Collaborating for success reducing readmissions. Mercy Care Provider Newsletter 2014 Quarterly Volume 1, August 2014 CONTENTS.

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1 Mercy Care Provider Newsletter 2014 Quarterly Volume 1, August 2014 CONTENTS Collaborating for success reducing readmissions...1 Coordination of Care Performance Improvement Project...2 DRG transition effective 10/1/ Hospital observation authorization requirements...3 Integrated Care Training Academy upcoming events...3 Medical record responsibility...3 New benefit change - physical therapy for adult AHCCCS members...4 Obstetrical billing - new requirements...4 PCP application of fluoride varnish...4 Balance billing members...5 Medicare Part D formulary update...5 Dental Home initiative...6 Connect with us on Facebook!...6 High blood pressure education...6 ICD-10 implementation and readiness...7 New form required after July 1, CMS 1500 (02-12)...7 Pharmacy Restriction Program description for health care providers...8 Skilled Nursing Facility (SNF) reference guide updates...9 Skilled Nursing Facility transportation update...9 Mercy Care is proud to introduce Collaborating for success reducing readmissions Transition of Care and reducing readmission is a huge focus within the healthcare arena and an important part of a member s whole healthcare experience. To help with this focus, it is really important to start the collaboration of care prior to the member having surgery. A great way to achieve this is by assessing a member s discharge needs at the time of the surgical evaluation and consent. The following questions can be helpful in ensuring there is a safe and appropriate discharge plan prior to the member s surgery: 1. Anticipated D/C date 2. Anticipated disposition SNF, home, LTACH, shelter, etc. Continued on page 2 1

2 Collaborating for success reducing readmissions Continued from page 1 3. Home/family Support: What is the extent of the family involvement, if any? Family involvement helps to determine whether they will have the care they need to recover properly. Does the patient care for someone in or outside the home? This may prevent patient from recovering properly and/ or make the right discharge decision. If they live alone, do they have friends with in the community or receive services? Who provides daily transportation? 4. Level of functioning? What is the patient able to do for him/herself? What tasks must be completed by someone else? Transportation? 5. Services and DME: Do they have any services currently that can be resumed after discharge? Do they have any additional DME requirements that they don t currently have? With this information available, proactive discharge planning can be arranged prior to the member s surgery reducing the chances of a readmission. This process not only applies to outpatient surgical procedures, but can be helpful as well for inpatient surgical admission. Collaboration and proactive planning accelerates the discharge process. Here is a helpful discharge planning template that you can use when speaking with a member regarding their discharge following surgery. 1. Anticipated discharge date 2. Anticipated disposition 3. Home/family support 4. Level of functioning 5. Required services and DME Mercy Care Plan Corner Coordination of Care Performance Improvement Project Mercy Care Plan is pleased to participate in a statewide effort to promote better health outcomes through coordination of care for members receiving AHCCCS covered services in both the medical and behavioral health delivery systems. This initiative is targeting those members who are being prescribed opiates and benzodiazepines concomitantly. All AHCCCS health plans and Regional Behavioral Health Authorities (RBHAs) have implemented an AHCCCS Coordination of Care Performance Improvement Project (PIP), which enables the exchange of benzodiazepine and opioid pharmacy data between health plan and RBHA providers. Coordination of Care PIP Goals: Exchange pharmacy data between behavioral health and health plan providers to assist them in making informed clinical decisions when prescribing benzodiazepine and/or opioid medication. Coordinate with each prescriber to improve quality of care, reduce morbidity/mortality, decrease potentially hazardous drug interactions and minimize potentially hazardous drug interactions. Coordination of care efforts, exchange of medical records or correspondence with the Mercy Care Plan prescriber is documented in the member s medical record. The ultimate goal is to impact the potentially hazardous co administration of benzodiazepines and opioids. Increase the routine use of the Arizona Controlled Substance Prescription Monitoring Program (CSPMP), which is an online centralized database used to track the dispensing of controlled substances. If you are not registered yet, as required by statute, please go to For additional information regarding the above, please review our Provider Notification titled Coordination of Care Performance Improvement Project on our website or feel free to contact our behavioral health representative, Thomas White, at

3 DRG transition effective 10/1/14 In order to align with AHCCCS guidance, Mercy Care Plan will be changing their inpatient pricing methodology from the current tier based per diem to APR DRG effective October 1, Additional information is available on the AHCCCS website under the AHCCCS Transition to DRG based Payment webpage. In addition, please review Mercy Care s Provider Notification titled DRG Transition Effective October 1, 2014 available on our website. As we get nearer to the implementation, we will provide you with additional detail. We look forward to the transition to the APR DRG system and the many opportunities that it will afford providers, members, and the AHCCCS program. Hospital observation authorization requirements Hospital observation status should not exceed 24 hours. This time limit may be exceeded, if medically necessary, to evaluate the medical condition and/or treatment of a recipient. Any extension to the 24 hour limit must be prior authorized. Hospital observation does not require prior authorization if 24 hours or less. Integrated Care Training Academy upcoming events Our next Integrated Care Training Academy topic is called Mental health issues during pregnancy and lactation. You can earn 2 AMA PRA Category 1 Credits at no cost to you! Date: October 23, 2014 Time: 5:30 8:00 p.m.* Location: Foundation for Senior Living Caregiver House 1201 E. Thomas Rd. Phoenix, AZ Click here to register for the October 23 event, or contact: Kat Montano, MCP LTC Behavioral Health Trainer, at or montanok@mercycareplan.com Please register by October 17, 2014 Date: October 30, 2014 Time: 5:30 8:00 p.m.* Location: Operations Division Midtown Tucson Police Department 1100 S. Alvernon Way Tucson, AZ Click here to register for the October 30 event, or contact: Kat Montano, MCP LTC Behavioral Health Trainer, at or montanok@mercycareplan.com Please register by October 24, 2014 *Includes dinner and refreshments Medical record responsibility As indicated in our provider manual under Section Member s Medical Record, the provider serves as the member s medical home and is responsible for providing quality health care, coordinating all other medically necessary services and documenting such services in the member s medical record. Please review the provider manual for additional detail regarding requirements. It is important to note: Medical records necessary for the payment of claims must be made available to MCP within fourteen (14) days of the request or by the date stated in a formal request letter. Medical records shall be furnished at no cost to MCP. Each member is entitled to one copy of his or her medical record free of charge. Members have the right to amend or correct medical records. The record must be supplied to the member within fourteen (14) days of the date of the request. 3

4 New benefit change - physical therapy for adult AHCCCS members A new benefit change for outpatient physical therapy was implemented for Mercy Care Plan adult members with dates of service March 1, 2014 and forward. This new benefit will cover 15 additional outpatient physical therapy visits when they are needed to keep a level of function or help get to a level of function. Currently, all AHCCCS adult members receive up to 15 outpatient physical therapy visits to restore a level of function, but no additional visits to keep or get to a level of function. This new outpatient physical therapy benefit will start March 1, The benefit will renew again on October 1, 2014, at the start of the new benefit year. Please refer to our provider notification titled New Benefit Change - Physical Therapy for Adult AHCCCS Members on our website for additional information. Obstetrical billing - new requirements As indicated in our last provider newsletter, in the AHCCCS Medical Policy Manual, Chapter 400, changes were made related to the maternity care package global claim. The policy change does NOT change how care or services are paid for by Mercy Care. The policy change requires Mercy Care to implement processes to ensure that the maternity claim form includes all dates of service. This billing change is a required by AHCCCS and providers need to bill in accordance with this policy. Chapter 400 is available on the AHCCCS website and states below: CHAPTER 400 MEDICAL POLICY FOR MATERNAL AND CHILD HEALTH POLICY 410 MATERNITY CARE SERVICES D. MATERNITY CARE PROVIDER REQUIREMENTS 3. All maternity care providers will ensure that: f. All prenatal and postpartum visits are recorded on claims forms to the Contractor regardless of the payment methodology used. Mercy Care requests that you: Submit a line item on each claim for each pre-natal visit with $0.00 billed amount and 1 unit using CPT code Submit the delivery service on one line with the amount billed for the total OB package and 1 unit. Submit the post-natal care on one line with 1 unit using CPT code Mercy Care s provider notification titled Obstetrical Billing is available on our website and clearly outlines these requirements. Information regarding this is also in Section of the Mercy Care Provider Manual. PCP application of fluoride varnish Effective 4/1/2014, a change was made to the AHCCCS Medical Policy Manual (AMPM) under Policy EPSDT Oral Health Care. The change advises that a physician, physician s assistant or nurse practitioner must perform an oral health screening as part of the EPSDT physical examination. Physicians who have completed the AHCCCS required training may be reimbursed for fluoride varnish applications completed at the EPSDT visit for recipients who are at least 6 months of age, with at least 1 tooth eruption. Additional applications occurring every 6 months during an EPSDT visit, up until the recipient s 2nd birthday, will also be reimbursed. For further information regarding this new requirement, a provider notification titled PCP Application of Fluoride Varnish has been posted to Mercy Care s website. 4

5 Mercy Care Advantage Corner Balance billing members As a reminder, it is never appropriate to balance bill Mercy Care Advantage enrollees. According to the Mercy Care Advantage provider manual, under Section Financial Liability for Payment for Services, it states the following: In no event should MCA contracted providers bill an MCA plan enrollee (or a person acting on behalf of an MCA plan enrollee) for payment of fees that are the legal obligation of MCA. However, a contracted provider may collect deductibles, coinsurance or copayments from MCA plan enrollees in accordance with the terms of the enrollee s Evidence of Coverage. Note: CMS issued a memo to MCA dated September 17, 2008, ( CMS Guidance ) providing guidance regarding balance billing by providers of certain individuals enrolled in both Medicare Advantage plans and a State Medicaid plan ( Dual Eligible beneficiaries ). More specifically, this CMS Guidance states that providers are prohibited from balance billing Dual Eligible beneficiaries who are classified as Qualified Medicare Beneficiaries (QMB) for Medicare Parts A and B cost sharing amounts. The CMS Guidance explains that providers must accept Medicare and Medicaid payment(s), if any, as payment in full. A QMB has no legal liability to make payment to a provider or Medicare Advantage plan for Medicare Part A or B cost sharing, and a provider may not treat a QMB as private pay patient in order to bill a QMB patient directly. In addition, the CMS Guidance states that federal regulations require a provider treating an individual enrolled in a State Medicaid plan, including QMBs, to accept Medicare assignment. Providers participating in Medicare networks are required to comply with all of the requirements set forth in this CMS Guidance. Medicare Part D formulary update Deletion of Products Containing More Than 325 mg of Acetaminophen On April 28, 2014, the FDA issued a reminder to health care professionals to stop prescribing and pharmacists to stop dispensing prescription combination drug products that contain more than 325 milligrams (mg) of acetaminophen per tablet, capsule, or other dosage unit. These products are no longer considered safe by the FDA and have been voluntarily withdrawn. Effective May 16, 2014, CVS/Caremark removed the following products from all Medicare Part D formularies and sent a notification regarding this: Name of Affected Drug Oxycodone w/ Acetaminophen, Cap MG Oxycodone w/ Acetaminophen, Tab MG Oxycodone w/ Acetaminophen, Tab MG Hydrocodone-Acetaminophen, Cap MG MG MG MG MG MG MG MG MG Hydrocodone-Acetaminophen, Soln MG/15ML For more information regarding the Medicare Part D Formulary, please click here to view our website. 5

6 Dental Corner Dental Home initiative Mercy Care Plan (MCP) has identified children 1 to 20 years of age in need of preventative dental care and children ages 6 to 9 years of age who are in need of dental sealants. MCP will be partnering with participating dental providers via a Dental Home Initiative. As the dental home for these members, these participating dental providers will be reaching out to the member or their parent/guardian to schedule and provide these important services. MCP will furnish the dental provider with a list of members within the geographic service area of their practice in need of preventative dental care and dental sealants. Through this partnership, the participating dental provider agrees to the following: MCP will provide the participating dental providers with a list of members who will be assigned to their practice as their dental home on a quarterly basis. Information will include member name, phone number and address. Data Sharing will be done with the participating dental provider and MCP via secure . The participating dental provider will make outreach calls to the members contained on the list and assist them in scheduling a visit to their office. MCP expects the office to make several attempts to reach each member if the first attempt is unsuccessful. The participating dental provider s staff conducting outbound and answering inbound calls for MCP members will be bilingual. All Plans Corner Connect with us on Facebook! Mercy Care Plan is now on Facebook! Like us and Share our page and posts with your Friends today. Join our Facebook community at facebook.com/ MercyCarePlan. Mercy Care Plan s Facebook page offers the health plan latest news, events and updates. Plus, we offer a variety of helpful health and wellness tips to encourage members and the community to stay healthy. We care about the privacy of our members. We consistently monitor our Facebook page and may remove potentially harmful information to protect our member s privacy. Not on Facebook? Signing up is easy! Go to to get started. High blood pressure education It s important to keep in mind that according to the CDC, about 1 in 3 U.S. adults - or 67 million people - have high blood pressure. Only 47% of these individuals have their condition under control. High blood pressure was a primary or contributing cause of death for more than 348,000 Americans in 2009, nearly 1,000 deaths each day. It also costs the nation $47.5 billion each year in health care services, medications and missed days of work. Because it is called the silent killer often with no warning signs or symptoms, many people don t know they have it. That s why it s important to check blood pressures regularly at office visits. You may also want to refer appropriate patients to the American Heart website at heart360.org. Heart360 is an easy to use tool which helps the patient understand and track the risk factors that affect their health, including blood pressure, physical activity, cholesterol, glucose, weight and medications. Heart360 safely and securely stores information in a Microsoft Health Vault and the patient can give you access to their information. 6

7 ICD-10 implementation and readiness As you are aware, ICD-10 implementation has been delayed until October 1, 2015 (a one year delay). Even though there has been a year delay in implementation, Mercy Care would like to assure you that we are on track to transition our claims system to ICD-10 in order to meet this implementation requirement. We are working with our regulatory agencies, both federal and state, to assure this happens. In addition, we will be working with selected providers that we have already identified for testing purposes to assure a smooth transition to ICD-10. As we get closer to the new implementation date, we will provide you with more detailed information. In the meantime, feel free to review our Provider Notification titled ICD-10 Implementation that provides you with additional detail. New form required after July 1, CMS 1500 (02-12) As indicated in our 1500 (02-12) - Form Completion Instructions document published in April 1, 2014, Mercy Care previously indicated that we would accept submission of claims on the old CMS 1500 form until July 1, Per CMS guidelines, the form went into effect on January 1, 2014 and as of April 1, 2014, instruction was given that this would be the only acceptable form to be submitted. Mercy Care had agreed to allow providers up until July 1, 2014 to bill on the old form, but recommended transition as soon as possible. A copy of the Form 1500 (02-12) is on our website under the forms section for your review. Please note: Currently all claims received after July 1, 2014, regardless of the date of service, will be denied until billed on the new 1500 (02-12) form. To avoid unnecessary denials or delays, please incorporate this change into your billing process. 7

8 Pharmacy Restriction Program description for health care providers Opioid analgesic utilization is increasing in the United States, and is the leading cause of injury or death for people aged years, surpassing both firearm-related and motor vehicle-related deaths in this age group. Mercy Care Plan developed the Pharmacy Restriction Program to monitor overutilization of medications by our members, for their safety. When we identify a member who may be misusing controlled substances, we can place them in a care coordination program called Pharmacy Restriction. The program does not limit the amount of medically necessary pain medicines, but directs the member into a comprehensive, coordinated treatment program. Who is not eligible? Members with an active cancer diagnosis are not eligible. Medicare members are not eligible. Must be on Mercy Care Plan (other plans will have different programs, and we are bound by HIPAA regulations.) Signs of aberrant drug use behaviors: Lost or stolen prescriptions Requests for early refills Paying cash for controlled substances Refusal to complete diagnostic tests or receive treatments other than medication Unexplained positives on a drug screen Multiple prescribers, multiple pharmacies Frequent ER use, medication overdose/ poisoning How does the program work? Restricted members are locked into specific prescribers for their prescribed controlled substances which may then be filled at any of the participating Mercy Care Plan pharmacies. Restricted members have a phone number for a Care Associate to notify if they have problems, such as a need to change the restriction doctor. If the member needs more comprehensive assistance, then the member may be assigned to a Case Management Coordinator to: Find a new primary care provider; Find a pain management provider; Coordinate with Behavioral Health (RBHA); or Facilitate Case Management. The Case Management Coordinators (and the Care Associates) work(s) with a Medical Director to: Gather data on prescription history, ER visits, doctor notes; Review plan reports on high utilizers; Identify members who need restriction; and Identify members who are ready to graduate. Do members stay in the program forever? When the member does not require controlled substances, or they are not misusing them, then the restriction can be lifted. Most members are in the program for about one year. Who can refer? Any healthcare professional can refer a patient for the program. The MCP team will research to see if the program is appropriate for the member. You do not need to research it yourself. Your name will not be shared with the member or with AHCCCS. How do I refer someone? To refer - call: or You may leave a message with your callback number if it is after hours. Please include the following information: Patient name ID number Date of birth It is helpful, but NOT MANDATORY to know why you think this person may be misusing controlled substances. 8

9 Skilled Nursing Facility (SNF) reference guide updates Please note that our Skilled Nursing Facility (SNF) reference guide was updated in April of The document has been reformatted and all changes are highlighted in yellow. For additional information regarding the changes, please review our Provider Notification titled Skilled Nursing Facility (SNF) Reference Guide available on our website. Skilled Nursing Facility transportation update Making transportation arrangements from a Skilled Nursing Facility no longer necessitates calling Mercy Care directly. Please use the following contact information: Skilled Nursing Facilities can contact Total Transit directly and do not need to contact Mercy Care s Member Services. Transportation requests can be faxed to Total Transit by nursing care staff members for the following services: Standard Wheelchair New Transportation Requests - 24-Hour Advance Notice Required Fax to Standard Wheelchair Change Orders - Call Agent can make changes to an existing order already in the system Bariatric Wheelchair New Transportation Requests - 24-Hour Advance Notice Required Fax to Bariatric Wheelchair Change Orders - Call Agent can make changes to an existing order already in the system Bariatric Stretcher New Transportation Requests - 24-Hour Advance Notice Required Fax to Standard Stretcher New Transportation Requests - 24-Hour Advance Notice Required Fax to Standard Stretcher Change Orders - Call Agent can make changes to an existing order already in the system Ambulatory New Transportation Requests - 24-Hour Advance Notice Required Fax to Ambulatory Change Orders - Call Agent can make changes to an existing order already in the system Mercy Care is proud to introduce Lillian Petroni Provider Relations Manager Mercy Care Plan Lillian Petroni is one of our Provider Relations Managers in the Provider Relations department. She currently oversees all the primary care physicians, specialists, dentists, ancillary providers and long term care providers for Mercy Care Plan. Lillian oversees a staff of 15 Network Account Managers and Network Consultants in both Phoenix and Tucson. Lillian has over 20 years of experience in managed care and has held positions in delegation oversight, provider relations and contracting for both commercial and Medicare/Medicaid plans, working for United Dental, PacifiCare, Coventry and HMA. She has worked with Medicaid in both Arizona and Hawaii. Lillian has a Master s Degree in Business, is a Certified Toastmaster and was on the Volunteer Speaker s Bureau for over 20 years. Lillian also participates in the Volunteer Council. In her spare time, Lillian is a board member and a volunteer for the Botanical Gardens in Phoenix. 9

10 Our mission Southwest Catholic Health Network Corporation (SCHN) d/b/a Mercy Care Plan is a not for profit corporation founded by Carondelet Health Network and St. Joseph s Hospital & Medical Center, a Dignity Health facility. SCHN is committed to promoting and facilitating quality health care services with special concern for the values upheld in Catholic social teaching, especially of the poor and for persons with special needs. Our vision SCHN will lead the transformation of the care delivery model by: Enhancing care coordination and collaboration across the continuum (Sponsors, SCHN, provider network). Enhancing health literacy and patients accountability in their health. Seeking a long term partnership with our provider network by offering effective and personalized services. Impacting the care and outcome of high risk/complex patients. Applying learning and capabilities to other patient populations to improve community health outcomes. Our values Passion: SCHN will pursue its mission with enthusiasm, optimism and diligence. Stewardship: SCHN will act prudently, focusing on the interests of those we serve. Teamwork: SCHN will collaborate with others to create exceptional results. Advocacy: SCHN will work on behalf of the underserved to improve health outcomes.... MERCY CARE S PROVIDER NEWSLETTER is published as a community service for the Mercy Care provider network. Mercy Care Plan Mercy Care Advantage 4350 E. Cotton Center Blvd., Bldg. D Phoenix, AZ Phone: or or TTY/TDD: 711 Website: