epower: *PLEASE NOTE*

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1 January 2018 P r o H e a l t h P r o v i d e r R e l a t i o n s U p d a t e I N S I D E T H I S I S S U E : 1 epower 1 New Provider Credentialing 1 3D Mammograms in 2018 epower: ProHealth s epower (Provider Portal) is now available on our website at: New & Termed Payors 2-3 New Providers, effective 1/1/ Termed Providers ProHealth PA Updates 4 MRIs of the Spine ProHealth PA Process PA Quick Reference Guide PA Member Quick Reference Guide 8 CareSource Medicare Terming 9 Better Doctor, Inc. Validation 10 Provider Relations Staff Directory Credentialing of New Providers: *PLEASE NOTE* Credentialing through ProHealth for ALL new providers can take anywhere from days from notification to completion. The Credentialing fee has increased to $200 for ALL new providers wishing to join the Community/ProHealth network, effective 11/1/2016. ProHealth Credentialing/Enrollment Supervisor: Jenna White jwhite2@ecommunity.com Phone#: (317) D Mammography Covered in 2018: Effective 1/1/2018, 3-D Mammography will be covered by the Community Gold & Silver healthcare plans at no cost to the patient. New Payors for CHNw Employed/CPN providers, effective 1/1/2018: AllWell (MHS Medicare) - ALL CHNw Employed/CPN providers Community Health Direct - ALL Tier 1 providers and those in the Basic PPO Plan Humana Military - ALL CHNw Employed/CPN providers Payors Terming for CHNw Employed/CPN providers, effective 12/31/2017: CareSource Medicare MDWise Marketplace Anthem Pathway (Marketplace plan) Anthem PathwayX (Marketplace plan) 1

2 Contracting and Credentialing Corner Providers Joining ProHealth We would like to welcome the following providers to the ProHealth Network effective December 1, Hospital affiliations will be listed with each provider. Prime SCP Aslam MD, Muhammad - Anesthesiology Community Anderson Anesthesia (Employed) - CHA Bledsoe LCSW, Elizabeth M. - Behavioral Health Gallahue Mental Health Services (Employed) Bricker MD, Heather - Pediatrics Community Pediatric Hospitalists (Employed) - CHE/CHN, CHV Dotson LCSW, Melissa - Behavioral Health Gallahue Mental Health Services (Employed) Elango MD, Subha - Family Medicine MedCheck (Employed) - CHE/CHN, CHV Gray MD, Brian W. - Pediatric Surgery Pediatric Surgical Care (Employed) - CHE/CHN, CHV Mallipeddi MD, Sahitya - Internal Medicine Community Physician Network, Rheumatology Care (Employed) - CHS Myers LCSW, Margaret - Behavioral Health Gallahue Mental Health Services (Employed) Pannell LCSW, Robin - Behavioral Health Gallahue Mental Health Services (Employed) Pittman MD, Luke - Family Medicine MedCheck (Employed) - CHE/CHN, CHV Rescorla MD Frederick J. - Surgical Critical Care Pediatric Surgical Care (Employed) - CHE/CHN, CHV Rouse MD, Thomas - Pediatrics Community Pediatric Hospitalists (Employed) - CHE/CHN, CHV Snowden MD, Ryan D. - Orthopedic Surgery Orthopedic Specialty Care (Employed) - CHE/CHN, CHV, CHA Timothy DO, John - Preventive, Occupational Medicine Community Occupational Health Services (Employed) - CHE/CHN, CHV Tredemyer DO, Julie - Internal Medicine Community Howard Gastroenterology (Employed) - CHRH 2

3 Prime SCP Advanced Practice Practitioners Asava NP, Caroline - Nurse Practitioner Center for Pain Management Brown NP, Angela - Nurse Practitioner Radiation Oncology Care (Employed) Parrish PA, Samantha C. - Physician Assistant Heart and Vascular Care (Employed) Sinclair PA, Samantha - Physician Assistant Orthopedic Specialty Care (Employed) Sipes NP, Susan - Nurse Practitioner Center for Pain Management Wendell NP, Allison - Nurse Practitioner Community Hospital Oncology Physicians Wentz PA, Jacqueline - Physician Assistant Contracting and Credentialing Corner Providers Joining ProHealth We would like to welcome the following providers to the ProHealth Network effective January 1, Hospital affiliations will be listed with each provider. Community Physician Network, Family Medicine Care (Employed) Prime OBG Johnson MD, Brittany E. - Obstetrics & Gynecology Southside OB-GYN, P.C. Randolph MD, TIenne K. - Obstetrics & Gynecology Southside OB-GYN, P.C. Prime OBG Advanced Practice Practitioners Noel PA, Arielle N. - Physician Assistant Southside OB-GYN, P.C. - CHS, CSC-S Termed Providers The following providers will no longer be participating with ProHealth: Raj MD, Shekhar S. - Pediatric Critical Care, termed 12/7/2017 Community Physicians of IN, Inc / Community Pediatric Hospitalists (Employed) Singh MD, Urmila - Pediatrics, termed 12/31/2017 Urmila Singh, M.D. Woolhiser MD, Kenten D. - Neurology, termed 12/31/2017 Indiana Neuroscience Associates 3

4 Medical Management Prior Authorization Changes 2018 Community Self-Funded Gold/Silver Plans Outlined below are changes to the Prior Authorization requirements for 2018: 1. Prior authorization for MRI of the knee is no longer required MRI s of the spine, including cervical, require authorization. 2. Genetic testing continues to require prior authorization, with the exception of prenatal tests outlined in the American College of Obstetricians /Gynecologists (ACOG) guidelines, and surgical specimen testing. 3. Durable Medical Equipment (DME) purchase limit has increased from $200 to $500 so routine items such as off-the-shelf air cast boots, splints, CPAP supplies, insulin pump supplies, and ostomy supplies no longer require a prior authorization. However, regardless of the dollar amount, initial wheelchair purchases, initial CPAP rental/ purchase, initial insulin pump purchase, prosthetics and custom orthotics continue to require prior authorization. 4. Routine office visits for behavioral health therapy no longer require prior authorization. All inpatient, partial hospitalization and intensive outpatient services require prior authorization. **Due to regulatory and legal issues, ProHealth will no longer allow providers to withdraw prior authorization requests that list incorrect tests or procedures. Any request submitted with incorrect information will result in a denial of the request, and the provider and member will be notified by mail. A new prior authorization request must then be submitted with the correct test or procedure for review.** MRIs of the Spine: In order to clarify the criteria used for reviews of MRIs of the spine in adults, the following must be submitted within the clinical information: 1) Rule out syringomyelia, transverse myelitis or demyelinating condition 2) Suspected post-operative spinal complication or known trauma 3) Acute onset of back pain where no red flag symptoms are present will require documentation of a minimum of 6 weeks of conservative management, that includes two of these three treatments: A. NSAIDs or acetaminophen/analgesics and/or oral steroids for > 3 weeks (Unless contraindicated or not tolerated) B. Physical therapy and/or a home exercise program for 6 weeks C. Activity modification for 6 weeks 4) Red flag symptoms associated with back pain A. Unexplained weight loss B. Unexplained fever C. Immunosuppression D. History of cancer E. Bowel or bladder incontinence F. Severe nighttime pain G. Saddle anesthesia H. Prolonged use of corticosteroids, osteoporosis I. Age > 70 4

5 HRA Gold and HSA Silver Health Plans: 2018 Prior Authorization Process I. Paperless referral process: Primary Care Physicians (PCP) will continue to direct patient care by referring plan members to in-network specialists as defined by the network s specialist s directories. A physician order may be used for this referral. PCP s should document the referral in the patient record. Verification of member s insurance eligibility is recommended at every visit. If the specialist finds an additional problem outside of the original diagnosis or cause, but within the scope of his/her specialty, the specialist may treat the problem and report findings back to the PCP. If an additional problem arises that is not within the scope of this specialty, the member s care should be coordinated by the member s PCP as part of their medical home, and therefore the member must be referred back to the PCP for additional referral to another specialist. II. The following services MUST BE CALLED AND/OR FAXED FOR PRIOR APPROVAL by ProHealth Medical Management staff: Behavioral Health 1. Any referral to non-tier I providers when the request is for the service to be reimbursed at a Tier I level This includes services that are potentially not available from a facility or provider within the Tier I directory 2. All services which may be deemed cosmetic/aesthetic (i.e. moles, skin lesions, varicose veins) 3. All transplant services 4. All services where benefit coverage is questioned (i.e. breast reduction, bariatric surgery) 5. All referrals for infertility services 6. Genetic testing (Excludes prenatal tests outlined in the American College of Obstetricians /Gynecologists (ACOG) guidelines, and surgical specimen testing) 7. All referrals to for pain management programs 8. All outpatient back and neck surgeries 9. All rhinoplasties and septoplasties 10. All inpatient admissions, including rehabilitation and LTAC facilities 11. Any surgery that will result in a scheduled inpatient admission 12. Endoscopic Procedures 13. Colonoscopies for patients under the age Radiology: A) MRI of the spine (cervical, thoracic, lumbar, sacrum) B) Non-oncology related PET scans Home Care/ Hospice/TPN Administration in the home 1. Skilled Nursing Facilities 2. Durable medical purchases over $500 this includes wheelchairs, CPAP (initial rental/purchase ONLY), hospital beds, insulin pump (initial purchase ONLY) 3. Prosthetics 4. Custom Orthotics 5. Emergency Room referrals 6. Dialysis and Epogen administration with Dialysis 1. All inpatient admissions for behavioral health treatment This includes inpatient hospital and Partial hospitalizations (PHP) for mental health and substance abuse 2. Intensive outpatient (IOP) for mental health and substance abuse require precertification Failure to do so may result in denial of the claim and the inability to bill the member. Please submit requests as soon as possible to allow time for review. Routine requests for authorizations are processed within 3 business days after receipt of all needed information. A new referral for the services outlined above is required at a minimum annually. A CPT list of procedures that require prior authorization is attached. Please note that this list is not entirely inclusive; new procedures, experimental or investigation procedures, cosmetic procedures and limited benefits may not be listed. Authorization does not guarantee payment; payment is based on benefit structure and limitations 5

6 Indiana ProHealth Network, LLC HRA Gold, HAS Silver Health Plans 2018 Authorization Quick Reference Guide Indiana ProHealth Network, LLC supports the concept of the PCP as the medical home for its members. Services from Tier II and Tier III providers will only be considered for coverage at the Tier I level if those services are unavailable with a Tier I provider. Please submit requests as soon as possible to allow time for review. Routine requests for authorizations are processed within 3 business days after receipt of all needed clinical information. Contact information Medical Management: Medical Management Fax: Provider Relations: Benefits/ Eligibility: Authorizations Required Standard Authorization Requests Fax your request; include CPT and ICD 10 codes and clinical documentation with authorization request. Requests for Tier II and Tier III services at Tier I coverage: Any requests for services not provided by the Community Health Network or Tier I providers as listed in directory Home Health Care Home Health Services Hospice care TPN Durable Medical Equipment Durable medical purchases over $500 this includes wheelchairs, CPAP (initial rental/purchase ONLY), hospital beds, insulin pump (initial purchase ONLY) Prosthetics Custom Orthotics Inpatient Notification All inpatient admissions, including clinical updates for continued stay Rehabilitation facility admissions Skilled nursing home facilities Outpatient Cosmetic/Aesthetic Procedures Dialysis and Epogen administration with dialysis Transplant Requests Genetic testing (Excludes prenatal tests outlined in the American College of Obstetricians /Gynecologists (ACOG) guidelines, and surgical specimen testing) Routine labs/genetics tests performed by non-tier I laboratories Endoscopy services Colonoscopies for patients under the age of 50 Investigational and experimental procedures Pain management programs Infertility Surgeries of the neck and back Rhinoplasties and Septoplasties Radiology MRI Spine (includes cervical) Non oncology related PET Scans Behavioral Health All inpatient admissions for behavioral health treatment this includes inpatient hospital and partial hospitalizations (PHP) for mental health and substance abuse Intensive outpatient (IOP) for mental health and substance abuse No Authorization Required Urgent Care at Urgent Care Centers, such as Med Check and Community Clinic at Walgreens Primary Care PCP office visits and treatment. Diagnostic tests and procedures covered by the plan as part of an office visit Laboratory Laboratory tests consistent with CLIA guidelines Laboratory tests performed by Tier I providers (MACL) Genetic pre natal tests outlined in the American College of Obstetricians /Gynecologists (ACOG) guidelines, and surgical specimen testing Durable Medical Equipment Medical purchases less than $500 Bilirubin blankets for newborns Nebulizers CPAP supplies after initial authorization Insulin pump supplies after initial authorization Ostomy supplies Catheters Other disposable supplies after initial authorization Outpatient Colonoscopies for patients aged 50 or older Radiology All radiology services except MRI(s) Spine (includes cervical) All cardiac studies (stress test, cardiac SPECT, thallium, all diagnostic cardiac services.) Nuclear medicine Mammograms X rays Ultrasonography Diagnostic ultrasounds Miscellaneous Services Audiograms Sleep studies performed at in-network sleep labs Sleep studies performed in home under the direction of an in-network sleep lab Behavioral Health Behavioral health office visits Neuropsych testing 6

7 2018 Gold Silver Member Quick Reference Guide Prior Authorizations Required* You must ensure that your physician faxes the request, including procedure and diagnosis codes and all pertinent clinical documentation to the fax number listed above before receiving or scheduling services *Failure to obtain prior authorization/precertification will result in a denial of services Requests for Tier II and Tier III services at Tier I coverage: Any request for services not provided by the Community Health Network or Tier I providers as listed in directory. Emergency Department referrals Home Health Care All Home Health Services Inpatient and Outpatient Hospice care Total Parental Nutrition (TPN) Durable Medical Equipment (DME) (This does not includes supplies dispensed in a providers office or replacement supplies for approved DME such as CPAP, Insulin pumps and Home Oxygen) Durable medical equipment purchases over $500 this includes wheelchairs, CPAP (initial rental/purchase ONLY), hospital beds, insulin pump (initial purchase ONLY), Custom Orthotics Prosthetics Inpatient Notification All inpatient admissions All inpatient surgeries that result in a scheduled inpatient admission Rehabilitation facility admissions Skilled nursing home facilities Outpatient Cosmetic/Aesthetic Procedures Dialysis and Epogen administration with dialysis Organ transplant evaluations Endoscopy services Colonoscopies for patients under the age of 50 Treatment that may be of an Investigational and/or experimental nature Genetic testing (Excludes pre natal tests outlined in the American College of Obstetricians /Gynecologists (ACOG), guidelines, and surgical specimen testing) Pain management programs Infertility All surgeries of the neck and back this does not include epidural injections or medial branch blocks Rhinoplasties and Septoplasties Radiology MRI- Spine (includes cervical, thoracic, lumbar, sacral) Non-cancer related PET Scans Behavioral Health (Behavioral Health providers are subject to the same rules regarding Tier I, II and III services) All inpatient admissions for behavioral health treatment This includes inpatient hospital and partial hospitalizations (PHP) for mental health and substance abuse 7

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9 BETTER DOCTOR, INC. VALIDATION - Employed Providers : Many Community employed practices have received phone calls or faxes from a company by the name of Better Doctor, Inc. This organization is a third party vendor that seeks contracts with many of the Medicare Advantage (MA) plans to verify provider data on a quarterly basis. CMS has required all MA companies to verify data on a quarterly basis. Community Health Network has contracts in place with several of the MA companies. ProHealth transmits provider demographic data to these organizations on a bi-weekly basis. Please do not verify provider data either via fax or phone with Better Doctor, Inc. at the practice level. The provider data is shared by ProHealth to the MA companies bi-weekly on your behalf. We have reached out to the MA plans and Better Doctor, Inc. to assist in streamlining their process and ask that they do not contact our offices for this project. It has been communicated to Better Doctor, Inc. that we do not verify provider data at the practice level. If you have further questions or concerns, please contact Lori White, Medicare Program Manager, ProHealth Lwhite4@ecommunity.com or

10 Provider Relations Department 6626 E. 75th St, #500 Indianapolis, IN Phone: Department Staff Manager Provider Relations: Jenny Bouck, Business Information Coordinator Hollie Putzback, Provider Relations Analysts: Carol Boyd, Dawn Widgery, Amanda Bobo, Governmental Programs Manager (Medicare): Lori White, Governmental Programs Manager (Medicaid): Salena Woodson, Supervisor Provider Credentialing: Jenna White, Credentialing Coordinators: Kim Tibbets, Julia Chumbley, Julie Starr, Aletha Burnett, April Woodruff, Adrianne Stocks, Provider Credentialing Assistants: Amy Walls, Denise Smith, Dianne Castillo, Sharon Harlan, Lori Jones, Melissa Baldwin, 10