July Provider and Clinical Updates. An Update for West Virginia Family Health Providers and Clinicians

Transcription

1 July 2018 An Update for West Virginia Family Health Providers and Clinicians Provider and Clinical Updates National Correct Coding Initiative (NCCI) Edits LabCorp is Preferred Provider for Outpatient Lab Testing... 4 Medical Drug Management Clinical Practice and Preventive Health Guidelines Continuity of Care Across Settings Ensuring Quality and Care of Service Provider Account Liaison Contacts Important Phone Numbers Important Phone Numbers

2 2 National Correct Coding Initiative (NCCI) Edits The Center for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI) promotes national correct coding methodologies and reduces improper coding which may result in inappropriate payments of Medicare Part B and Medicaid claims. Types of NCCI Edits The NCCI contains two types of edits: NCCI procedure-to-procedure (PTP) edits that define pairs of Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes that should not be reported together for a variety of reasons. The purpose of the PTP edits is to prevent improper payments when incorrect coding combinations are reported. Medically Unlikely Edits (MUEs) define for each HCPCS/CPT code the maximum units of service (UOS) that a provider would report under most circumstances for a single beneficiary on a single date of service. NCCI PTP Edits PTP Edits consist of Column I and Column II codes. Column II codes are often the component of a more comprehensive Column I code. These codes are typically considered to be mutually exclusive and should not be reported together. However, there are some instances when codes may be billed together when an appropriate modifier is used. The NCCI PTP table will have the following indicators: Modifier Indicator Definition 0 (Not Allowed) 1 (Allowed) 9 (Not Applicable) There are no modifiers associated with NCCI that are allowed to be used with this PTP code pair; there are no circumstances in which both procedures of the PTP code pair should be paid for the same beneficiary on the same day by the same provider. The modifiers associated with NCCI are allowed with this PTP code pair when appropriate. This indicator means that an NCCI edit does not apply to this PTP code pair. The edit for this PTP code pair was deleted retroactively. Modifiers that will bypass a Column I/Column II edit 1 Allowed When clinically appropriate, the following modifiers may be used with PTP pairs with status indicator 1 Allowed. Documentation in the medical record must support use of these modifiers: Anatomic Modifiers: E1 E4 Anatomic modifiers of the eyelid FA, F1 F9 Anatomic modifiers of the fingers TA, T1-T9 Anatomic modifiers of the toes LT Left side of the body RT Right side of the body LC, LD, LM, RC, RI Anatomic modifiers of the coronary arteries

3 3 National Correct Coding Initiative (NCCI) Edits Global Surgery Modifiers: 24 Unrelated E&M service by the same physician during a postoperative period 25 Significant, separately identifiable E&M service by the same physician on the same day of the procedure or other service 57 Decision for surgery 58 Staged or related procedure or service by the same physician during the postoperative period 78 Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period 79 Unrelated procedure or service by the same physician during the postoperative period Further instructions on the NCCI PTP tables are found in CMS How to Use the Medicare National Correct Coding Initiative (NCCI) Tools : Network-MLN/MLNProducts/Downloads/How-To-Use-NCCI-Tools.pdf The NCCI PTP tables are found at this link: NCCI edits for Durable Medical Equipment (DME) NCCI PTP tables for DME can be found on the Medicaid.gov site at this link:

4 4 LabCorp is Preferred Provider for Outpatient Laboratory Testing Effective Immediately, West Virginia Family Health (WVFH) members are required to have all of their outpatient laboratory work completed through LabCorp. Failure to do so could result in non-payment of services. West Virginia Family Health requires participating practitioners to utilize LabCorp for any and all studies that are ordered for West Virginia Family Health members. All outpatient laboratory testing should be ordered with a prescription. Practitioners are encouraged to perform venipuncture in their office and arrange for the specimens to be picked up by LabCorp. Participating providers who do not perform venipuncture in their office should send members to LabCorp. Please contact Provider Services at if you have any additional questions.

5 5 Medical Drug Management As of March 5, 2018, a subset of medications require a pre-service authorization for medications obtained through the medical benefit. This prior authorization process applies to all West Virginia Family Health members. Medical necessity criteria for each medication listed below is outlined in the specific medication policies available online. To access WVFH medical policies, please visit Failure to obtain authorization will result in a claim denial. Procedure Codes Requiring Authorization JCODE DRUG NAME (brand) DRUG NAME (generic) J1300 Soliris Eculizumab injection J1322 Vimizim Inj, elosulfase alfa, 1mg J1459 Privigen Inj IVIG privigen 500 mg J1556 Bivigam Inj, Imm Glob Bivigam, 500mg J1557 Gammaplex Gammaplex injection (5%, 10%) J1561 Gamunex Gamunex-C/Gammaked Immune globulin, powder J1568 Octagam Octagam injection J1569 Gammagard Gammagard liquid injection J1572 Flebogamma DIF Flebogamma injection IVIG, non-lyophilized J1745 Remicade Infliximab injection J9042 Adcetris Brentuximab vedotin inj J9228 Yervoy Ipilimumab injection J9271 Keytruda Inj pembrolizumab J9299 Opdivo Injection, nivolumab J9305 Alimta Pemetrexed injection J9355 Herceptin Trastuzumab injection J3590 Unclassified biologics J3490 Unclassified drugs J9999 Misc Antineoplastic Drugs

6 6 Medical Drug Management (cont.) *** NEW as of August 6, 2018*** Botox onabotulinumtoxina injection Neupogen filgrastim injection Neulasta Pegfilgrastim injection Leukine Sargramostim injection Granix tbo-filgrastim injection Zarxio filgrastim-sndz injection (biosimilar) Rituxan Rituximab injection Xolair Omalizumab injection Avastin Bevacizumab injection Kyprolis Carfilzomib injection Erbitux Cetuximab injection Perjeta Pertuzumab injection Faslodex Fulvestrant injection Tysabri Natalizumab injection Medication not on the list? If the medication you are prescribing for your patient is not on this list that means it does not require a pre-service prior authorization. The process for obtaining this medication (that is not listed above) has not changed. If you intend to bill the medication on the medical benefit, you will administer the medication and submit the claim as you have in the past. This claim might be subject to post-service, prepayment edits, but no pre-service authorization is required. Want to get the medication through pharmacy? This change only applies to the medical benefit. If the medication is to be billed at the pharmacy/specialty pharmacy, you will continue to submit requests to Rational Drug Therapy Program. They can be reached at

7 7 Medical Drug Management (cont.) Submitting a Request The most efficient path of submitting a request (for one of the medications on the list above) is via Navinet. A form has been added to NaviNet with autofill functionality to make completing and submitting your online request easier and faster. If you have questions regarding the authorization process and how to submit authorizations electronically via NaviNet, please contact your West Virginia Family Health Provider Relations Representative directly or Provider Services Department using the phone number Additional Information Any decision to deny a prior authorization or to authorize a service is made by a licensed pharmacist based on individual member needs, characteristics of the local delivery system, and established clinical criteria. Authorization does not guarantee payment of claims. Medications listed above will be reimbursed by West Virginia Family Health only if it is medically necessary, a covered service, and provided to an eligible member. Non covered benefits will not be paid unless special circumstances exists. Always review member benefits to determine covered & non-covered services.

8 8 Clinical Practice and Preventive Health Guidelines West Virginia Family Health adopts clinical practice and preventive health guidelines to assist practitioners in providing appropriate healthcare for specific clinical conditions relevant to our members. These guidelines are developed using evidence-based clinical practice guidelines from professionally- and industry-recognized sources, or through the involvement of board-certified practitioners from appropriate specialties when guidelines from recognized sources are not available. They are provided in an effort to improve health care quality by promoting peer-reviewed standards-of-care and best practices. The Guidelines also serve as a guide for West Virginia Family Health s various Disease Management programs. West Virginia Family Health routinely monitors for industry changes that would affect its adopted guidelines. Before distribution, the guidelines are reviewed and approved by West Virginia Family Health s Quality Improvement Committee. Guidelines include: Adult Preventive Care Asthma Cardiac Child Obesity Child Preventive Care COPD Diabetes HIV in Adults and Adolescents Hypertension Palliative Care Access to the guidelines are available online at Go under the Providers Tab and click on Clinical Guidelines. Guidelines can be printed from the website.

9 9 Continuity of Care Across Settings The seamless sharing of information between healthcare providers, such as between primary care physicians (PCPs) and specialists, presents many challenges to the continuity of care and treatment of our members. West Virginia Family Health s membership includes some of the most vulnerable individuals who may suffer from severe or chronic illnesses. Enhanced communication among and between all those who participate in providing care to a patient is imperative in ensuring that all decisions about the patient s care are informed and contribute to the patient s overall wellbeing. Continuity of care issues can result in suboptimal outcomes, increased costs, and medical errors. It is to the benefit of both the patient and healthcare professional to communicate any reports, therapies, medications, and concerns identified by providers across treatment settings. Please contact your Provider Relations Representative with questions about how you can help improve patient care between settings.

10 10 Ensuring Quality Care and Service Ensuring the excellent provision of health care and services for our members is the primary goal of the West Virginia Family Health Quality Improvement/Utilization Management (QI/UM) Program. West Virginia Family Health continuously monitors how well we re helping our members: Get preventive care Get care for long-standing health problems Understand the medicines they take Stay out of the hospital Have appropriate access to practitioners Make and keep doctor appointments Share health information with their doctors Receive care in a culturally-competent manner The Quality Program leverages results from member surveys, medical record reviews, the Healthcare Effectiveness Data Information Set (HEDIS), and other tools to measure how we are doing and to help set goals for future quality activities. We also work closely with doctors in our network to monitor the care and services our members receive, as well as determine what we can do to better serve our members. West Virginia Family Health maintains a QI/UM Work Plan to analyze activities conducted as part of its QI/UM Program. This Work Plan is evaluated every three months to identify issues and ensure that actions have been taken to address them. West Virginia Family Health also conducts an annual review of its QI/UM Program to see how well we ve met the health care and service needs of our members. The evaluation of the 2017 QI/UM Program is complete. We met many of the QI/UM Program goals, implemented new and innovative programs, identified areas for improvement, and are developing plans to address improvement opportunities in Please call Provider Services at if you would like to request more information about our Quality Program, QI/UM Work Plan, or summary evaluation of the 2017 QI/UM Program.

11 11 WVFH Provider Account Liaison Contact List Territory Account Assignments by Counties WVFH Provider Account Liaison Stephanie Twyford Phone and Fax (412) WVFH Provider Account Liaison Matt Brannon Phone and Fax (681) WVFH Provider Account Liaison Open Territory - WV Region I Brooke, Calhoun, Doddridge, Gilmer, Hancock, Harrison, Jackson, Lewis, Marion, Marshall, Monongalia, Ohio, Pleasants, Ritchie, Roane, Tyler, Wetzel, Wirt, and Wood WV Region II Boone, Braxton, Cabell, Clay, Kanawha, Lincoln, Logan, Mason, McDowell, Mingo, Putnam, Wayne, and Wyoming WV Region III Coverage by Matt Barbour, Berkeley, Fayette, Greenbrier, Hampshire, Hardy, Jefferson, Mercer, Mineral, Monroe, Morgan, Coverage by Stephanie Nicholas, Pendleton, Pocahontas, Preston, Raleigh, Randolph, Summers, Taylor, Tucker, Upshur, and Webster

12 12 CALL TO INQUIRE ABOUT: TELEPHONE NUMBER HOURS OF OPERATION FAX NUMBER Behavioral Health Monday Friday 8:30 a.m. to 4:30 p.m. Care Management Option 1: Maternity Program Option 2: Care Management/ Disease Management Congestive Heart Failure/Asthma/COPD/Diabetes Option 3: Preventive Health Services/EPSDT/Outreach Option 4: Complex Care Management Dental Provider Services (Claims Inquiries and Eligibility Verification) Digital Voice Assistant - DIVA (Eligibility Check/Generate and Review Referrals) Fraud and Abuse and Compliance Hotline Medical Management (Utilization Management) Monday Friday 8:30 a.m. to 4:30 p.m Monday Friday 8:30 a.m. to 4:30 p.m. (Central Time) hours a day/ 7 days a week hours a day/ 7 days a week Please do not leave multiple voic messages or call for the same authorization request on the same day. Monday Friday 8:30 a.m. to 4:30 p.m. (Voic during off hours. The call will be returned the next day.) Member Services Monday Friday 8 a.m. to 8 p.m. Rational Drug Therapy Program General: Prenatal Risk Forms & Member Outreach Forms: Molina Pharmacy Help Desk Molina Pharmacy Member Services Provider Services (Claims Inquiries and Eligibility Verification) TTY/TDD Line 711 or Monday Friday 8:30 a.m. to 4:30 p.m Hour Nurse Help Line WVFH(9834) 24 hours a day/ 7 days a week NaviNet Click here to enter the NaviNet portal