Provider newsletter. Dental Home Program launches for member s age 0 6

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1 Provider newsletter Dental Home Program launches for member s age 0 6 Aetna Better Health of New Jersey is pleased to inform you of our new Primary Care Dental Home Program for member s ages 0 6 has launched. Under the program, all Aetna Better Health of New Jersey children ages 6 and younger will be assigned to a primary care dentist (PCD) (unless the family requests to opt out). The PCD assignment considers existing relationships for the member and siblings; if there is no prior relationship, proximity to the member s home will be used. The PCD is responsible for primary, urgent and emergency dental care for assigned children. The Dental Home Program ensures our youngest members have access to consistent care for their dental needs. Preventive dental care reduces early childhood caries and hospital visits for non traumatic dental emergencies and prevents complications that result from untreated dental issues. You will receive a letter, if you haven t already, with the PCD assignment of members in your practice. Please encourage establishing a dental home and preventive dental care as an important component of our members overall healthcare. Contents Dental Home Program launches for member s age Is your patient s health information protected?... 2 Appropriate testing for children with pharyngitis... 2 State requirements for lead screening... 3 Reminder about fluoride varnish... 4 Changes to how unlisted and non specific CPT and HCPCS codes are reviewed and paid... 4 CAHPS and member satisfaction... 5 Clinical policy bulletins and guidelines... 5 Limitations regarding the billing of Medicaid/NJ FamilyCare 0(NJFC) beneficiaries... 6 NJ FamilyCare coverage of smoking cessation products... 6 Aetna Better Health of New Jersey NJ

2 Is your patient s health information protected? Aetna Better Health of New Jersey practitioners and providers are required to maintain the privacy and confidentiality of all information and records regarding members, including but not limited to medical records, in accordance with all State and Federal laws, including regulations promulgated under the Health Insurance Portability and Accountability Act (HIPAA). The law sets rules and limits on who can view and receive member information. Health care practitioners and providers are required to: Adopt and implement privacy procedures that include a description of staff that may access protected information, how it will be used, how it will be stored and when it may be disclosed. Appropriate testing for children with pharyngitis Most cases of pharyngitis are due to viral infections. Physical examination is unreliable in distinguishing streptococcal pharyngitis from viral pharyngitis. As a result, many children are given unnecessary antibiotics for presumed strep infection. A simple lab test available in the office can detect whether there is strep pharyngitis. Rapid antigen detection test (RADT), also referred to as a rapid strep test, can help you to avoid prescribing unnecessary antibiotics. This HEDIS measure looks at the percentage of children who had a rapid strep test prior to prescription for antibiotics for pharyngitis. Improvement Tips: If a patient tests negative for a RADT test, a throat culture is needed. Positive RADTs do not require a throat culture. Document the performance of a rapid strep test and code claims correctly and accurately. Don t send a prescription home with the patient as just in case ; rather offer to call it in once the test results come back. Educate patients on the difference between bacterial and viral infections. Designate a Privacy Official who ensures privacy procedures are carried out. Ensure member information confidentiality. Store medical records in a secure manner that allows for easy retrieval by authorized personnel only. Provide periodic training on office privacy procedures for all employees. For a copy of Aetna Better Health of New Jersey s written policies for confidentiality, contact your Provider Relations representative. For more information on Health Information Privacy, visit hhs.gov/hipaa. Discuss with patients ways to treat symptoms and realistic expectations for recovery time. Explain that unnecessary use of antibiotics can lead to antibiotic resistance in the future. Advise patients to get extra rest, drink plenty of fluids, and use over the counter medications. Educate patients and their parents or caregivers that they can prevent infection by: Washing hands frequently. Keeping an infected person s eating utensils and drinking glasses separate from other family members. Diagnosis Codes that prompt the HEDIS measure: J02.0, J02.8, J02.9, J03.00, J03.01, J03.80, J03.81, J03.90, J03.91, 034.0, 462, 463. Procedure Code for Rapid Strep Testing: Sources: hcp/ outpatient hcp/pediatric treatment rec.html hcp/ strep throat.html 2

3 State requirements for lead screening Lead screening for children includes two components: Verbal Risk Assessment and Blood Lead Testing. Verbal Risk Assessment: At every visit with children at least 6 months of age and less than 72 months of age, the provider should do a verbal risk assessment for lead exposure The questions must include at least the following questions: Does your child live in or regularly visit a house built before 1978? Does the house have chipping or peeling paint? Was your child s day care center/preschool/ babysitter s home built before 1978? Does the house have chipping or peeling paint? Does your child live in or regularly visit a house built before 1978 with recent, ongoing, or planned renovation or remodeling? Have any of your children or their playmates had lead poisoning? Does your child frequently come in contact with an adult who works with lead? Examples include construction, welding, pottery, or other trades practiced in your community. Do you give your child home or folk remedies that may contain lead? If all answers are negative, risk is considered low for high exposure; all children at low risk need blood lead testing at ages shown below If any answer is yes or I don t know, risk is considered high; all children at high risk need testing immediately The questions must be asked every time since risk can change Blood Lead Testing All blood lead testing requires a blood lead level (not a zinc EP test) Capillary specimen testing, such as by LabCorp s MedTox methology, is acceptable Venous specimen testing at any NJ licensed outside commercial lab is acceptable as long as results are sent to us If a provider has a lead testing analyzer (Magellan LeadCare analyzer) in the office, the only appropriate specimen is capillary All blood lead tests should be reported to the health plan LabCorp (including Med Tox) and Quest submit results directly to the plan All other labs may or may not; the provider must send results to the plan All levels above 5 µg/dl are considered elevated, per recent change in the state threshold Any level above 5 µg/dl done via capillary sample must be confirmed by a venous sample at a NJ Department of Health licensed lab Any level above 5 µg/dl must also be reported to the health plan All children at high risk by Verbal Risk assessment (even if younger than 6 months) should be tested immediately Every child in Medicaid or NJ FamilyCare, regardless of risk, must be tested between nine (9) months and eighteen (18) months, preferably at twelve (12) months of age AND at months, preferably at twenty four months (24) of age. Any child between 24 months and 72 months who has not been tested by a blood lead test before should be tested immediately regardless of the Verbal Risk Assessment If the level is less than 5 µg/dl, the child should have Verbal Risk Assessment at every subsequent visit until age 72 months and be tested again if risk is high by this screen If the level is between 5 µg/dl and 10 µg/dl, the provider should use professional judgement to determine patient management and follow up as well as follow up testing; the provider should cooperate with the local health department to facilitate environmental evaluation If the level is above 10 µg/dl and capillary, a repeat test should be done by venous specimen and all other children and pregnant women in the home should also be tested Medicaid health plans are required to contact families of children who have no lead test on file with the plan Medicaid health plans are required to contact all PCPs with lead test screening rates of less than 80% for children aged 9 months to 72 months 3

4 Reminder about fluoride varnish Aetna Better Health of New Jersey encourages medical providers to apply fluoride varnish to children s teeth, perform dental assessments and promote routine oral heath visits for Aetna s young members. Participating pediatricians, nurse practitioners and physician assistants who have completed an online training curriculum or who have received training from an already trained provider can be reimbursed for the application of fluoride varnish. Pediatricians will be reimbursed $15 for each varnish application every three months on members up to age five. Enter CPT code and ICD 10 diagnosis code Z00.12X or Z76.2 on the claim form when billing Aetna. Only trained providers will be reimbursed. Online training is available at org. Click course 6: Caries Risk Assessment, Fluoride Counseling on the right side column. Only one provider per facility needs to complete the online curriculum. The trained provider can train their colleagues. Providers who have completed the training must sign an attestation confirming completion of the course. Providers can download the form on our website at aetnabetterhealth.com/newjersey/providers/training. Please fax completed forms to Dr. Joseph Maggio at Changes to how unlisted and non specific CPT and HCPCS codes are reviewed and paid Effective September 15, 2017, Aetna Better Health of New Jersey changed the way unlisted and non specific CPT and HCPCS codes are reviewed and paid. With a few exceptions listed below, these codes will no longer be managed through the prior authorization process. They will be managed with Medical Records at the time of claim submission. That is, records supporting the use of these codes must be submitted with the claim. These claims will pend to our AMA Edit Team who will review for: Experimental/Investigational status per relevant Aetna CPB (aetna.com/health care professionals/ clinical policy bulletins.html); and Medical necessity applying relevant criteria; and Assignment of a more appropriate specific code if one exists; or Approval to pay as submitted. Codes not included in the process change are: Code(s) Process General Anesthesia for dental procedures Prior Authorization E1399 and K0108 wheelchair components and services Prior Authorization unlisted dialysis procedure Prior Authorization with dialysis services Unlisted J code Prior Authorization If records are not submitted with any claim including one of the codes listed below, the claim will be denied for lack of documentation. You may resubmit the claim with required supporting records. Please visit our website at aetnabetterhealth.com/newjersey/providers/notices to view a complete list of codes covered by this process. 4

5 CAHPS and member satisfaction The Consumer Assessment of Healthcare Providers and Systems (CAHPS ) Survey is a measure of member satisfaction that examines the percentage of members satisfied with the health plan. It empowers prospective members to benefit from the experience of others. Overall levels of satisfaction provide an indication of whether a health plan is meeting member expectations. Aetna Better Health of New Jersey uses the NCQA HEDIS CAHPS 5.0H Membership Satisfaction Survey to assess member satisfaction. Members surveyed are selected from a random sample of all eligible members. As participating providers, the care you give our members impacts their satisfaction with Aetna Better Health of New Jersey. The following physician related measures provide opportunities for future improvement: Personal MD Overall Specialist MD Overall Getting Care Quickly Getting Needed Care Health Care Overall Here are a few tips that may enhance your time with Aetna Better Health of New Jersey members and help to improve their healthcare experience: Be an active listener Ask the member to repeat in their own words what instructions were given to them Rephrase instructions in simpler terms if needed Clarify words that may have multiple meanings to the member Limit use of medical jargon Be aware of situations where there may be cultural or language barriers The 2018 CAHPS survey will begin in January of 2018, with mailers and telephone calls to our members. Aetna Better Health of New Jersey continuously works to improve member satisfaction with our health plan and with the health care our members receive. To help you take care of our members, we have several resources: Case managers are available to assist you in arranging timely care/services for our members. You can call us at and ask to be transferred to a case manager. Member service representatives are available to assist with general member issues including claims and billing questions. You can reach Member Services at Your provider relations representative is available to assist you with any questions or issues. Call and select option 2 for provider relations. 5

6 Clinical policy bulletins and guidelines To help provide our members with consistent, high-quality care that uses services and resources effectively, we have chosen certain clinical guidelines to help our providers. These include treatment protocols for specific conditions, as well as preventive health measures. To view our bulletins and guidelines, visit aetnabetterhealth.com/newjersey/ providers/guidelines Limitations regarding the billing of Medicaid/NJ FamilyCare (NJFC) beneficiaries The practice of balance billing Medicaid/NJFC beneficiaries, whether eligible for FFS benefits or enrolled in managed care, is prohibited under both federal and State law. These prohibitions apply to both Medicaid/NJFC-only beneficiaries, as well as those eligible for Medicare coverage or other insurance. A provider enrolled in the Medicaid/NJFC FFS program or in managed care is required to accept as payment in full the reimbursement rate established by the FFS program or managed care plan. All costs related to the delivery of health care benefits to a Medicaid/NJFC eligible beneficiary, other than authorized cost-sharing, are the responsibility of the FFS program, the managed care plan, Medicare (if applicable) and/or a third party payer (if applicable). If a provider receives a Medicaid/NJFC FFS or managed care payment, the provider shall accept this payment as payment in full and shall not bill the beneficiary or anyone on the beneficiary s behalf for any additional charges. To learn more about limitations regarding balance billing, visit Source: The New Jersey Division of Medical Assistance and Health Services and the New Jersey Department of Health NJ FamilyCare coverage of smoking cessation products The Division of Medical Assistance and Health Services (DMAHS) has recently clarified that over-the-counter smoking cessation products are included in the benefit under NJ FamilyCare. Aetna Better Health of New Jersey covers a full range of products for smoking cessation, as per the table below: Product Drug Class Prior Authorization Required Nicotine gum OTC Not needed Nicotine Lozenge OTC Not needed Nicotine Patch OTC Not needed Nicotine Nasal Spray RX Yes Nicotine Oral Inhaler Rx Yes Bupropion Rx Not needed Varenecline Rx Yes There are eligible generic products of each type available for members. Pharmacies have been instructed as to which manufacturers products are eligible for coverage under NJ Medicaid (and Aetna Better Health of New Jersey). Members who have primary Medicare coverage along with Aetna Better Health of New Jersey are covered under their Medicaid benefit for these products. Aetna Better Health of New Jersey encourages providers to discuss smoking cessation with their patients and to provide support and tools, as needed to succeed. You should provide your patient with a prescription, even for OTC products, to assure that the product will be covered under the plan. 6