Diabetes Management and Community Health Alliance

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Beryl Wheeler
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1 VOLUME I Issue No. 2 The latest information for providers in the Community Health Alliance network. Diabetes Management Community Health Alliance According to a study commissioned by the American Diabetes Association 1, the total estimated cost of diabetes in the U.S. in 2012 was $245 billion. That number includes $176 billion in direct medical costs $69 billion in reduced productivity. This amount indicates a 41 percent increase since Community Health Alliance (CHA) takes these statistics seriously that is why we have disease management programs integrated into our health plans. Our diabetes management program is focused on patients diagnosed with diabetes with an A1C > 7.0 a fasting glucose greater than 125. When you refer a patient to the program, a trained coach will contact your patient. Goals are set by you, your patient coach. The coach will help the patient identify what motivates them to change unhealthy habits will encourage lifestyle choices that lead to improved compliance outcomes. Together patients their coaches celebrate each small step leading toward a healthier lifestyle. To refer a patient to our diabetes management program, call Customer Service at Additional information about the CHA disease management programs is available in your Provider Manual located at or by calling to receive a hard copy. Tennessee - Number of Adults (18 years or older) with Diagnosed Diabetes, By Age Centers for Disease Control Prevention: National Diabetes Surveillance System. Available online at: 1 American Diabetes Association. Economic costs of diabetes in the U.S. in Diabetes Care 2013; 36:

Additional Support for Patients With Complex Health Needs Patients who have life-threatening or multiple chronic diseases may feel overwhelmed.

The program is voluntary provided at no additional cost to the patient.

2 Additional Support for Patients With Complex Health Needs Patients who have life-threatening or multiple chronic diseases may feel overwhelmed. Their care may require services from many different health care disciplines. The CHA Complex Case Management Program is designed to alleviate those feelings to support both the patient the physician. The program is voluntary provided at no additional cost to the patient. Your patient may be eligible for the program if they: Need or have had an organ transplant Have unstable HIV/AIDS /or exacerbations of degenerative disorders Suffer with a terminal disease are facing end-of-life decisions Require coordination of multiple services assistance with transition along the continuum of care Need assistance with physical or developmental disabilities, serious mental illness, multiple chronic conditions or severe injuries Additional information about the program may be found in your Provider Manual at You may call to refer patients to the complex case management program. A nurse case manager will contact your patient begin providing him or her with some peace of mind. From the Desk of the Director of Provider Relations On behalf of the entire staff of Community Health Alliance, I d like to thank you again for your participation in our health plan. Our Chief Medical Officer clinical team are eager to share their innovative approach to complex case disease management with you your patients who may require this level of care. There are several diseases/conditions included in our medical management programs. In this issue we focus on diabetes. The medical management team s goal is to support you your patient to reach his or her optimum health outcome. Referring a patient to our complex case or disease management program is simple. You can either call Customer Service at or secure fax a patient referral on your letterhead to our clinical team at Kim Carter kcarter@chatn.org Understing the Appeals Process You may act on your patient s behalf to appeal an adverse determination by utilization management. The appeal must be submitted to CHA by calling Customer Service at or mailing to Community Health Alliance, P.O. Box 34161, Little Rock, AR within 180 days from the date the adverse determination was received. First level appeals are hled by CHA. Second level appeals are sent to an Independent Review Organization (IRO) chosen by the Tennessee Department of Commerce Insurance. Stard appeals are resolved within 30 days. We recommend that you request an expedited appeal if the stard time frame will seriously jeopardize the life or health status of your patient or their ability to regain maximum function. Expedited appeals are resolved within 72 hours. The appeals process, in its entirety, may be found in your Provider Manual at or by calling Customer Service at Clinical Practice Guidelines Community Health Alliance provides guidelines to our provider partners for use in determining appropriate health care for specific clinical circumstances behavioral health services. Our approved adopted guidelines are evidence based known to be effective in improving health outcomes. They are reviewed a minimum of every two years are updated when new scientific evidence or national stards are published. The guidelines may be found in the Provider Manual located at If Internet access is unavailable, call Customer Service at to request a hard copy. Community Health Alliance has approved adopted minimum clinical practice guidelines for: Non-preventive acute or chronic medical conditions; diabetes coronary artery disease Behavioral health conditions, either preventive or nonpreventive; major depression ADHD Preventive health guidelines for perinatal care, children adults DIABETES Diabetes Care Jan;36 Suppl 1:S doi: /dc13-S100. National stards for diabetes self-management education support. Haas L, Maryniuk M, Beck J, Cox CE, Duker P, Edwards L, Fisher EB, Hanson L, Kent D, Kolb L, McLaughlin S, Orzeck E, Piette JD, Rhinehart AS, Rothman R,Sklaroff S, Tomky D, Youssef G; 2012 Stards Revision Task Force. Diabetes Care Jan;35 Suppl 1:S doi: /dc12-s011. Stards of medical care in diabetes American Diabetes Association. CORONARY ARTERY DISEASE AHA/ACC Guidelines for Secondary Prevention for Patients With Coronary Other Atherosclerotic Vascular Disease: 2006 Update. Endorsed by the National Heart, Lung, Blood Institute. Sidney C. Smith Jr, MD; Jerilyn Allen, RN, ScD; Steven N. Blair, PED; Robert O. Bonow, MD; Lawrence M. Brass, MD; Gregg C. Fonarow, MD; Scott M. Grundy, MD, PhD; Loren Hiratzka, MD; Daniel Jones, MD; Harlan M. Krumholz, MD; Lori Mosca, MD, PhD, MPH; Richard C. Pasternak, MD; Thomas Pearson, MD, MPH, PhD; Marc A. Pfeffer, MD, PhD; Kathryn A. Taubert, PhD. Circulation.2006; 113: doi: /CIRCULATIONAHA DEPRESSION Major depression in adults in primary care. Bibliographic Source(s) Trangle M, Dieperink B, Gabert T, Haight B, Lindvall B, Mitchell J, Novak H, Rich D, Rossmiller D, Setterlund L, Somers K. Major depression in adults in primary care. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2012 May. 119 p. [320 references] ATTENTION-DEFICIT/HYPERACTIVITY DISORDER ADHD: clinical practice guideline for the diagnosis, evaluation, treatment of attention-deficit/ hyperactivity disorder in children adolescents. Subcommittee on Attention-Deficit/Hyperactivity Disorder, Steering Committee on Quality Improvement Management, Wolraich M, Brown L, Brown RT, DuPaul G, Earls M, Feldman HM, Ganiats TG, Kaplanek B, Meyer B, Perrin J, Pierce K, Reiff M, Stein MT, Visser S. ADHD: clinical practice guideline for the diagnosis, evaluation, treatment of attention-deficit/hyperactivity disorder in children adolescents. Pediatrics 2011 Nov;128(5): PREVENTATIVE HEALTH GUIDELINES The ACOG Guidelines for Perinatal Care, 2013 seventh edition Editors Laura E. Riley, MD, FACOG Ann R. Stark, MD, FAAP. ICSI Guidelines for Routine Prenatal Care Interactive0712.pdf Adult Childhood Preventive Services Recommendations. U.S. Preventive Services Task Force. recommendations.htm Recommendations for Preventive Pediatric Health Care Bright Futures Guidelines (Hagan JF, Shaw JS, Duncan PM, eds. Bright Futures Guidelines for Health Supervision of Infants, Children Adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2008). PRIOR AUTHORIZATION ADDITIONS: The following have been added to the prior authorization list. View the complete list in your provider portal at Transplant services Chemotherapy Developmental evaluation & treatment Hyperbaric oxygen treatment Hospice Respiratory therapy after initial visit Cardiac rehab Implantable device incl. cochlear implants Proton beam therapy Page 2 Page 3

3 Utilization Affirmative Statement As a provider partner, you know that CHA encourages patient participation provider engagement in the coordination of care. That principle is reflected in our utilization policy. The policy maintains that medical management decision-making is based only on the appropriateness of care service existence of coverage does not specifically reward doctors or other individuals for issuing denials of coverage. Financial incentives for medical management decision-makers do not encourage decisions that result in under-utilization. Additional information about CHA s utilization policy is in your Provider Manual at or by calling Customer Service at Question: Can Your Patients Speak Directly With Utilization Management? Answer: Yes! Although your input is needed for most prior authorizations, your patients may also discuss any request with CHA by calling Monday through Friday from 8 a.m. to 5 p.m. Eastern time requesting utilization management. CHA will conference in translators for members needing language line service. Members with hearing loss may use their TTY machine by dialing 711 provide the communications assistant (CA) with the CHA customer service number which is found on the back of their ID card. They may also access the TTY service directly at Pharmacy Corner CHA wants doing business with us to be easy. That is why we have multiple ways for you to find information to assist your patients. You can access information using the Internet or by telephone. For telephone assistance, you may reach us 24 hours a day, seven days a week at If you prefer using the internet, we encourage you to go to register on the Provider Portal. After registering, you will have access to a wealth of information documents that may be useful when prescribing medications for our members. Information you will find online includes: Updated Formulary Abbreviated Pharmacy Listing Non-Formulary Exception Criteria Drug Prior Authorization Request Form Appeal Form Eligibility Verification Tool If you do not have access to the Internet need one of the forms or a paper copy of the formulary, please call us at Catamaran is the pharmacy benefit manager for CHA. Pharmacy questions related to prior authorization or appeal requests may be made to either CHA at or Catamaran at In the event of a Class I or Class II drug recall or a drug market withdrawal, Catamaran will notify your office via U.S. Mail, , or fax should you have an affected patient. It is critical that we have the correct fax number for you to receive these notifications. Please check the provider directory to verify your office fax number. If it is not current or you do not see your fax number listed, contact your provider relations manager with the correct number or use the contact us form on our Web page. When using this method, please make sure you select Provider Support in the Type field. Notification of formulary updates will appear Notification in the of formulary provider newsletter. updates will The most appear current in the provider copy of newsletter. the formulary The most recent current quarterly copy of the changes formulary to the formulary recent quarterly are available changes online to the formulary at www. cchpsc.org. are available If online you do at not have access If to you the do Internet not have access would to the like Internet a paper copy, would please like call a paper Customer copy, please Service call at Customer Service at Page 5

4 Your Provider Relations Team Ready To Assist The CHA Provider Relations (PR) team is ready to assist you with any questions you may have. Check the map below to find your area manager. SHELBY TIPTON LAKE LAUDERDALE DYER FAYETTE OBION CROCKETT HAYWOOD GIBSON HARDEMAN WEAKLEY MADISON MCNAIRY CARROLL HENRY HENDERSON CHESTER BENTON HUMPHREYS DECATUR HARDIN STEWART PERRY HOUSTON WAYNE MONTGOMERY HICKMAN LEWIS DICKSON LAWRENCE MAURY ROBERTSON CHEATHAM GILES DAVIDSON WILLIAMSON MARSHALL MACON SUMNER TROUS- DALE LINCOLN WILSON SMITH DEKALB RUTHERFORD CANNON BEDFORD MOORE COFFEE FRANKLIN WARREN CLAY JACKSON GRUNDY MARION PUTNAM WHITE VAN BUREN OVERTON SEQUATCHIE PICKETT BLEDSOE FENTRESS CUMBERLAND RHEA MEIGS HAMILTON BRADLEY SCOTT MORGAN ROANE MCMINN POLK CAMPBELL ANDERSON LOUDON MONROE UNION KNOX BLOUNT CLAIBORNE SEVIER HANCOCK HAWKINS GRAINGER HAMBLEN JEFFERSON COCKE GREENE WASHINGTON UNICOI SULLIVAN CARTER JOHNSON Provider Relations Managers by County Vivian Harris Patti Muccillo Valerie McDonald Jason Webb Page 4

5 445 S. Gay Street, Suite 101 Knoxville, TN CHA s Inclusive Quality Process CHA earned Interim Accreditation, a designation for new health plans, from NCQA in This achievement is formal recognition that CHA has the infrastructure formal processes in place to monitor, evaluate, improve care service delivery to our members. Our board of directors delegates authority for oversight of the quality program to the quality improvement committee (QIC). The QIC includes representation from the claims, customer service, technical support systems, information technology, provider relations, clinical operations pharmacy departments. The QIC s primary objective is to ensure processes are monitored, results evaluated, appropriate action plans are implemented to support enterprise wide awareness integration of quality activities. The objective serves both the member provider populations. Additional details regarding the CHA quality program evaluation are available in the Provider Manual at CHA Provider Credentialing Rights You, as a CHA provider, have the right to review the information obtained to evaluate your credentialing application, attestation or CV. Reviewable information includes all documents in the credentialing application as well as from outside sources such as from a malpractice insurance carrier or state licensing board. The reviewable information excludes references, recommendations or peer review protected information. CHA will notify you when there is a substantial variation in the credentialing information obtained from other sources from you. Though the source may not be provided, you have the right to correct erroneous information. You also have the right to request the status of your application. Detailed information about the application, credentialing re-credentialing processes may be found in the Provider Manual at or by calling Customer Service at If you have suggestions for future articles, we d love to hear from you. Contact Marie Parker at mparker@chatn.org. Community Health Alliance Mutual Insurance Company 2014

State of Tennessee. Department of State. Tennessee State Library and Archives 403 Seventh Avenue North Nashville, Tennessee (615)

State of Tennessee. Department of State. Tennessee State Library and Archives 403 Seventh Avenue North Nashville, Tennessee (615) Tre Hargett Secretary of State State of Tennessee Charles A. Sherrill State Librarian and Archivist Department of State Tennessee State Library and Archives 403 Seventh Avenue North Nashville, Tennessee