AETNA BETTER HEALTH OF TEXAS Provider newsletter

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1 AETNA BETTER HEALTH OF TEXAS Provider newsletter Spring 2017 Table of contents STAR KIDs News you can Use...1 Utilization Management...2 New Contract Requirements for Managed Care Medicaid Health Plans...2 The Long Acting Reversible Contraceptives (LARC)...3 Check out our updated and easy to use provider portal...3 Help us stop fraud...4 Reminder on balance billing...4 Community outreach...5 Who to call? TX STAR KIDs News you can Use The STAR Kids program is a new TX Medicaid managed care program for children under the age of 21 who have special health care needs. Children in the STAR Kids program all need a complete assessment and evaluation, called the STAR KIDS Screening and Assessment Instrument (SK SAI). The SK SAI is used by Aetna to best understand each child and family s needs so we can work effectively with providers, legally authorized representatives (LARs) and members to achieve optimal well being for the child. In home visits to complete the SK SAI are underway and have been invaluable in ensuring every child has the right care at the right time and in the right place. However, outreach efforts to families are not always successful, so unfortunately there are children who still have not completed this necessary and important assessment. Every child in the STAR Kids program will complete an in home SK SAI visit by 4/30/17. It is important that families contact the Aetna Service Coordination department at 844 STR KIDS ( ) or their specific service coordinator to schedule and complete the SK SAI. Providers can help in this process by educating their clients on the need for the SK SAI to ensure ongoing services. If the family does not know the contact information for their service coordinator, they can call the Aetna Service Coordination department. 1

2 Utilization Management The purpose of the utilization management department is to coordinate delivery of the best possible care to members and manage the use of health care resources to ensure an effective and efficient physical and behavioral health care delivery system. The UM department adheres to the below timelines for making coverage determinations. Within 3 business days after receipt of the request for routine authorization of services Within 1 business day after receipt of the request for urgent authorization of services Within 1 business day for concurrent hospitalization decisions Requests for urgent care services that do not qualify as urgent will be handled within the routine authorization of services timeline. Routine care or elective surgeries are examples of care that typically would not qualify as urgent. To avoid rescheduling of appointments, please keep in mind the timelines above for making coverage determination prior to the appointment being made. The following are the fax numbers to submit your requests. Please submit the Texas Standard Prior Authorization of Services form and include all pertinent information, ICD 10 code(s), dates of service and signature. STAR Kids Long Term Services and Supports (LTSS) Fax: Acute Services Prior Authorization Fax: Concurrent Review: To prevent delays in processing requests, please New Contract Requirements for Managed Care Medicaid Health Plans The Health and Human Services Commission (HHSC) and Vendor Drug Program (VDP) have put contractual requirements in all Managed Care Medicaid Health Plans (MCO) contracts which will require the MCO s to begin an outreach to prescribers of behavior health drugs. Specifically the therapeutic classes affected by this contractual language are antipsychotics, antidepressants; all ADHD drugs both stimulants and non stimulants. Expect outreach from the MCO s for those patients on concomitant therapy in each of the above classes. VDP is requiring the MCO and prescribing practitioners need to communicate via a conversation or via a letter regarding concomitant drug use within a class of drugs. Any questions please call (Tarrant) (Bexar)

3 The Long Acting Reversible Contraceptives (LARC) We want to make you aware of a situation which we have discovered. Now that the long acting reversible contraceptives (LARC) can be obtained and delivered to your office Aetna has found instances where there have been charges from the pharmacy but no charge from a physician s office for insertion. If the member does not show up for any reason and the LARC is never inserted the LARC should be returned to the pharmacy for crediting to Aetna. Aetna is providing the policy which was sent out by the Texas Medicaid Health Plan (TMHP) along with the Vendor Drug Program, with instructions on how to order and if for any reason the LARC isn t administered how to return the product to the pharmacy for crediting to Aetna. Long Acting Reversible Contraception Products to be available as a Pharmacy Benefit of Texas Medicaid and TWHP Effective August 1, 2014 Information posted July 15, 2014 Effective for dates of service on or after August 1, 2014, long acting reversible contraception (LARC) products will be available as a pharmacy benefit of Texas Medicaid and Texas Women s Health Program (TWHP). These LARC products will only become available through a limited number of specialty pharmacies that work with LARC manufacturers. These pharmacies will be listed on the Vendor Drug Program website at Providers who prescribe and obtain LARC products through the specialty pharmacies listed will be able to return unused and unopened LARC products to the manufacturer s third party processor. Prescribers should refer to the manufacturer for specific instructions. General buy back instructions are also available at TxVendorDrug.com. After August 1, 2014, LARC will remain a medical benefit and providers will continue to have the option to receive reimbursement for LARC as a clinician administered drug. For more information, call the TMHP Contact Center at Texas Medicaid Vendor Drug Program HEP C changes Vendor Drug added the following new direct acting anti viral to the PDL. Daklinza, Epclusa, Technivie, and Viekira XR Check out our updated and easy to use provider portal At Aetna Better Health of Texas we re always looking for ways to improve service to our providers and to our members. Our enhanced, secure and user friendly web portal is now available. This HIPAA compliant portal is available 24 hours a day. It supports the functions and access to information that you need to take care of your patients. Popular features include: Single sign on One log in and password allow you to move smoothly through various systems. Mobile interface Enjoy the additional convenience of access through your mobile device. Personalized content and services After log in, you will find a landing page customized for you. Real time data access View updates as soon as they are posted. Better tracking Know immediately the status of each claim submission and medical PA request. Detailed summaries Find easy access to details about denied PA requests or claims. Enhanced information Analyze, track and improve services and processes. Member details Access member details containing eligibility, PCP and copay information. We think you ll like the web portal. For more information, you can call Provider Relations or visit 3

4 Help us stop fraud We urge you to remember that it is your responsibility as a Medicaid program provider to report suspected fraud and abuse. To report fraud or abuse, you can call the Office of the Inspector General Hotline at Or you can call the Aetna Better Health of Texas Special Investigations Unit Coordinator at We prefer, but do not require, that you provide enough information to help us investigate, including: Name of the Aetna Better Health of Texas member or provider you suspect of fraud Member s Aetna Better Health of Texas Plan card number Name of doctor, hospital or other health care provider Date of service Amount of money that Aetna Better Health of Texas paid for service, if applicable Description of the acts you suspect involve fraud or abuse You can also visit our website at aetnabetterhealth.com/texas/, and fill out the form under Fraud Reporting. You can then send us the suspected fraud information. Thank you for your continued support! Reminder on balance billing Are you preparing to bill a Medicaid and/or CHIP Member? If so, please remember the following: Medicaid: 42 C.F.R means Acceptance of State payment as payment in full. CHIP: Health and Human Services Commission (HHSC) rule at prohibits balance billing to Children s Health Insurance Program (CHIP) members. Basically, this means that a provider is not to bill the difference between the amount paid by Aetna Better Health of Texas and the provider s customary charge to the patient, the patient s family or a power of attorney for the patient. Balance billing for Medicaid or CHIP services is a violation of your provider contract. The number one highest volume of member complaints is balance billing issues. In essence, Aetna Better Health of Texas Member Advocates have to contact the billing provider s business office to resolve the issue and zero balance the member. Many of these issues are sent to a collection agency, which requires an additional discussion with your office. In effect, this becomes a non issue but countless hours are spent on resolution. Aetna Better Health of Texas will continue to resolve balance billing issues as received. However, we wanted to provide this gentle reminder for your reference when preparing bills for Medicaid members. 4

5 Community outreach You can usually find our community outreach department members out in the community attending health fairs and community events geared towards educating existing and potential members about our plan. In addition to representing the plan in the community, our outreach team can also be a great asset to any provider office. We are available to offer a number of services that enhance members experience not only with our plan but with their providers as well. Here are a few of the services we can offer: Member education One on one education session with a member that must be conducted in a private room at the provider s office. Community outreach will normally coordinate a date/time with a provider when multiple members are scheduled. Texas Health Steps drives This is a new initiative that we are kicking off in all of our service areas. Our community outreach and provider relations teams will coordinate with any interested providers in offering members a designated Saturday where they can come into a provider s office to complete their Texas Health Steps exams. The provider sets aside a designated Saturday exclusively for plan members and provides the date/time to our community outreach / provider relations teams. The plan provides outreach to a designated number of members via mail, along with outbound calls that encourage attendance at each event. Our community outreach and provider relations teams support each event by offering refreshments, games and door prizes to enhance the member experience. For more information please contact Ernest Gil at or gile@aetna.com 5

6 AETNA BETTER HEALTH OF TEXAS Provider Relations P.O. Box Dallas, TX Who to call? Provider Relations and Member Services lines: Medicaid Tarrant Medicaid Bexar CHIP Tarrant CHIP Bexar Superior Vision LogistiCare Medical Transportation (For Medicaid members only) (Aetna Bexar County) (Aetna Tarrant County) Nurse Line Behavioral Health Provider Credentialing Report Fraud, Waste or Abuse Fax Numbers Aetna Prior Authorization fax# Aetna Inpatient Authorization fax# Behavioral Health Prior Authorization fax # (Concurrent Review) Dental MCNA Dental Denta Quest (Medicaid) (CHIP) Vital Savings (adults only) CVS Caremark (Pharmacy) CVS Caremark Help Desk BIN# PCN: ADV GROUP# RX8801 Prior Auth Call In Prior Auth fax