PROVIDER UPDATE NEWS FOR THE NETWORK May 2015 60-DAY NOTIFICATIONS Coverage Updates for Commercial Products Effective for dates of service on or after July 1, 2015, the following services will require prior authorization: } External mobile cardiovascular telemetry (CPT codes 93228 and 93229 only): This change is documented in the Medical Necessity Guidelines for Mobile Outpatient Cardiac Telemetry (MOCT). } Cryopreservation of sperm (89259): This change is documented in the medical necessity guidelines for Infertility Services for both Massachusetts and Rhode Island products. Commercial medical necessity guidelines are available in the Clinical Resources section at. DME Claim Edits Effective July 1 For dates of service on or after July 1, 2015, Tufts Health Plan will no longer compensate for additional units billed by any provider for a particular member when the number of units billed for a specific procedure or supply exceeds the assigned frequency. Specific DME and supply codes have been assigned a maximum number of units that may be billed within a specified time frame for a member by any provider. These unit settings are based on CMS regional LCDs and the DME Regional Carrier. Each DME and supply code included in this policy is assigned a maximum number of units for only one of the following time frames: } One month } Three months } Six months } One year This policy applies to commercial plans only. For additional information, refer to the commercial Durable Medical Equipment Payment Policy. Modifier 25 Change for Commercial Claims In response to provider feedback, Tufts Health Plan will implement a change to its modifier 25 policy applied to commercial claims. Effective for dates of service on or after July 1, 2015, when an E&M code with modifier 25 (a significant, separately identifiable E&M service) and a procedure code having a 0-, 10- or 90-day post-operative period (as designated by CMS) are billed by the same provider for the same date of service, Tufts Health Plan will compensate the E&M service at 50 percent of the otherwise allowed amount. This policy will apply to commercial professional and outpatient claims and is documented in the commercial Evaluation and Management, Outpatient and Modifier payment policies. Note: This change does not apply for Tufts Medicare Preferred HMO or Tufts Health Plan Senior Care Options claims billed with modifier 25.! Provider Update Available Online This issue and past issues of Provider Update are available on our public Provider website. Go to, and under Help Me Find... click Provider Updates.
Effective July 1, 2015 Commercial Pharmacy Coverage Changes Extavia (interferon beta-1b) to Noncovered Effective for fill dates on or after July 1, 2015, Tufts Health Plan will no longer routinely cover Extavia (interferon beta 1-b). Extavia will be added to the List of Noncovered Drugs With Suggested Alternatives in its commercial formularies. For a member to continue on Extavia, the prescribing provider must request coverage through the medical review process subject to the Pharmacy Medical Necessity Guidelines for Noncovered Drugs With Suggested Alternatives. Victrelis and Olysio TM to Noncovered Effective for fill dates on or after July 1, 2015, Tufts Health Plan will no longer routinely cover Victrelis or Olysio, and these drugs will be added to the List of Noncovered Drugs With Suggested Alternatives in its commercial formularies. For a member to continue on Victrelis or Olysio, the prescribing provider must request coverage through the medical review process subject to the Pharmacy Medical Necessity Guidelines for Noncovered Drugs With Suggested Alternatives. Viscosupplementation for Osteoarthritis Effective for prior authorization requests received on or after July 1, 2015, Tufts Health Plan will implement changes to its Medical Necessity Guidelines for Viscosupplementation for Osteoarthritis (hyaluronic acid derivatives). These changes include updated guidelines for initial and reauthorization requests for the use of viscosupplements as well as updated approval limitations. Euflexxa (J7323) remains the sole preferred viscosupplement for treatment of osteoarthritis and must be obtained through our designated specialty pharmacy, Accredo, at 877-238-8387. These changes are documented in the Pharmacy Medical Necessity Guidelines for Viscosupplementation for Osteoarthritis at. Copies are also available upon request by calling Provider Services.! Find Current Pharmacy Information on the Web For the most current information regarding the Tufts Health Plan pharmacy benefit including tier changes, online formularies and descriptions of pharmacy management programs go to the Pharmacy section of our website. Physician, Outpatient Hospital Fee Schedules to Be Updated July 1 Tufts Health Plan reviews its commercial physician and outpatient hospital fee schedules quarterly to ensure that they are current, comprehensive and consistent with industry standards to the extent supported by our systems. In most cases, changes involve adding fees for new or existing codes to supplement the fees already on the fee schedule. The next update will occur on July 1, 2015. Changes may involve both new and existing CPT and HCPCS codes and will include the planned quarterly update to physician immune globulin, vaccine and toxoid fees. Detailed information about changes to existing fee schedules will be distributed to provider organization and hospital leadership. Independent physicians who have questions about fee schedule changes should contact Tufts Health Plan s Network Contracting Department at 888-880-8699, ext. 2169. Correct Coding Reminder As a normal business practice, claims are subject to payment edits that are updated at regular intervals and generally based on Centers for Medicare & Medicaid Services guidelines, specialty society guidelines, evaluation of drug manufacturers package label inserts, and the National Correct Coding Initiative. Procedure and diagnosis codes undergo annual and quarterly revision by CMS, the American Medical Association and NCCI. As these revisions are made public, Tufts Health Plan will update its system to reflect these changes during the second calendar quarter of 2015. Payment policies will be updated to reflect the addition and replacement of procedure codes, where applicable. Pharmacy information on our website is updated regularly. Check Pharmacy Updates for postings of formulary changes, notification of new pharmacy programs, and important information about drug recalls and alerts from the FDA or drug manufacturers. Copies of information regarding our pharmacy management programs can also be provided upon request by calling Provider Services at 888-884-2404. 2
Changes to Spinal Conditions Management Program Effective for dates of service on or after August 1, 2015, Tufts Health Plan will implement changes to its prior authorization program for management of spinal conditions, including spine surgery and interventional pain management. Tufts Health Plan has selected National Imaging Associates, Inc. (NIAMagellan) to provide utilization management for spinal surgeries and interventional pain management. Beginning August 1, 2015, providers must request prior authorization for cervical and lumbar spinal surgeries and interventional pain management through NIAMagellan at www.radmd.com, rather than through Tufts Health Plan s Precertification Department. Providers may no longer fax authorization requests for those services to Tufts Health Plan as of this date. For procedures performed in an inpatient setting, an inpatient notification will continue to be required according to the current process. Using evidence-based criteria and guidelines, NIAMagellan will review coverage requests and provide authorizations for the above services, as appropriate. For specific procedure codes requiring prior authorization beginning August 1, 2015, refer to the Spinal Conditions Management Program in the Clinical Resources section at. Note: Effective for dates of service on or after August 1, 2015, thoracic spine procedures will no longer require prior authorization. These changes will apply to Massachusetts and Rhode Island commercial plans, with the exception of Tufts Medicare Complement, Tufts Medicare Supplement Plan, USFHP, commercial PPO plans with the PHCS network, and CareLink SM. Tufts Health Public Plans, Tufts Medicare Preferred HMO and Tufts Health Plan SCO plans are also excluded. ADMINISTRATIVE UPDATES Tufts Health Plan Now Offers Online Claim Submission Tufts Health Plan now offers online claim submission to its providers through MD On-Line, now part of ABILITY Network. This option is available for professional claims only for all Tufts Health Plan products. If you are already registered with MDOL, you can add Tufts Health Plan as a payer. If you are not yet registered, call MDOL at 888-499-5465 and mention that you are a Tufts Health Plan provider. All questions about registration should be directed to MDOL. Claims that require supporting documentation cannot be submitted electronically and providers should continue to submit these claims as they do today. Provider-Specific Cost Share Information for Members of Tiered Products Contracted Tufts Health Plan providers can view their specific cost share information for members of Tufts Health Plan s commercial tiered products through the 270/271 Eligibility Inquiry/Response Transaction. In addition, registered users of our secure Provider website are now able to access a provider s specific cost share information by entering the provider s NPI in the Eligibility and Benefits Inquiry tool. Previously, that inquiry returned the cost share for all tiers. If you have questions about this new functionality, please call Provider Services at 888-884-2404. ICD-10 Program Update ICD-10 is still on track for a compliance date of October 1, 2015. Tufts Health Plan continues to move forward with its commitment to be ICD-10 compliant. For more information about ICD-10, refer to the ICD-10 Resources page at. 3
PLANS New Plan Offering: Lifespan Premier Choice Effective July 1, 2015, Tufts Health Plan, in association with Lifespan, will be offering Lifespan Premier Choice. Lifespan Premier Choice is a tiered product and is available only to residents of Rhode Island. Providers are tiered based on member utilization, areas of specialization and other criteria. To support providers existing practice and referral patterns, providers are tiered at the integrated provider level. All physicians and hospitals within the same contracted provider system are placed within the same tier. Member cost share varies by tier, with the lowest cost share applied to providers in Tier 1. If you have any questions about Lifespan Premier Choice, please call Provider Services at 888-884-2404. Tufts Health Freedom Plan Tufts Health Plan and Granite Healthcare Network are proud to announce the launch of a New Hampshire-based health insurance company, Tufts Health Freedom Plan. Tufts Health Freedom Plan will offer an array of health plans for employers and their employees. The five Granite Healthcare Network systems Catholic Medical Center, Concord Hospital, LRGHealthcare, Southern New Hampshire Health System and Wentworth-Douglass Health System will form the core of the Tufts Health Freedom Plan provider network. Tufts Health Plan is currently expanding the provider network to the New Hampshire area and is working directly with Granite Healthcare Network to enroll providers in the network. If you know other providers who may be interested in joining Tufts Health Plan as a participating provider, you can begin the credentialing and contracting application process by going to tuftshealthplan.com/freedom. For additional information about Tufts Health Freedom Plan, you may also call us at 855-288-7578, Monday Friday, 8 a.m. 5 p.m. Coverage for Methadone Maintenance Treatment Tufts Health Plan will cover methadone maintenance treatment for all fully insured Massachusetts group plans effective July 1, 2015. GIC Plan Changes Effective July 1 Effective on the plan renewal date of July 1, 2015, the Commonwealth of Massachusetts Group Insurance Commission (GIC) will make significant changes to its requirements for GIC members covered under Navigator by Tufts Health Plan TM. Beginning July 1, the Navigator plan for GIC members will move from a Preferred Provider Organization (PPO) plan to a Point of Service (POS) plan. Members will be required to select a Primary Care Provider (PCP) and to obtain a referral for most specialty services. Tufts Health Plan and the GIC are committed to helping members understand these new requirements, and current GIC Navigator members have already been notified of these changes. For many members who did not previously have a PCP, a PCP has been assigned based on providers they have seen in the past or geographic proximity. A process is in place for members who wish to change their assigned PCP. GIC Navigator members will receive new ID cards indicating their copayment amounts effective July 1, 2015. Note: Tufts Health Plan Spirit is not subject to the PCP and referral requirements. Providers are reminded to check member eligibility, benefits and cost-share amounts using Tufts Health Plan s secure Provider website or other self-service channels, even for GIC members seen on a regular basis. Tufts Health Plan Medicare Preferred Part C EOBs Now Required by CMS As a reminder, beginning in 2014, CMS requires all Medicare Advantage Organizations to send Part C Explanations of Benefits (EOB) to its members. The EOB provides information to members on the medical services they received. The EOB includes specific claim details, including the provider who performed the service, the date of the service, the procedure and the charges. The EOB also displays cost-share information, including any copayment and deductible amounts, as well as the member s annual out-of-pocket accumulation totals. Tufts Health Plan Medicare Preferred continues to assist members who have questions about their EOB. Providers who have questions about Part C EOBs can call Tufts Health Plan Medicare Preferred Provider Relations at 800-279-9022. 4
QUALITY UPDATES Tufts Health Plan Adopts Clinical Practice and Preventive Health Guidelines Tufts Health Plan encourages providers to review the following clinical practice and preventive health guidelines. Guidelines marked with an * were recently updated. All the guidelines were reviewed and adopted by the Tufts Health Plan Clinical Practice and Preventive Health Guidelines Committee. } Acute Stress Disorder } Alzheimer s Disease } Antibiotic Treatment Guidelines for Upper Respiratory Infections } Asthma } Attention Deficit/Hyperactivity Disorder } Bipolar Disorder } Cholesterol Management } Chronic Kidney Disease } Chronic Obstructive Pulmonary Disease * } Coronary Artery Disease } Depression } Diabetes * } Diabetes in Older Adults } Eating Disorders } Elder Abuse and Neglect } Heart Failure } HIV * } Hypertension } Immunizations (Adult and Pediatric) * } Panic Disorder } Perinatal Care } Prevention of Falls } Preventive Care Guidelines (Adult and Pediatric) * } Schizophrenia } Substance Abuse } Tobacco Use The guidelines are based on the review of clinical evidence developed by nationally recognized organizations in addition to Massachusetts Health Quality Partners. Visit the Clinical Resources section at tuftshealthplan. com/providers to review the guidelines and for additional information. Chronic Kidney Condition Management Program Beginning June 1, 2015, Tufts Health Plan care managers will begin managing members with chronic kidney conditions, including the management of end-stage renal disease. Prior to June 1, 2015, Fresenius Health Partners, Inc., (KidneyTel), had been the administrator of the chronic kidney condition program. The goals of this program are to educate members about kidney disease as a complement to the provider s plan of care, improve self-management, and facilitate care and services between the member, physicians, hospitals and other health care providers. The program is available to Tufts Health Plan commercial and Uniformed Services Family Health Plan members who have been diagnosed with chronic kidney disease, stages 3 5. Members are identified through claims data, care management, physician or self-referrals. The Chronic Kidney Condition Management Program includes the following components: } Screening evaluation to determine appropriateness for the program } Telephone-based care management to coordinate and optimize care based on the stage of the member s chronic kidney disease } Physician contact to provide care plan updates } Assistance so members can understand their benefits and to provide referrals to other health programs as needed Tufts Health Plan commercial members with end-stage renal disease who have primary coverage with Tufts Health Plan are eligible to join the program. USFHP members with ESRD are also eligible to join this program. For members starting or receiving dialysis or anticipating kidney transplant, there are specific eligibility considerations related to the timing of Medicare becoming the primary payer and Tufts Health Plan becoming secondary payer. If you have questions about this program, please call the Priority Care line at 888-766-9818, ext. 3532. 5
UPDATE PROVIDER NEWS FOR THE NETWORK Tufts Health Plan 705 Mount Auburn Street Watertown, MA 02472 Presorted Standard U.S. Postage PAID Brockton, MA Permit No. 301? For More Information ADDRESS SERVICE REQUESTED } } Tufts Health Plan s Provider Services Department 888-884-2404 } Tufts Health Plan Medicare Preferred Provider Relations 800-279-9022 WHAT S INSIDE Coverage Updates for Commercial Products... 1 DME Claim Edits Effective July 1... 1 Modifier 25 Change for Commercial Claims... 1 Commercial Pharmacy Coverage Changes... 2 Physician, Outpatient Hospital Fee Schedules to Be Updated July 1... 2 Changes to Spinal Conditions Management Program... 3 Tufts Health Plan Now Offers Online Claim Submission... 3 New Plan Offering: Lifespan Premier Choice... 4 GIC Plan Changes Effective July 1... 4 Tufts Health Freedom Plan... 4