AFC CONNECT LABORATORIES. How to Submit a Referral or a Pre-Certification Request. Our Preferred. AFC HMO Provider Newsletter

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com > Providers >Tools and Resources >Forms >UM Referral Form A copy of the form should be placed in the patient s chart, another faxed to the Provider, and a third copy faxed to

A Specialist may request additional services through the PCP who may provide an additional referral for the added services. Our Preferred LABORATORIES LabCorp...(800) 43-6078 www.

com TIP: Lab and pathology tests for America s 1st Choice members performed at a participating facility can improve HEDIS scores. www.americas1stchoice.

Medical Records are required for this process. Services requiring pre-certification requests should be faxed to the health plan by the PCP.

1 AFC HMO Provider Newsletter AFC CONNECT Summer 015 How to Submit a Referral or a Pre-Certification Request Primary Care Physicians (PCPs) should provide a referral for specialized services using the health plan s Referral Form. The form is located in the back of the Provider Manual or online at > Providers >Tools and Resources >Forms >UM Referral Form A copy of the form should be placed in the patient s chart, another faxed to the Provider, and a third copy faxed to the health plan for data entry. A number is not used on this form. A Specialist may request additional services through the PCP who may provide an additional referral for the added services. Our Preferred LABORATORIES LabCorp...(800) Quest...(866) Solstas Lab Partners...(888) TIP: Lab and pathology tests for America s 1st Choice members performed at a participating facility can improve HEDIS scores. Pre-Certification Requests The Pre-Certification Process must be used when the services being ordered require review for medical necessity. Medical Records are required for this process. Services requiring pre-certification requests should be faxed to the health plan by the PCP. Pre-certification requests will be processed within the following timeframes: Standard The health plan s average time to completion is two days if all information is complete. Please fax requests to Expedited A request can only be expedited if it is felt that waiting up to the standard time for a decision would place the patient s life, health or ability to regain maximum function in serious jeopardy. Expedited requests may be submitted by phone at or fax to

HEDIS What You Need to Know The 016 HEDIS (DOS 015) season began on January 1 and ends December 31. However, some measures have distinct allowable dates of service.

2 HEDIS What You Need to Know The 016 HEDIS (DOS 015) season began on January 1 and ends December 31. However, some measures have distinct allowable dates of service. Here is a brief guide on the most common measures and their requirements. HEDIS Measure Name Members Requiring Measure Intervention Required Frequency BMI (Adult BMI Assessment) Patients years of age Body Mass Index and weight assessment Once every years Breast CA Scn (Breast Cancer Screening) Women years of age Mammogram Once every years, 3 months Colon CA Scn (Colorectal Cancer Screening) DM: Eye Exam (Diabetic: Eye Exam) DM: HbA1c < 9% (Diabetic: HbA1c Poorly Controlled >9) DM: Nephro (Diabetic: Monitoring Diabetic Nephropathy) Osteo Mgmt (Osteoporosis Management in Women Who Had a Fracture) RA Drug Tx (Disease Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis) Well Visit (Adults' Access ID Preventive/ Ambulatory Health Services) COA: Func. Stat (Care for Older Adults: Functional Status Assessment) COA: Pain Asmt (Care for Older Adults: Currently listed in the portal as Pain Screening) COA: Rx Review (Care for Older Adults: Medication Review) MRP (Medication Reconciliation Post-Discharge) Patients years of age Patients years of age with diabetes Patients years of age with diabetes Patients years of age with diabetes Women years of age who have had a fracture Patients 18+ years of age diagnosed with Rheumatoid Arthritis Must complete one of the following: FOBT, or Flexible Sigmoidoscopy, or; Colonoscopy Ophthalmoscopic eye exam for diabetic retinal disease and the results by an ophthalmologist or optometrist Most recent HbA1c test result (must be < 9% to be compliant) Urine microalbumin test Bone Mineral Density Test or Osteoporosis therapy or prescription for a drug to treat or prevent osteoporosis. For a complete list of drugs go to: HEDISMeasures/HEDIS015/HEDIS015NDC License/HEDIS015FinalNDCLists.aspx At least one prescription of a Disease Modifying Anti-Rheumatic Drug (DMARD) dispensed. Once a year Once every 5 years Once every 10 years Once every years America s 1st Choice HMO Provider News TTY: 711 Within 180 days of fracture Patients 0+ years of age Preventive care visit Patients 66+ years of age Patients 66+ years of age Patients 66+ years of age Patients 66+ years of age Source - HEDIS 015 Technical Specifications For Health Plans Volume These measures are for SNP members only Documentation in the medical record of three out of the four items assessed: cognitive status, ambulation status, sensory ability (including hearing, vision, speech), or other functional independence (e.g., exercise, ability to perform job) Documentation in the medical record must include evidence of a pain assessment and the date when it was performed. List of medications and an evidence of a review of these medications in the calendar year on the same DOS Documentation in the medical record of medication reconciliation and the date when it was performed. On or within 30 days of discharge On or within 30 days of discharge

HEDIS & CMS Part D Reminders to Your Patients Beyond working with you, the health plan reaches out to members through call campaigns and personalized letters.

In your discussions with your patient, you may find that some tests have been completed but we show no record of those in our system.

your facility. Please make sure to document all tests and screenings performed at the VA and your facility in the patient s medical record.

Personalized letters to our members that outline their individual needs. These letters direct members to take the letter to their PCP to discuss and schedule the needed screenings.

3 HEDIS & CMS Part D Reminders to Your Patients Beyond working with you, the health plan reaches out to members through call campaigns and personalized letters. We ask our members to take those letters to their PCP to address specific preventive care needs. In your discussions with your patient, you may find that some tests have been completed but we show no record of those in our system. This may be due to a number of factors, including: The member completed the test prior to joining the Plan; The member has services rendered at the VA; or The member had certain tests completed at your facility. Please make sure to document all tests and screenings performed at the VA and your facility in the patient s medical record. Additional HEDIS related efforts for this year include: Automated phone calls for members that require a specific test or annual screening. Personalized letters to our members that outline their individual needs. These letters direct members to take the letter to their PCP to discuss and schedule the needed screenings. Please be sure to make note in our member s medical record of any tests and screenings performed in 015, at the VA or at your facility. EASY HEDIS WINS Tips on How to Leverage Claims Coding for HEDIS Compliance Many times you can lessen the amount of medical record requests for HEDIS documentation by simply utilizing CPT or CPT Category II codes. The health plan will not request records for a measure if it has been filed on your claim. For Example: Colorectal screening should be documented in the patient s chart and by filing the claim, along with the corresponding CPT or HCPCS code, trigger HEDIS compliance for the patient. FOBT CPT: 870, 874 HCPCS: G038 Flexible Sigmoidoscopy CPT: , , HCPCS: G0104 Colonoscopy CPT: 44388, 44389, 44390, 44391, 4439, 44393, 44394, 44397, 45355, 45378, 45379, 45380, 45381, 4538, 45383, 45384, 45385, 45386, 45387, 45391, 4539 HCPCS: G0105, G011 You can do the same with HbA1c screenings by submitting the corresponding CPT II code: 3044F, 3045F. Let your claims do all the work! Summer

MENTAL AND BEHAVIORAL HEALTH SERVICES How to Refer Our Members Psychcare is the health plan s partner for mental and behavioral health services.

However, Psychcare authorizes services, coordinates all treatment and pays claims directly to providers in its network, which includes: Psychiatrists Doctorate level licensed psychologists Masters

medications, which may include stimulants, sedative-hypnotics, and other controlled substances The member requires s psychiatric evaluation to determine if psychotropic medications would be an

4 MENTAL AND BEHAVIORAL HEALTH SERVICES How to Refer Our Members Psychcare is the health plan s partner for mental and behavioral health services. It is a managed behavioral health care organization and it does not provide direct care. However, Psychcare authorizes services, coordinates all treatment and pays claims directly to providers in its network, which includes: Psychiatrists Doctorate level licensed psychologists Masters level licensed clinicians Inpatient treatment programs You may determine that a member can benefit from Psychcare s services when: The member requires an assessment of their current psychotropic medications, which may include stimulants, sedative-hypnotics, and other controlled substances The member requires s psychiatric evaluation to determine if psychotropic medications would be an appropriate treatment option The member requires an acute non-life threatening crisis The member may benefit from psychotherapy to deal with acute or chronic stressors The member has a severe and persistent mental illness The member has an eating disorder However, members may be referred to Psychcare without an underlying mental health issue. PCPs may refer to the psychiatrist when there are questions regarding a particular medication or if assistance is required to wean members off of specific medications. In addition, a psychiatrist can do a thorough screening if abuse of misuse of medications is suspected. In order for a behavioral health specialist to share information with a PCP, the member is required to sign specific consent for the release of such information. A PCP may facilitate the exchange of information by having the member sign the release in the office and faxing it to the behavioral health provider, if known. Please be sure that the release of information is HIPAA compliant. The member requires evaluation and treatment for substance abuse Psychcare Psychcare s business hours are weekdays 8:30 am - 5:30 pm. During this time, Psychcare can assist both members and providers with questions regarding access to behavioral health services and give referrals to all levels of care, as determined to be appropriate. A fax referral form and a PCP guide for behavioral health services can be found on the Psychcare website at If a PCP is seeking assistance with a medication question, a board certified psychiatrist is available during normal business hours by calling Psychcare is also available after hours and on weekends for urgent or emergent services. A clinician will respond to the call within 30 minutes. If you have a member who is in CRISIS, please call 911 prior to calling Psychcare. 4 America s 1st Choice HMO Provider News TTY: 711

5 Keeping diabetic patients out of the coverage gap is a big challenge. Here are a few tips that may help them stay on their treatment all year long. MIND THE GAP The Prescription Coverage Gap or Donut Hole May Affect Diabetes Treatment Success 1. Use generics which would include Novo-Relion insulin, available at WalMart. Avoid Tier or 3 brand names, if possible 3. If your patient requires Lantus, Levimir, Humalog or Novolog, the only inexpensive insulin when in the donut hole is Novo-Relion In 015, the Coverage Gap cost for members is 45% for brand drugs and 65% for generics. What you prescribe may result in your patient reaching the donut hole quicker. Please consider the following to prevent undue costs for your patient: 1. Talk to your patients about drug costs. Avoid samples (and/or consider the price prior to offering a drug sample) 3. Prescribe a 90-day supply 4. Recommend that they use their over-the-counter benefit While not all patients have this benefit as part of their plan, those that do can save hundreds per year by ordering items such as Nasacort OTC or Flonase and other health care items. Our Member Services department will be glad to assist them in using this benefit. HIGH RISK DRUGS FOR THE ELDERLY These Three Medications Pose Tremendous Safety Issues for Our Members Description Drug 015 Tier Nonbenzodiazepine hypnotics (include when cumulative day supply is >90 days) Skeletal Muscle Relaxants (as a single agent or as part of a combination product) Tertiary TCAs (as a single agent or as part of a combination product) Eszopliclone (Lunesta) Zaleplon, Non-Formulary 3 Zolpidem Carisoprodol, Non-Formulary 3 Cyclobenzaprine Methocarbamol, Non-Formulary 3 Amitriptyline Doxepin 3mg, 6mg, Non-Formulary 3 Imipramine Tier 3 Prior Authorization 1 Step Therapy Prior Authorization Prior Authorization Prior Authorization Special Quantity Limits Zolpidem is limited to 90 tabs per benefit year. Quantities >90 tabs are classifed as high risk. Cyclobenzaprine 90tabs/30 days Doxepin quantities >6mg/day are classified as high risk. Alternative(s) Discuss sleep hygiene and avoidance of caffeine, alcohol, nicotine and medications that cause insomnia. Evaluate for depression, a common cause of insomnia in the elderly. Secondary insomnia can be treated with trazodone 50 mg (may cause orthostatic hypotension). Quetiapine 5mg, 50mg although not FDA approved has been used. Over-the-counter option: melatonin, if appropriate; regarded as safe in recommended doses (up to 15 mg daily) for up to two years. Baclofen Tizanidine Nonpharmacologic treatment for muscle spasms: heat, massage, stretching & exercise. Citalopram Escitalopram Fluvoxamine Sertraline Venlafaxine Alternatives 015 Tier Summer (except Melatonin which can be obtained through the OTC benefit) Additional information for calculation of cumulative days supply and average dose: Use the first two prescription fills to calculate average daily dose of the medication with the following equation: (quantity dispensed x dose) / days supply. 1 Prior Authorization - Plan approval is necessary prior to the delivery of care. (Generally, this is different from a referral in that, an authorization can be a verbal or written approval from the Plan whereas a referral is generally a written document that must be received by a doctor before giving care to the patient.) Step Therapy - Step Therapy is a process where a preferred prescription drug is filled first (Step 1). When appropriate, a more costly (Step ) medication can be authorized if the Step 1 prescription is not effective in treating the condition. In other words, Step prescription drugs will not be covered until Step 1 prescription drugs are first tried. 3 Non-Formulary - All non-formulary drugs require prior authorization. Source: PQA (Pharmacy Quality Alliance) Technical Specifications for PQA Approved Measures 014

ASSESSING YOUR PRACTICE FOR CULTURAL COMPETENCY Federal regulation requires that all physicians deliver healthcare services in a culturally competent manner.

Physicians must also assure that individuals with disabilities are furnished effective communication when making treatment option decisions.

Posting signs and providing educational materials with easy-to-read text, written in common languages encountered in your service area. Using nonverbal methods of communication (e.g., pictographic symbols) with patients who cannot speak English or whose primary language may not be English.

Being aware that direct or prolonged eye contact is considered disrespectful or aggressive in some cultures. Being aware that personal space requirements vary by culture.

6 ASSESSING YOUR PRACTICE FOR CULTURAL COMPETENCY Federal regulation requires that all physicians deliver healthcare services in a culturally competent manner. The health plan expects its network physicians to provide information and services to members in a manner that is respectful and responsive to unique cultural and linguistic needs. Physicians must also assure that individuals with disabilities are furnished effective communication when making treatment option decisions. The following are some examples of culturally competent practices that should be incorporated into your practice: Allowing extra time with patients for whom English is a second language. Posting signs and providing educational materials with easy-to-read text, written in common languages encountered in your service area. Using nonverbal methods of communication (e.g., pictographic symbols) with patients who cannot speak English or whose primary language may not be English. Accommodating and respecting patients unique values, beliefs and lifestyle choices when customizing treatment plans. Being aware that direct or prolonged eye contact is considered disrespectful or aggressive in some cultures. Being aware that personal space requirements vary by culture. The Bureau of Primary Health Care (BPHC), the Health Resources and Services Administration (HRSA), and the U.S. Department of Health and Human Services (DHHS), in conjunction with Georgetown University, have created a tool for physicians to assess their practice for cultural competency. This self-assessment tool benefits physicians by enhancing awareness, knowledge and skills of cultural competency, and by informing physicians of opportunities for improvement both at the individual and organizational levels. You may download the cultural competency tool at georgetown.edu/resources/assessments.html. There are also many other free resources online which offer accredited continuing education programs on culturally competent practices. The following sites identify needs and opportunities in your practice, as well as how to implement cultural and linguistic appropriate services. Office of Minority Health website featuring Communication Tools and Education Resources: Health Resources and Services Administration (HRSA) of the U.S. Department of Health & Human Services website for Culture, Language and Health Literacy: MEMBER RIGHTS & RESPONSIBILITIES The health plan strongly endorses the rights and responsibilities of members as described by State and Federal laws. The health plan expects providers to adhere to member rights, including treating members with the utmost courtesy and respect, advising members on preparing advance directives and protection of their need for privacy. The health plan distributes Member Rights and Responsibilities to Member upon enrollment and on an annual basis through other member materials. For a full list of Member Rights and Responsibilities, please refer to our website at the following location: > About Us > Quality Management > Member Rights and Responsibilities 6 Visit our website at for a wealth of health plan information. Here are a few highlights: Claims Information: Providers > Tools & Resources > Claims Clinical Health Guidelines: Providers > Clinical Health Resources > Clinical Practice Guidelines Forms: Fraud, Waste & Abuse: Appeals & Grievances: Providers > Tools & Resources > Forms Quick Links > Fraud, Waste & Abuse Quick Links > Appeals & Grievances Medical Record Standards: About Us > Quality Management > Medical Record Standards Newsletters: Providers > Provider Newsletters Preventive Health Information: About Us > Quality Management > Preventive Health Information America s 1st Choice HMO Provider News TTY: 711

IS YOUR INFORMATION CURRENT ON THE CAQH DATABASE? This past spring, the Council for Affordable Quality Healthcare (CAQH) launched its new CAQH ProView database.

CAQH alerted providers of the following: Providers with incomplete applications need to complete and attest to any outstanding applications prior to the transition to CAQH ProView.

Providers must enter and complete their information online. Paper versions of the credentialing application are no longer accepted.

7 IS YOUR INFORMATION CURRENT ON THE CAQH DATABASE? This past spring, the Council for Affordable Quality Healthcare (CAQH) launched its new CAQH ProView database. If you are a CAQH user, you may have received notifications on the action items listed below to help prepare you for the transition from UPD to ProView. CAQH alerted providers of the following: Providers with incomplete applications need to complete and attest to any outstanding applications prior to the transition to CAQH ProView. Unattested data will not convert into CAQH ProView. CAQH ProView requires an address for all providers as a primary method of contact. Providers must enter and complete their information online. Paper versions of the credentialing application are no longer accepted. If you have not already done so, please follow CAQH instructions so that we may continue to download your information for re-credentialing purposes. The health plan s access to your current and complete information via CAQH ProView will facilitate a smooth and timely re-credentialing process. Remember to Update Your Practice Information If you require a practice update or correction, please use our Provider Update Form to submit your changes. A copy of the form is available on the website or in your Provider Manual and it can be mailed or faxed to us at or How to Identify the Plan-type for Our Members <INSERT PLAN NAME> RxBIN#: <XXXXXX> RxPCN#: <XXX> RxGrp#: <XXXXXXXX> Issuer#: <XXXXX> RxID#: <Insert member ID#> Member Since ID: < > <0000> <FIRST><MI><LAST> This portion of the ID card s front panel will show if the member belongs to our HMO, PPO or PFFS Plan. Eff. Date: <XX/XX/XXXX> PCP: <FIRST> <LAST> Phone: <XXX-XXX-XXXX> H PBP - <XXX> ACCESS STANDARDS Our network physicians ensure the availability of services to members on a 4-hour per day, 7-day per week basis, including arrangements for coverage of members after hours or when the physician is otherwise unavailable. The following criteria comply with access standards as set forth by the Centers of Medicare & Medicaid Services (CMS): 1. Primary Care Providers should: Provide medical coverage 4-hours a day, seven days a week; Scheduled appointments should be seen within 30 minutes; Schedule emergent referral appointments immediately; Schedule sick care appointments within one (1) week; and Schedule wellness visits within one (1) month.. Specialty Care Providers should: Schedule emergent referral appointments immediately; Schedule urgent referrals within 4 hours; Schedule sick care appointments within one (1) week; and Schedule wellness visits within one (1) month. In the event participating providers are temporarily unavailable to provide care or referral services to members, they should make arrangements with another health plan-contracted and credentialed physician to provide these services on their behalf. Please refer to your Physician Agreement or the Provider Manual for more information. Summer

..page 5 HIGH RISK DRUGS FOR THE ELDERLY These Three Medications Pose Tremendous Safety Issues for Our Members...page 5 ASSESSING YOUR PRACTICE FOR CULTURAL COMPETENCY.

..page 7 ACCESS STANDARDS...page 7 50 Berryhill Road, Suite 311, Columbia, SC CONNECT 910 Coming Soon... The New Provider Portal! Provider Relations Directory 1-888-563-389 TTY: 711 8am - 8pm, Mon.

8 AFC HMO Provider Newsletter AFC CONNECT Summer IN THIS ISSUE HEDIS What You Need to Know...page HEDIS AND CMS PART D REMINDERS TO YOUR PATIENTS...page 3 EASY HEDIS WINS...page 3 MENTAL AND BEHAVIORAL HEALTH SERVICES How to Refer Our Members...page 4 PHARMACY SERVICES - MIND THE GAP The Prescription Coverage Gap or Donut Hole May Affect Diabetes Treatment Success...page 5 HIGH RISK DRUGS FOR THE ELDERLY These Three Medications Pose Tremendous Safety Issues for Our Members...page 5 ASSESSING YOUR PRACTICE FOR CULTURAL COMPETENCY...page 6 MEMBER RIGHTS & RESPONSIBILITIES...page 6 ON OUR WEBSITE...page 6 IS YOUR INFORMATION CURRENT ON THE CAQH DATABASE?...page 7 HOW TO IDENTIFY THE PLAN-TYPE FOR OUR MEMBERS...page 7 ACCESS STANDARDS...page 7 50 Berryhill Road, Suite 311, Columbia, SC CONNECT 910 Coming Soon... The New Provider Portal! Provider Relations Directory TTY: 711 8am - 8pm, Mon. - Fri. Your America s 1st Choice Provider Relations Team (please press option 6, then the extension) Name Title Office Number Ext Fax Jane Young Assoc. Vice President of Provider Relations (888) (803) jyoung@americas1stchoice.com Jennifer Marchant Manager Provider Relations (888) (803) jmarchant@americas1stchoice.com Judy Legg Provider Relations Representative (Upstate 864 Area Code) (888) (803) jlegg@americas1stchoice.com Lisa Sox Project Coordinator HEDIS/MRA (888) (803) lsox@americas1stchoice.com Regina Meade Provider Relations Representative (Midlands Area Code) (888) (803) rmeade@americas1stchoice.com Zachary Johnson Provider Relations Representative (888) (803) zjohnson@americas1stchoice.com

provider Pre-Certification Requests INSIDE HEDIS WHAT YOU NEED TO KNOW

provider Pre-Certification Requests INSIDE HEDIS WHAT YOU NEED TO KNOW news provider Freedom Health Optimum HealthCare Provider News Summer 2015 How to Submit a Referral or a Pre-Certification Request Primary Care Physicians (PCPs) should provide a referral for specialized