Totally Connected. Celebrating 40 Years of Serving the Community

Transcription

1 Celebrating 40 Years of Serving the Community Totally Connected. A newsletter for THC Physician Offices THC Growing, Changing, Working to Better Serve You! At THC, we value our relationship with our growing Provider community. Along with significant membership growth in 2012, THC expanded our network by adding over 1500 physicians and partnering with Value Options and its 900 mental health specialists. To make doing business with THC even easier, we simplified access to care by removing referral requirements for most services. Claims are processed and paid in under 10 days! Our product lines have expanded to include Medicare membership, and now we are working to improve outreach to our physician community. Look for our quarterly newsletter to provide in depth information about THC and what s going on in health care. THC remains committed to help you better serve our patients. Coming soon you can expect: Improved online tools Improved referral / authorization guidelines Updated Provider Manual Redesigned web site 2013 will be an exciting year for THC and our provider community. Thanks for participating with us and we look forward to a strong partnership to improve health care! MISSION: Our mission is to be the industry leader in providing quality cost effective healthcare for our members 1

2 Affordable Care Act Increases Rates for Certain Primary Care Services As you know, health care reform in 2013 and 2014 provides for increased payment for physicians performing primary care services when treating Medicaid members good news for our provider community! What does this mean for you? Physicians who are board certified in internal medicine, family medicine or pediatrics are eligible for reimbursement at Medicare rates for Evaluation and Management (E & M) codes, regardless of the specialty in which they currently practice. Since many of our PCPs participate with THC under a capitation model, this payment increase will be reimbursed as a pass through adjustment payment, rather than an incremental raise to the capitation rate. The Department of Community Health will determine the method of passing this enhanced payment to the health plans, and THC will subsequently communicate the downstream arrangement with each provider and IPA group, including those who are currently paid fee for service. These enhanced arrangements are likely not expected until 3 rd quarter 2013, but will reflect dates of service back to January 1, Requirements for the enhanced payment: Board certification in either internal medicine, family medicine, pediatrics Registered on CHAMPS by end of May Actively participating in primary care services based on claim volume Product Overview Total Health Care offers a suite of products including HMO, inclusive of MIChild, CSHCS (Children s Special Health Care Services), Medicare/Medicaid Dual Eligible, Total Medicare Plus (Medicare Advantage Special Needs Plan) and Total Select USA POS. Our HMO plan requires members to choose a Primary Care Physician and also requires referrals for certain Total Select USA and Cofinity Why is the Cofinity logo on the back of THC ID Cards? THC has contracted with Cofinity to provide a wrap network for our commercial POS product only. If you are a contracted provider with THC, then you are also contracted with Total Select USA. Do not file your claims with Cofinity. Cofinity prices claims for out of network services. THC is the payer for services performed through the Cofinity network. services. Network restrictions apply for particular services in particular lines of business, including but not limited to DME, behavioral health and hearing aids. Providers can contract for all lines of business by calling Back of ID Card 2

3 Foster Children and ESPDT Screenings Requirement Effective April 1, 2013, all children in foster care up to the age of 21 must receive a complete medical examination from a PCP within 30 days of entering foster care. The exam is required whether or not previously completed prior to the child entering foster care and must follow Medicaid ESPDT/Well Child preventive screening and American Academy of Pediatrics (AAP) Bright Futures guidelines. To ensure the appointment timeline is met, the foster parent will identify the patient and will provide a completed Department of Human Services (DHS) Consent to Routine, Non Surgical Medical Care and Emergency Medical or Surgical Treatment form. PCP will perform a psychosocial/behavioral health assessment and make appropriate recommendations for follow up with a mental health professional, as necessary. If the PCP determines there is a mental health diagnosis, no psychotropic medication can be prescribed until an informed consent document is signed by an appropriate party which means either the birth parent, the child if over the age of 18 years or the legal guardian. A foster parent cannot consent to the administration of psychotropic medications. For more information, refer to the Michigan Department of Community Health bulletin MSA ******************************************************** Credentialing Process Total Health Care has established minimum standards for participation in its contracted provider network. Providers (MD/DO/DDS/DPM/DC) are required to sign a contract, submit a completed Physician Credentialing Application and/or allow THC to access the CAQH application online. Upon primary source verification of required documents, an office site visit will be conducted to assess minimum office requirements, including safety and record keeping. Additional inquiries will be made to the National Practitioner Data Bank and Healthcare Integrity and Protection Data Bank. All of the aforementioned information is then reviewed by the Credentialing Committee. Upon approval by the Committee, which is comprised of participating physicians, providers receive a Welcome Letter and effective date with the plan. ATTN PHYSICIANS: Effective in May: The Michigan Dept of Community Health has mandated that Physicians who are not registered with CHAMPS will be unable to write prescriptions for any Medicaid Managed Care or FFS member. This includes Total Health Care patients. To avoid potential adverse continuity of care issues register NOW. 3

4 Medical Management ~ Quality Reporting Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents ~ Document for Improved Score in PRO HEDIS THC follows the HEDIS measure Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents. Clinicians are asked to document and report annually in conjunction with an outpatient office visit on assessment of this information for patients 3 to 17 years of age, as indicated below: Measure CPT/ HCSPCS Diagnosis Documentation Code Code BMI V85.5 Plot on growth chart. Adolescents 16 and 17 years BMI value only Nutrition Counseling G0270, G0271 V65.3 Discussion of current nutritional behaviors; provision of educational materials S9449, S9452 S9470 Physical Activity Counseling S9451 V65.41 Discussion of current physical activity; provision of educational materials Because pediatric obesity has been steadily increasing over the last decade and overweight children are at increased risk of becoming obese adults, THC is emphasizing the importance of early and routine intervention, including promotion of healthy eating and frequent exercise to combat future serious health complications of heart disease, diabetes and hypertension. Help Boost Lead Testing Scores THC has partnered with MedTox to provide blood lead screening. Providers can order free test kits to be delivered directly to the office when initially registering through THC. A simple finger stick with two blood droplets on filter paper is all that is needed. Collect the specimen, mail in the postage prepaid envelope, and results are ready within 3 days. MedTox will send results directly to the PCP and THC to ensure you receive credit and earn your Pay for Performance Incentive! Guidelines: Test children 12 months up to their 2 nd birthday to meet HEDIS measure. Additional recommendation is for testing children 2 3 years. Meaningful Use Capturing and reporting BMI information on your patients is a requirement for Meaningful Use. Most quality measures are aligned with your opportunity to meet either PQRS measures for Medicare or MU measures, as well. Call us at if you have any questions about how to capture this information in your EMR or electronic disease registry. 4

5 2013 PRO HEDIS ~ PAY FOR PERFORMANCE PROGRAM Below are the specifics of THC s Pay for Performance Incentive Program, which has been revamped for 2013 and will be updated on the Provider Portal during the month of April. Bonus incentive rewards per measure will be paid out twice yearly (July and December). Log on to the Provider Portal available at totalhealthcareonline.com to access your PRO HEDIS information, including assigned members who are due for services. You may self report services and the data will be refreshed on the web site every Thursday. If you need assistance, contact Provider Relations at Calling all Registries did you know that THC can accept an excel file from your registry to self report Quality Metrics for PRO HEDIS? It s an easy way to improve your scores and increase your P4P payment. Contact us for details! Category Measure Bonus Criteria Child and Adolescent Care Immunizations Childhood Combo 3 4 DPT or Dtap $ , 90700, 90721, IPV $ , 90713, MMR $ , HIB $ , 90698, 90721, Hepatitis B $ , 90740, 90744, 90747, TOTAL BONUS OPPORTUNITY $105 Adolescent Combo 1 1 Meningococcal $ , Tdap/TD $ , 90714, 90715, New 1 MMR $ , Female 3 HPV $ , TOTAL BONUS OPPORTUNITY $60 Well Visits 0 to 15 months 1 5 visits $10 0 to 15 months 6th visit $ years $15 New Adolescent years $15 TOTAL BONUS OPPORTUNITY $100 Lead Screening 12 months up to 2 years $ Women's Care 5

6 Breast CA Screening Mammogram $25 Cervical CA Screening Pap smear $25 Chlamydia Screening years $25 Diabetes Comprehensive Diabetes Care Retinal Eye Exam $25 Report CPT II 2022F, 2024F, 2026F or 3072F LDL C test $25 A1C test $25 Monitoring for nephropathy $25 Report 3060F, 3061F, 3062F, 3066F or 4009F New Controlling High Blood Pressure $15 Report 4050F, 3074F 3080F New Completion of Diabetes Care measures above plus LDL C < 100 mg/dl & A1C < 7% $50 Report CPT II 3044F & 3048F TOTAL BONUS OPPORTUNITY $200 Colorectal Care Colorectal CA Screening Fecal Occult Blood test $20 Flexible Sigmoidoscopy $20 Colonoscopy $20 Asthma New Appropriate asthma medications $15 Report 4015F Children s Special Health Care Services (CSHCS) Physicians who have contracted to participate with this specific patient population need to be especially aware of concerns related to care coordination. Because of the complex care needs of a CSHCS patient, it is critical to involve the entire family in care plans and treatment options. Specific transportation and travel arrangements may apply for patients requiring treatment out of the local service area. PCPs should work with the family and care team members to refer patients based on family preferences, regardless of network concerns. Leniency in referrals should be given to ensure continuity, quality and timeliness of care. The Department of Community Health has reported specific concerns about abrupt medication and treatment plan changes without family and care team involvement. Therefore, CSHCS patients (THC group numbers M3000 and M3500) should be appropriately identified within your practice. Contact our CSHCS Care Coordinator, Natalie Burke, at

7 Successful Tips on use of THC Online Provider Portal: 1. When registering or signing on, remember that your PAYER ID is the same as Physician or Provider ID. 2. Always have your screen zoom set to 100% to access all dropdown menus. 3. Access EOPs (Explanation of Payment) exclusively through the Portal. Enter the Check Number and no other data for easiest retrieval of information. 4. Use the portal to help direct specialty referrals to innetwork providers. You may search by provider name or specialty and pare down the search using zip code and mileage range. 5. Edit or amend a referral ~ when done via the portal, copy the existing referral and then add additional service lines. This will generate a new Referral number, but will not terminate the prior referral. 6. PT/OT/ST Referrals: process for the evaluation only. Specific treatments will be requested and authorized through Navant ~ our vendor for rehab services. 7. Use Page 11 of this newsletter to register for the Portal as a 1 st time user to assist you with care coordination and specialized community resources to address the specific care needs of CSHCS patients. Referrals and Authorizations ~ What, When and How THC continues to respect and support the role of the Primary Care Physician to direct and deliver the appropriate patient care at the appropriate time and place. Based on feedback, THC previously removed the administrative burden of processing referrals for specialty care. Now we have further refined our processes to help you know when a referral or authorization is required. Visit totalhealthcareonline.com via the Provider Page to view our enhanced referral and authorization rules, which provide greater detail regarding particular services and the corresponding referral or authorization requirements. UPDATE: As of March 1, 2013, referrals are no longer required for clinic charges at hospitalbased locations. This aligns with the no referral policy for specialty offices!!! Navant (formerly known as Pravant) New contact #s for referral /authorization requests effective April 1: Fax: Phone: Navant is our Rehabilitation Education Vendor that authorizes therapy treatment for Physical, Occupational, Speech Therapy 7

8 Member Rights and Responsibilities All contracted THC providers are required to comply with the following Rights & Responsibilities for all THC members. If a THC member fails to follow this code of conduct, please notify Customer Services at Members have the right: To get information about Total Health Care, its services, its providers and member rights and responsibilities. To make recommendations regarding Total Health Care s member rights and responsibilities policy. To be treated with respect and dignity. To have privacy while receiving care. To take part with doctors in decisionmaking about their health care, including the right to refuse treatment. To talk openly about treatment options regardless of cost or benefit coverage. To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation. To be free to exercise their rights without adversely treatment. To be free from other discriminations prohibited by State and Federal regulations. To receive healthcare services consistent with their contract, State and Federal regulations. To voice their complaints or grievance/appeals about Total Health Care or the care provided. Members have the responsibility: To receive all their health care services through Total Health Care. To understand their healthcare benefits. To provide THC and its providers with the information needed for their care. To help their doctor decide what treatment will work best. To follow the care plan and instructions agreed upon with their doctor. To respect the rights of other patients, doctors and staff of Total Health Care. Advanced Directives The Patient Self Determination Act 1990 allows competent adults the right to make decisions concerning medical care, including the right to accept or refuse any medical or surgical treatment and the right to formulate Advance Directives. Advance Directives are instructions given by individuals specifying what actions should be taken for their health in the event that they are no longer able to make decisions due to illness or incapacity. PCPs are asked to encourage members, as appropriate, to plan for medical care in the event of loss of decision making ability by developing a Living Will or Durable Power of Attorney for Health Care. A copy of the directive should be maintained in the patient s medical record. A copy of the Advance Directive Michigan Notice to Patient can be found at totalhealthcareonline.com / Members; More Options, or contact the Provider Relations Department at Language Interpretation Services Available Total Health Care will make language interpretation services (either written or spoken) available to members in any setting (ambulatory, inpatient and outpatient). If one of your patients requires services, contact us at Race/Ethnicity/Language Proficiency for Network Providers THC collects and reports on R/E/L and will publish practitioner language information in our provider directory. ATTENTION Providers and Office Managers: Please provide your address to ensure you receive the most upto date information! Please complete page 10 of this newsletter and return via fax 8

9 Autism Screening & Referral Requirements for Medicaid and MiChild Members The American Academy of Pediatrics endorses the early identification of developmental disorders as essential to the well being of children and their families. Early detection and treatment of Autism Spectrum Disorder (ASD) can have a significant impact on a child s development and help ensure appropriate intervention and positive outcomes. Therefore, PCPs for all THC Medicaid and MiChild members (Products M01 and M08, Groups M1000, M1500, M1006, M2000, M2500, M3000, M3500, M8000) aged 18 months through 5 years are required to use a validated screening tool as part of a well child exam to assess for ASD. Tools, such as the M CHAT (Modified Checklist for Autism in Toddlers for 16 through 30 months) or SCQ (Social Communication Questionnaire for children 30 months through age 4) can be completed by the parent and reviewed at the well exam by the PCP. If further evaluation is necessary, the PCP must contact one of the Pre paid Inpatient Health Plan s (PIHP) listed below for a follow up evaluation. The PIHP will contact the child s parent(s) to arrange for a follow up appointment for a diagnostic evaluation. PCPs report completion of the assessment using code with U5 modifier. Detroit Wayne County CMH Genesee County CMH Services Sandra Peppers, Act COO Danis Russell, Exec. Director 640 Temple, 8 th FL 420 West Fifth Avenue Detroit, MI Flint, MI (24 hrs) (24 hrs) Macomb County CMH Services Oakland County CMH Authority John Kinch, Exec. Director Jeff Brown, Exec. Director Hall Road 2011 Executive Hills Blvd Clinton Township, MI Auburn Hills, MI (24 hrs) (24 hrs) Process for Commercial HMO members: PCPs should follow the same screening process as defined above, but make referrals for diagnostic evaluations by contacting: Value Options (24 hrs) Home Health Care Plan of Care Upon initiation of a PCP referral, Home Health Agencies (HHCA) are now required to develop a patientspecific Plan of Care based on an initial nursing assessment (with both subjective and objective data that support the diagnosis), risk factors, expected outcomes/goals, and nursing interventions. The Plan of Care is then presented to the PCP for approval and signature. HHCA are asking physicians to expedite review and signature of these documents to facilitate timely patient care as well as allow for reimbursement of their services. Medicare will not reimburse HHCA for treatment without a signed Plan of Care. 9

10 Physician Attention Drug Formulary Updates Effective April 2013 Total Health Care s Pharmacy and Therapeutics Committee met in March 2013 and made the following Formulary updates: Prenatal Vitamins added to Medicaid, Commercial, MIChild and CSHCS Formularies Atabex EC Obstetrix DHA Prenatal Vitamins Atabex Prenatal One A Day Women s Prenatal Prenatal U Brainstrong Prenatal Perry Prenatal Prenatabs OBN Calna Prenatal Profe Forte Clinical Nutrients Prenatal Formula Prenatal 19 Purefe OB Plus CVS Prenatal Multi+DHA Prenatal 19 Chewable RA One Daily CVS Women s Prenatal+DHA Prenatal And Iron Similac Prenatal Early Shield EZFE Forte Prenatal Formula A Free Stuart Prenatal + DHA GNP Daily Prenatal Pre Natal Formula Taron BC KPN Prenatal Forte Theranatal Complete KPN Prenatal Prenatal Plus DHA Triveen U Marnatal F Prenatal+DHA Vitane Calcium Maranatal F Plus Duo Pack Prenatal Multi+DHA Vinate II Nutricion Porvida Prenatal Multivitamin + DHA Vita Pren Quantity Limits on Acetaminophen Products Prescriptions with acetaminophen containing medications will have an edit to not allow more than 4 grams per day to be dispensed. This is consistent with FDA licensure of acetaminophen and is a patient safety concern. The edit will be in place by mid April. Pharmaceutical Management Procedures Please visit THC s web site at totalhealthcareonline.com to view the Condensed and Expanded Drug Formularies for Medicaid, MIChild, CSHCS and Commercial Members. THC s pharmaceutical management procedures regarding generic substitution, step therapy, quantity limits and prior authorization are listed under the Expanded Formulary tab. If you would like copies of the formularies or pharmaceutical management procedures, call the Pharmacy Department at , extension 300. Catamaran, formerly known as Catalyst Rx, is THC s Pharmacy Benefit Manager is available for questions at You may fax prior authorization requests to

11 Stay Totally Connected: Please complete this page with required office information and addresses and fax to: Name of Office: Address Location: City, Zip: Phone: Fax: Physician Name(s) Office Manager Name THC will not share s. s will be used to communicate THC business only, including Provider Bulletins, reports and PHI through a secured server, when necessary. 11

12 Provider Portal Registration Request Totalhealthcareonline.com Please complete all the information below to register for the THC Provider Portal. This portal promotes self sufficiency and immediate access to information through a secure, electronic format. The following information is available: EOP / Remittance Advice (available exclusively online) Referrals (processing requests and viewing approved referrals) Pro HEDIS (Quality Measures) Claims Member Eligibility Log on to totalhealthcareonline.com: Select Providers tab; then select Log in to the Provider Portal. After login, select Provider tab and then Provider Checks to view EOPs. Preferred User Log on: Alternate User Log on: Last Name: First Name: Tax ID: NPI No.: I am a (check one): PCP Specialist Payee/Biller/Other Contact Name: Contact Phone: Preferred Hours to contact: 12

13 Total Health Care Contact Information Provider Contracting Gary Francis Susan Ryan Provider Relations Judith Idris Anita Wallace CSHCS Coordinator Natalie Burke Customer Service Angela Counsman Claims LaDawn Wyatt Utilization Management Pharmacy Department , ext 300 Catamaran Pharmacy Benefit Manager