PROVIDER NEWSLETTER WINTER

Transcription

1 in FOCUS PROVIDER NEWSLETTER WINTER 2018 Formulary Changes Provider Directory ACCURACY Care1st Blue Shield Health LITERACY INITIATIVE Provider OVERPAYMENTS Long Term Services and Supports ELECTRONIC FUNDS TRANSFER & Secure Remittance Advices

2 in FOCUS TABLE OF CONTENTS 3 Care1st/Blue Shield Health Literacy Initiative Long Term Services and Supports 4 (LTSS) information for providers 5 Provider Directory Accuracy 7 Provider Overpayments Pharmacy 3 rd Qtr Pharmacy & Therapeutic Formulary 8 Changes- Physician Notice Pharmacy 4 th Qtr Pharmacy & Therapeutic Formulary 10 Changes- Physician Notice Electronic Fund Transfer and 6 Secure Remittance Advices 2

3 Health literacy is a very important component of provider/patient interaction. The US Department of Health and Human Services defines health literacy as the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. CARE1ST/BLUE SHIELD HEALTH LITERACY INITIATIVE Health literacy is a very important component of provider/patient interaction. The US Department of Health and Human Services defines health literacy as the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. Care1st and Blue Shield of California recognize the importance of addressing health literacy and are working together to improve health literacy levels in our member populations by launching a company wide Health Literacy Initiative. The initiative aims to engage our staff, members, and participating providers in the health literacy conversation through trainings, outreach, and education on communicating simply and effectively with members and patients. The next phase of the initiative aims to reach Care1st/Blue Shield providers through webinars, outreach, and a training that will be available on our website in the near future. The trainings will cover recommendations for improving communication with patients, such as: Not making assumptions about language preferences or literacy level 3 Using visual aids Providing patients with a note pad so they can write down questions and information Creating a comfortable, helpful, shame-free environment Using plain and simple, nonmedical language Confirming patient understanding of key instructions and knowledge Involving patients in decision making around their own care Speaking slowly Breaking down information into small manageable steps For more information, please contact the Care1st/Blue Shield Health Education department at HealthEducation@care1st.com or visit the provider health education section of our website at The Centers for Disease Control and Prevention also offer a Health Literacy course for Public Health Professionals, which can be accessed online at

4 COULD ONE OF YOUR PATIENTS BENEFIT FROM LONG-TERMS SERVICES AND SUPPORTS? Here is how Long Term Services and Supports (LTSS) provides services intended to help seniors and persons with disabilities: Services intended to help seniors and persons with disabilities Helps people remain living in the community in the setting of their choice Rebalances service delivery away from institutional care (LTC) and into the home and community This Medi-Cal benefit includes Cal MediConnect (CMC) Long Term Services and Supports include: Home and Community Based Services (HCBS) In-Home Supportive Services (IHSS) Community Based Adult Service (CBAS) Multipurpose Senior Services Program (MSSP) Institutionalized Long Term Care (LTC) To refer a patient to Long Term Services and Supports please call our Care1st Social Services department at (323) x LTSS SERVICES: In-Home Supportive Services (IHSS) Allows individuals to receive support services which enable them to remain living in their home: Assistance with shopping Preparing food House keeping Bathing Community Based Adult Services (CBAS) Day program includes a variety of services designed to be an alternative to long term nursing home care: help people stay mentally and physically active reduce social isolation improve their health prevent decline of their abilities and promote selfmanagement as a safe, positive, caring Multipurpose Senior Services Program (MSSP) Provides on-going medical and social case management oversight to allow those who are eligible for LTC to remain living in the community. Long Term Care (LTC) Provides care in a skilled nursing facility for people unable to remain living in the community independently. Provides 24/7 medical care. 4

5 PROVIDER DIRECTORY ACCURACY Provider Directory Updates Keeping and maintaining an accurate provider network supports our goal to provide exceptional care for our members. Care1st would like to thank participating providers for being responsive to our attempts in soliciting and validating information. following occurs: 1. The provider had previously accepted new patients and the provider is not currently accepting new patients. 2. The provider had previously not accepted new patients and the provider is currently accepting new patients. What s next? Our Care1st Provider Network Operations department will continue to reach out to participating providers to collect information and update provider records on a semi-annual basis for our direct network. Network providers can review their information on our Care1st website and submit changes by contacting Care1st: Telephone: (323) Fax: (323) Demographicupdates@care1st.com You may also complete an online interface for providers to submit verification For San Diego Providers: By telephone: (888) Fax: (619) at: DemographicupdatesSD@care1st.com You may also complete an online interface for providers to submit verification Providers are required to notify Care1st or the participating provider group within five (5) business days when either of the 5 Online Profile Form The Online Profile Form is an electronic web form that contains provider directory information which Care1st has on file for the provider. Providers can notify Care1st of changes to their demographic data by completing the Online Profile Form and/or providing an affirmative response to Care1st s Outreach Program through the online interface. 1. Practitioners (i.e., physicians and other health professionals such as physical therapists, occupational therapists or podiatrists) 2. Participating provider groups 3. Hospital and ancillary providers A system generated acknowledgment is automatically sent upon your submission of the completed form Please note that these channels of communication are designed to report provider directory inaccuracies. For any additional provider related questions or concerns, please refer to our provider manual which can be found on our website:

6 ELECTRONIC FUND TRANSFER AND SECURE REMITTANCE ADVICES For several years, Care1st Health Plan has encouraged providers to receive claim payments and secure remittance advices (SRA) through electronic fund transfer (EFT). The remittance advices associated with payments for patient care contain patient health information (PHI) / personal identifiable information (PII) and that information is at risk when delivered in paper form. Care1st Health Plan takes the protection of our members PHI/ PII seriously and has teamed up with J.P. Morgan and Office Ally clearing houses to provide secure electronic download services. Both Office Ally and JP Morgan clearing houses permit providers to securely download remittance advices. Providers who enroll in EFT have the additional benefits of claim payments made directly into their bank account, minimize exposure to check fraud and lost checks, and have secure access to download SRA s for up to 10 years. Care1st Health Plan is committed to providing secure and efficient payments and remittance advices. For more information about EFT and SRA, including how to sign up for both, please call (855) or visit the following website: care1st.com/ca/providers/news-and-resources.asp Effective January 1, 2018 Care1st will no longer provide Remittance Advices on paper. They will be available only through SECURE electronic download. Providers who have not enrolled will continue to receive checks by regular mail, however, will not have the ability to access their SRAs without enrolling. 6

7 PROVIDER REPORTING REQUIREMENTS TO CARE1ST HEALTH PLAN ON OVERPAYMENTS Effective July 1, 2017, Title 42 of the Code of Federal Regulations (CFR), section (d), Care1st Health Plan ( Care1st ) is required to report overpayments and/ or recoveries made to providers to the Department of Health Care Services (DHCS). Care1st is obligated to require its network providers to report overpayments/ recoveries to the Care1st Health Plan. Effective July 1, 2017, when providers received an overpayment from Care1st Health Plan, including overpayments due to fraud, waste, and abuse, providers must take the following actions: Return the overpayment to Care1st within 60 calendar days after the date on which the overpayment was identified. Notify Care1st Health Plan in writing of the reason for overpayment by sending an to ComplianceDepartment@care1st.com DEFINITIONS: Overpayment is any payment made to a network provider made by Care1st Health Plan to which the network provider is not entitled under Title XIX of the Social Security Act. 1 Network Provider is any provider, group of providers, or entity that has a network provider agreement with Care1st Health Plan, or is a subcontractor and receives Medi-Cal funding directly or indirectly to order, refer or render covered services as a result of the state s contract with Care1st Health Plan. 2 Fraud is defined as intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable federal or state law. 3 Waste is generally understood to mean the overutilization or inappropriate utilization of services and misuse of resources, and typically is not a criminal or intentional act. 4 Abuse is defined as provider practices that are inconsistent with sound fiscal business, or medical practices that result in an unnecessary cost to the Medicaid program, or reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes beneficiary practices that result in unnecessary cost to the Medicaid program Ibid CFR and Welfare and Institutions (W&I) Code Fraud, Waste, and Abuse Toolkit. Healthcare Fraud and Program Integrity: An Overview for Providers (2014). Centers for Medicare and Medicaid Services. Retrieved at CFR 455.2

8 PHYSICIAN NOTICE 3RD QTR 2017 DRUG NAME LABEL NAME DRUG STRENGTH FORMULATION ANTICANCER AGENTS Brigatinib Alunbrig 30mg Tablet Durvalumab Imfinzi 20mg/2.4ml, 500mg/10ml IV vial Methotrexate Xatmep 2.5mg/ml Oral Solution Midostaurin Rydapt 25mg Capsule Neratinib Nerlynx 40mg Tablet ANTIVIRALS HIV Maraviroc Selzentry 20mg/ml Oral solution IMMUNOSUPPRESSIVES Sarilumab Kevzara 150mg/1.14, 200mg/1.14 Syringe OSTEOPOROSIS AGENTS Abaloparatide Tymlos 80mcg/dose Pen Injector SMOKING CESSATION Nicotine Nicotine Patch (various) 21mg, 14mg, 7mg/patch Transdermal Patch TOPICAL ANTIBIOTICS Erythromycinbenzoyl peroxide Benzamycin 3%-5% Gel VITAMIN A DERIVATIVES Adapalene Differin OTC 0.1% Gel Tretinoin Tretinoin All strengths Cream, Gel ANTIVIRALS - HEPATITIS C Ledispavir - sofosbuvir Harvoni 90mg-400mg Tablet ANTIVIRALS - HEPATITIS C VIRUS Glecaprevir - pibrentasvir Mavyret 100mg-400mg Tablet INSULINS - LONG ACTING Insulin Glargine, Hum, Rec. Analog Lantus 100u/ml Vial 8

9 This report provides formulary changes approved by the Care1st Pharmacy and Therapeutics Committee. For a complete listing, please refer to the Care1st website at You may also call the Care 1st Pharmacy Department at (877) RX-CARE1 or (877) FORMULARY COMMENTS MEDICARE FORMULARY MEDI-CAL FORMULARY Add to Medicare formulary tier 5 (Specialty) with a prior authorization requirement Yes No Add to Medicare formulary tier 5 (Specialty) with a prior authorization requirement Yes No Add to Medicare formulary tier 4 with a prior authorization requirement Yes N/A Add to Medicare formulary tier 5 (Specialty) with a prior authorization requirement Yes No Add to Medicare formulary tier 5 (Specialty) with a prior authorization requirement Yes No Add to Medicare Formulary at preferred brand tier (tier 3) Yes N/A Add to Medicare formulary tier 5 (Specialty) with a prior authorization requirement Yes N/A Remove prior authorization restriction, available on formulary with a quantity limit of 84 patches per year for each strength. N/A Yes Add a step therapy to erythromycin- benzoyl peroxide gel, requiring a prior trial in the last 120 days of either: adapalene, erythromycin topical, clindamycin topical, or benzoyl peroxide gel/cream/lotion. N/A Yes Add to Medi-Cal formulary, OTC version only, restricted to ages up to 25 years old N/A Yes Remove from formulary, alternative is adapalene gel OTC N/A Yes Remove from Medi-Cal formulary. Mavyret preferred Hep C treatment. N/A Yes Add to Medi-Cal formulary with a PA restriction. Preferred Hep C treatment. N/A Yes Remove from Medi-Cal formulary effective 11/01/2017 Basaglar KwikPen preferred insulin glargine product No Yes 9

10 PHYSICIAN NOTICE 4TH QTR 2017 DRUG NAME LABEL NAME DRUG STRENGTH FORMULATION ANTINEOPLASTICS Abemaciclib Verzenio 50mg, 100mg, 150mg, 200mg Tablet Copanlisib Aliqopa 60mg Vial Daunorubicin cytarabine liposome Vyxeos Liposome 44mg/100mg Vial Enasidenib Idhifa 50mg, 100mg Tablet Gemtuzumab ozogamicin Mylotarg 4.5mg Vial Inotuzumab ozogamicin Besponsa 0.9mg Vial Olaparib Lynparza 100mg, 150mg Tablet ANTIVIRALS - HEPATITIS C VIRUS Glecaprevir/pibrentasvir Mavyret 100mg/40mg Tablet C1 ESTERASE INHIBITORS C1 Esterase Inhibitor, human Haegarda 2000 units, 3000 units Vial GASTROINTESTINAL Infliximab-abda Renflexis 100mg Vial RESPIRATORY DRUGS Glycopyrrolate/formoterol Bevespi mcg Inhaler Umeclidinium bromide Incruse Ellipta 62.5 mcg Inhalation powder VACCINES Varicella-Zoster GE Shingrix GE Antigen Component 50mcg/0.5 Kit 10

11 This report provides formulary changes approved by the Care1st Pharmacy and Therapeutics Committee. For a complete listing, please refer to the Care1st website at You may also call the Care 1st Pharmacy Department at (877) RX-CARE1 or (877) FORMULARY COMMENTS MEDICARE FORMULARY MEDI-CAL FORMULARY Add to Medicare formulary at tier 5 (Specialty) with a prior authorization requirement Yes N/A Add to Medi-Cal formulary only with a step care, requiring the use of a Long Acting Beta Agonist (LABA) or Long Acting AntiMuscarinic Agent (LAMA) for at least 15 days in the last 45 days Add to Medi-Cal formulary only with a code 1 restriction: restricted for the diagnosis of COPD N/A N/A Yes Yes Add to Medicare formulary at tier 3 (Brand) with for ages 50 and older and a QL of 2 per lifetime Yes No 11

12 601 Portrero Grande Dr Monterey Park, CA in FOCUS PROVIDER NEWSLETTER WINTER 2018