment Food Examinations Tetanus vaccine Flu vaccine Pneumonia vaccine Colon cancer screening Advance directives Chronic Illness Asthma Diabetes Coronary Artery Disease Hypertension Pediatrics Current immunizations Lead screening Hemoglobin Chronic diseases Risk factors for heart disease, tuberculosis Funding Available to Help Physicians Apply for Diabetes Recognition Recognition benefits include: Posting of recognition on the ADA, NCQA and Univera Healthcare Web sites Referrals of consumers from the ADA National Call Center Identification of areas of performance where there may be variance from the standards of care in treating individuals with diabetes Assistance in meeting scores for pay for performance programs If you would like more information about the program, funding or how to apply, please contact Michelle Konwicki, clinical quality coordinator at (716) or via , michelle.konwicki@univerahealthcare.com. Funds are limited and will be provided on a first-come-firstserved basis.

2 2 A Message from the Chief Medical Officer As a physician, I can say with confidence that all physicians start out each day with every intention of delivering the best medical care possible. But realistically, we all know that there are outside influences that can often impede our ability to provide quality care. Univera Healthcare is keenly aware of this reality and constantly strives to find ways to support you as your care for our members. We provide many tools designed to assist, including: Birthday card reminders sent to members to prompt them to schedule annual preventive health screenings Quality measures reports provide listings of patients who need preventive health or disease management services Regional President Mary Lee Campbell-Wisley Univera Examiner is published four times a year by Univera Healthcare, 205 Park Club Lane Williamsville, NY For inquires regarding this publication, please contact Maria N. Valvo, Editor, at (716) Our health-coaching program, which supports your patients and enhances physician/patient communication. The program provides members with 24-hour telephone access to Health Coaches who are specially trained nurses, dietitians, and respiratory therapists. They provide unbiased, evidence-based health information specific to each patient s condition. No treatment advice is given and questions relating to care are referred back to the treating physician Physicians who have Community Computers MEDENT software are able to print a Patient Management reminder (PMR), which provides up-to-date patientspecific information each time the patient visits. This affords an opportunity to schedule any need- BH After Hours Access and Availability The Behavioral Health (BH) Access and Availability Standard states that telephone access to the behavioral health practitioners for urgent/emergent care should be available on a 24-hour/7-day per week basis. The BH After Hours Survey/Audit was developed to check the compliance of BH practitioners. Our goal is to reach an average compliance rate of 85 percent across all BH specialties. Our survey included 339 practitioners and showed a compliance rate of 84.7 percent, an increase from 76.1 percent in The answering options considered to be acceptable are: Reaching the practitioner or a person with the ability to patch the call through to the practitioner (i.e.; answering service), or Reaching an answering machine or voice mail with instructions for contacting the practitioner or his/her backup (i.e., message with home phone number, cell phone, or beeper). Our survey showed 52 practitioners out of compliance. Of those out of compliance, 35 were noncompliant for the first time and 17 for the second consecutive time. The Behavioral Health Access and Availability Standards policy and other BH policies are available on the Univera Healthcare Web site, ny/pdf/behavioralhealth. For additional information about our BH Quality Management Program, please call BH Quality and Compliance at (716) If you simply need to update your address or phone number, please write to Provider File Maintenance, Univera Healthcare, 205 Park Club Lane, Buffalo, NY ed services during that visit For more information about PMRs, please see the related article on the front page. As medicine becomes more and more complex, it behooves us to take advantage of tools such as these. We will continue to find more tools to make your job a bit easier and to improve your ability to care for our members. We are always interested in hearing your opinions about our current care systems, suggestions for improvement to those systems and ideas for new systems and programs. Feel free to drop me a line or give me a call. Jay I. Pomerantz, M.D. Consider These Factors for Chlamydia Screening As you are likely aware, the U.S. Preventive Services Task Force recommends strongly that clinicians conduct routine chlamydia screenings for all sexually active women ages 25 and younger and other asymptomatic women at increased risk for infection. The prevalence of chlamydia infection varies widely among patient populations and, in some instances, screening all patients age 25 and younger without the presence of other risk factors may not be justified. Please remember, however, to consider age along with the following factors that are associated with a higher prevalence of infection: Patient is unmarried African-American race Prior history of sexually transmitted disease New or multiple sexual partners History of a cervical ectopy Inconsistent use of barrier contraceptives

3 Drug Prior Authorizations for Medical Drugs and Pharmacy Drugs: What s the difference? We understand that there has been some confusion surrounding drug prior authorization because drugs are covered under both the medical and pharmacy benefit. To help alleviate confusion and better understand the differences in drug prior authorizations for medical and drug benefit coverage, we ve prepared the following explanation. Medical Benefit versus Pharmacy Benefit Drugs covered under a member s medical benefit are typically administered by a health care provider in the office, at an infusion center, at an outpatient facility or in some cases, by home care agency employees or otherwise via home infusion. Drugs covered under a member s pharmacy benefit are typically those drugs that can be self-administered. Prior Authorization Process for Medication Covered Under the Medical Benefit The following medications are covered under the medical benefit (when administered by a healthcare professional) and require prior authorization: Amevive Aralast** Aranesp Epogen Flolan** IVIG Procrit Prolastin** Remicade Remodulin** Synagis* Ventavis** Xolair Zemaira* * Prior authorization effective Oct. 1, 2005 ** Prior authorization effective Oct. 11, 2005 Please note that additional drugs will continue to be added to the program. The Medical Specialty Medication Review Program was created to facilitate medical necessity reviews for certain medications covered under the medical benefit. The Medical Specialty Medication Review Program unit is staffed with clinical pharmacists, physicians and nurses. As part of the program, we encourage the use of specialty pharmacies that will ship the drug to your office and bill Univera Healthcare directly. How does the Medical Specialty Medication Supply Program work? The Medical Specialty Medication Review Form is completed and faxed to the specialty pharmacy. The pharmacy will vary depending upon the drug The specialty pharmacy verifies eligibility and benefits coverage, and forwards the review form to the Medical Specialty Medication Review Program unit. Once approved, the specialty pharmacy dispenses and ships the medication to you for administration. The specialty pharmacy will bill Univera Healthcare directly for the cost for medication Providers who administer the drugs listed above have received information and the necessary forms. Because the prior authorization instructions and forms are unique to each specialty medication, it is important that you contact the Medical Specialty Medication Review Program unit if you need additional copies or information. We ve included a guide within this newsletter that identifies which specialty pharmacies administer each of the medications listed above. For questions and additional information, please contact the Medical Specialty Medication Review Program at: Telephone: Fax: Prior Authorization Process for Medication Covered Under the Pharmacy Benefit This prior authorization program applies to medications covered under a member s pharmacy benefit. Prior authorization helps assure that the prescribed medication, dose and frequency, is appropriate. A list of prescription drugs covered under the pharmacy benefit that require prior authorization is included in this newsletter. You can also access the list on our Web site. For questions and additional information, please contact the FLRx Pharmacy Help Desk at Where to Obtain Medications Covered Under the Medical Benefit In-network pharmacies available to dispense listed medication: Benefit Accredo Priority CuraScript Talecris Direct Medications Healthcare (formerly Bayer) Amevive Medical Yes Yes Aralast Medical Yes Aranesp Medical Yes Yes Epogen Medical Yes Yes Flolan Medical Yes IVIG Medical Yes Yes Procrit Medical Yes Yes Prolastin Medical Yes Remicade Medical Yes Yes Synagis Medical Yes Remodulin Medical Yes Yes Ventavis Medical Yes Yes Xolair Medical Yes Yes Zemaira Medical Yes The specialty medications listed above require a medical review, please contact: Specialty Medical Review Dept Phone: Fax: Pharmacy Contact Information (for ordering medication) Accredo Priority CuraScript Talecris Direct Healthcare (formerly Bayer) Fax: Fax: Fax: Fax:

4 Drug Prior Authorizations (Continued from page 3) 4 Specialty Pharmacies We encourage you to use our specialty pharmacy network for specialty medications covered under either the medical or pharmacy benefit. Specialty medications covered under the medical benefit can be ordered from designated specialty pharmacies, who will supply and ship medication directly to your office at no cost to you. Specialty medications covered under the pharmacy benefit can be ordered from our specialty pharmacy network. Participating national vendors CuraScript Pharmacy and Priority Healthcare will supply and ship all self-injected medication covered under the pharmacy benefit directly to the patient. There are also several local pharmacies that participate in the network. For a complete listing, please visit the Web site at Please note that effective January 1, 2006, (pending New York State Insurance Department approval), some members with Univera Healthcare prescription drug cover- age will be required to purchase specialty medications from a participating FLRx network specialty pharmacy in order to receive coverage. For those medications that require prior authorization (regardless of which benefit they are covered under), the appropriate specialty pharmacy will be listed on the form. Remember that network specialty pharmacies can be used for most specialty medications, regardless of whether or not a prior authorization is required.

5 Clinical Editing Review Process Includes New Form Any challenge of a clinical editing determination for a procedure code combination should now be submitted to Univera Healthcare using our new Clinical Editing Review Request Form. A copy of this form is available on our Web site at \formsforyouroffice. Please remember to include clinical documentation that supports your request. Univera Healthcare allows for a review to be requested within one year from the date our original claim determination is sent to you, unless your Provider Agreement states otherwise. As always, each request is reviewed by administrative and clinical staff, which includes a Univera Healthcare medical director. Univera Healthcare will make a determination on your review and notify you in writing within 45 days of receipt of all necessary information. Requests can be faxed to (716) or mailed to: Univera Healthcare 205 Park Club Lane Buffalo, NY Attn: Kristen Fazekas, Clinical Editing Coordinator For further information, please see the Question and Answer document on our Web site under tools\frequentlyaskedquestions. Change in Address, Hours Requires Notification in Writing Claims Address for Indemnity Business Please help us to better ensure that your patients who are our members always have access to the care you provide by letting us know if you change your service address or service hours. Not only is it a State Department of Health requirement, it enables us to update our provider directories and other important information. We must receive notification in writing via the Provider Information Update Form, which is available on our Web site, There is a special address for submitting paper claims related to UniveraPPO, HealthChoice and Traditional business lines. While electronic claim submission is encouraged, if you must submit a paper claim related to these lines of You can fax the form to or mail it to: Univera Healthcare Provider File Maintenance 205 Park Club Lane Buffalo, NY If you do not have access to the Web and need a copy of the form, please contact Provider Services at (716) or Thank you for your cooperation. business, please submit to: Univera Healthcare Claims P.O. Box Rochester, NY Submitting to the correct address allows for more efficient claims processing. Using Modifier 50 CMS1500 claim processing is very dependent on correct billing. When performed bilaterally, procedures that allow one on each side of the same anatomical site should be billed as a one-line procedure. The modifier 50 (bilateral) should be appended to the five-digit CPT code to indicate a bilateral procedure. Please do not bill two separate lines for a bilateral procedure because it could result in an incorrect payment. In addition, the unit fields should only contain one unit. The sevendigit (five digit CPT plus two-digit modifier) code will be reimbursed at 150 percent of the physician fee schedule for the surgical code billed. A Note to Specialty Care Physicians Please remember that it is important to send copies of patient care reports to the patient s Primary Care Physician. 5

6 Office-Staff Connection (Cont.) Improvements Made to CAQH Application CAQH Universal Credentialing DataSource is modifying its application based on suggestions and opinions from several physicians and providers, professional associations and national quality assurance organizations. The modifications are intended to increase overall acceptance by health plans, hospitals, and other healthcare organizations, thus adding value to all physicians and providers who use the Universal Credentialing DataSource. It is anticipated that each physician and provider who has completed his/her application will need to reattest to an average of 1-12 questions, a process expected to take 5 minutes or less. Physicians and providers will need to complete the Provider Services Is your Main Point of Contact Univera Healthcare encourages physicians and other healthcare practitioners to call Provider Services first whenever they have questions. Provider Services representatives can answer most questions. In situations where they cannot provide an answer, they will direct your call. Please call Provider Services to inquire about: Provider ID numbers Effective date of Provider Participation Agreement Medical policies Member eligibility and benefits questions the first time they reattest after the new version of the application is introduced in mid December. Also, please note that CAQH will be available to non-physician practitioners beginning January 1, More information will be available in coming months. For information about CAQH, please visit Copayment and coinsurance information Referral and preauthorization status Fee schedules Claim status Request for claims adjustment Request for appeal Coordination of Benefits (COB) Health Plan printed materials, including Participating Provider Manual Any other provider-related issue. Thank you for helping us to serve you in the most efficient manner. 6 Antepartum Billing Tips You can help us to process claims for antepartum care by keeping the following guidelines in mind. In general, when an obstetrician bills for a delivery (vaginal, cesarean or VBAC) and has managed the patient s entire pregnancy, the delivery CPT code billed includes the antepartum care. Occasionally, the delivering obstetrician is separate and distinct (not in the same practice) from the obstetrician providing the antepartum care. CPT codes and are used to report the services of an obstetrician who has handled the antepartum care, only. Obstetricians only performing antepartum care should report their services using only one of the following codes based on the total number of visits: Visits 1-3 the appropriate E/M code should be reported for each date of service. Visits 4-6 Procedure code should be billed. Date of service should reflect the earliest visit as the FROM date and the last visit as the TO date. This code is an all inclusive reimbursement, meaning the units should only be one. 7 or more visits Procedure code should be billed. Date of service should reflect the earliest visit as the FROM date and the last visit as the TO date. This code is an all inclusive reimbursement, meaning the units should only be one. Note: Procedure code or should be billed as one line using a date span representing the earliest and last office visit during the antepartum phase. Please bill one unit.

7 Three Minutes Can Make a Difference The U.S. Preventive Services Task Force strongly recommends that clinicians screen all adults for tobacco use and provide tobacco cessation interventions for those who use tobacco products. Minimal counseling of 3 minutes or less, compared to no intervention, has shown to increase overall tobacco abstinence rates. Repeated messages over long periods of time are associated with the greatest success. The 5-A behavioral counseling framework provides a useful strategy for engaging patients in smoking cessation discussions: 1. Ask about tobacco use 2. Advise to quit through clear personalized messages 3. Assess willingness to quit 4. Assist to quit 5. Arrange followup and support Helpful aspects of counseling include providing problem-solving guidance for smokers to develop a plan to quit and to overcome common barriers to quitting. FDA-approved pharmacotherapy that has been identified as safe and effective for treating tobacco dependence includes several forms of nicotine replacement therapy (i.e., nicotine gum, nicotine transdermal patches, nicotine inhaler, and nicotine nasal spray) and sustained-release bupropion. Other medications, including clonidine and nortriptyline, have been found to be efficacious and may be considered. Behavioral Health Practitioners Do Well in 2004 Treatment Record Review Congratulations to Univera Healthcare s Behavioral Health practitioners who participated in the 2004 Treatment Record Review. An average score of 93 percent was achieved. Our organization reviews treatment records of practitioners who are being recredentialed to determine whether these records meet established Behavioral Health Managed Care standards. The standards promote efficient and effective assessment, treatment, health promotion and delivery of behavioral healthcare services and are designed to facilitate confidential coordination and continuity of care. A passing cumulative score of 85 percent must be achieved. Those practitioners who score below 85 percent are required to submit a corrective action plan and will be reviewed again within six to 12 months. Among the opportunities for improvement identified through the 2004 review: 47 percent of treatment plans did not have objective measurable goals and estimated time frames for problem resolution 30 percent of the records lacked documentation of continuity of care between the primary clinician and Primary Care Physician 16 percent of the records lacked documentation of the past and present use of cigarettes, alcohol, and illicit, prescribed and OTC drug use for other family members 18 percent of the records lacked documentation of allergies/adverse reactions to pharmaceuticals or NKDA 12 percent of the records lacked documentation of the patient s premature termination of treatment Please remember that it is important to complete a thorough biopsy- chosocial evaluation for each patient before the third visit and to communicate with each patient s PCP and other practitioners involved in their treatment. In order to achieve this goal, please be sure that signed releases are an integral part of each patient s treatment record. Please call BH Quality and Compliance at (716) If you simply need to update your address or phone number, please write to Provider File Maintenance, Univera Healthcare, 205 Park Club Lane, Buffalo, NY

8 Preauth Required for HMO Out-of-Area, Out-of-Network Care Univera Healthcare requires preauthorization before a member with commercial HMO coverage is able to receive non-emergency care from a non-participating or out-of-area physician or provider. The member s Primary Care Physician is responsible for obtaining preauthorization. Members with Univera PPO, 4Front SM, Univera Traditional, SSA HealthChoice and Univera Medicare PPO may obtain out-of-area or outof-network care without preauthorization from a provider who participates in the Beech Street national provider network. Members can locate a participating provider by calling the Beech Street number on the back of their member identification card. WNY School Children Finding it s Fun 2B Fit Univera Healthcare s Fun 2B Fit program is now being offered in select Western New York schools. The program, which focuses on increasing levels of physical activity and the importance of making healthy food choices, involves students in grades 2-4. Participating students receive custom incentives upon completion of each component of the program to motivate them and encourage lifestyle changes. Parents also play a key role in Fun 2B Fit by encouraging their children to increase and vary their physical activity and increase their vegetable and fruit consumption. Each parent will receive a pedometer and is encouraged to wear it in the presence of his or her child. Additional pedometers will be given to parents to promote health and wellness for their entire family. Fun 2B Fit was designed in accordance with Centers for Disease Control and American Academy of Pediatrics guidelines, as well as input from parents, teachers and children. Willow Ridge second graders enjoy the taste test. Univera Healthcare Mission: To improve the health and quality of life of our members and the communities we serve. Let Us Know Your Thoughts Univera Healthcare is committed to assuring that all participating physicians and providers are satisfied with daily operational plan functions such as network management and provider services relationships, resource management processes, quality improvement activities, and customer service. To that end, we invite your comments, concerns and questions. Your feedback will help us know how we're doing. Please contact Maria N. Valvo, Provider Communications Manager in writing at 205 Park Club Lane, Williamsville, NY 14221; via fax, (716) or by calling (716) should you wish to share your thoughts. Univera Healthcare Fall Park Club Lane Williamsville, NY