INSIDE THIS ISSUE Look for HEDIS Reminder check marks...2 Access to care and case management...2 Affirmative statement regarding incentives...2 YOUR PROVIDER NEWSLETTER Important information for contracted providers caring for business-sponsored and exchange health plan membership Telemedicine services provided by Teladoc Prominence Health Plan commercial members now have access to U.S. board-certified doctors and pediatricians by phone, 24 hours a day, 365 days a year. What is Teladoc? Teladoc is the first and largest telehealth provider of medical consults in the nation. This service will provide Prominence members with access to quality medical care via phone or mobile app. Recent additions to the existing PHP formulary...3 Quality Improvement Program...4 Supporting follow-up treatment after behavioral health hospitalization...4 Prenatal and postpartum care...5 Colorectal cancer prevention starts with screening...5 Appropriate testing for children with pharyngitis...5 Does Teladoc replace a primary care provider? Teladoc does not replace a primary care provider (PCP). When the member is unable to see their PCP and needs immediate care for non-emergent medical issues, Teladoc is an affordable, convenient alternative to urgent care and ER visits. Members can talk to a doctor who can diagnose, recommend treatment and prescribe medication, when appropriate, for many medical issues including sinus problems, bronchitis, cold and flu symptoms and ear infection. Will Teladoc communicate with the PCP? Each time a consultation is provided, Teladoc will ask the patient to whom they should send a continuity of care communication. Who are Teladoc doctors? Teladoc doctors are U.S. board certified in Internal Medicine, Family Practice or Pediatrics. They average 15 years practice experience and are licensed. How does Teladoc work? Prominence members can register at www.teladoc.com, call Teladoc directly (1.800.TELADOC) or use the Teladoc mobile app to register and complete a medical history questionnaire. Once an account is established, members can contact Teladoc anytime. Members can request a consultation immediately following the registration process. For more information about Teladoc services, visit www.prominencehealthplan.com or call Prominence Health Plan at 866.500.2741. Reminder PHP member support from Accolade...6 Teladoc does not replace the primary care physician. Teladoc does not guarantee that a prescription will be written. Teladoc operates subject to state regulations and may not be available in certain states. Teladoc does not prescribe DEA-controlled substances, non-therapeutic drugs and certain other drugs that may be harmful because of their potential for abuse. Teladoc physicians reserve the right to deny care for potential misuse of services. Teladoc phone consultations are available 24 hours, seven days a week. Video services not eligible to health plan residents in Texas. Prominence Health Plan members are not eligible for behavioral health or dermatology services provided by Teladoc. Spring 2016
Page 2 Prominence Health Plan Access to care and case management Look for HEDIS Reminder check marks Throughout this newsletter, you may find check marks indicating HEDIS Reminders. These note information about the standards and specifications for HEDIS measures, as well as strategies designed to help practitioners and providers improve the quality of care and service provided to Plan members. Healthcare Effectiveness Data and Information Set (HEDIS) is a set of standardized performance measures designed to facilitate the reliable comparison of managed healthcare plans. Prominence HealthFirst collects and reports HEDIS data annually as part of the Plan s National Committee for Quality Assurance (NCQA) Accreditation process, and in support of quality initiatives and our QualityConnect clinical excellence program. The Utilization Management (UM) Department provides telephone coverage from 8 a.m. to 5 p.m. PST, Monday through Friday. Your patients and Prominence Health Plan members can call 775.770.9350 24 hours a day/seven days a week with questions about the UM process and care management/case management services provided by the health plan at no cost to our members who qualify. Messages received after midnight Monday through Friday will be returned the same day. Messages received after normal business hours will be returned the next business day. Confidential fax is also available at 775.770.9364. Telecommunications device for the deaf or hard of hearing and telephone typewriter for the speech impaired are offered. Language assistance is also available free of charge for members to discuss UM issues. Urgent care and emergency care services do not require prior authorization. Affirmative statement regarding incentives Prominence Health Plan distributes annually an affirmative statement regarding incentives to all members and to all practitioners, providers and employees who make utilization management decisions, affirming the following: Utilization Management (UM) decision-making is based only on appropriateness of care and services and existence of coverage. The organization does not specifically reward practitioners or other individuals for issuing denials of coverage or service care. Financial incentives for UM decision makers do not encourage decisions that result in under-utilization. Incentives, including compensation, for any person are not based on the quantity or type of denial decisions rendered. For questions regarding this statement, please call the Prominence Health Plan Utilization Management Department at 775.770.9350.
www.prominencehealthplan.com Page 3 Recent additions to the existing PHP formulary To help members get the most out of their pharmacy benefits, it s important to understand what is available to them. The most current Formulary Reference Guide can be found on www.prominencehealthplan.com, and a list of recent drug additions is noted below. Questions regarding Prominence Health Plan prescription drug coverage should be directed to the MedImpact Help Desk at 844.282.5339. MedImpact customer services representatives are available 24/7 to assist. FORMULARY UPDATES Drug Name Tier Status Drug Name Tier Status Belsomra Cholbam Corlanor Coumadin Tier 4 Dilantin Tier 4 Evotaz Fuzeon Isentress Tier 4 Tier 4 with step therapy of at least 2 other sleep disorder agents: Zolpidem IR, Zolpidem CR and Eszopiclone (Lunesta) in the past 365 days. Tier 3 Prior Authorization Prezcobix Selzentry 150mg and 300mg Spiriva Tier 3 Stiolto Stribild Striverdi Tier 3 Synthroid Tier 4 Tivicay Tier 3 with step therapy using LAMA = Long acting muscarinic antagonist or LABA = Long acting beta agonist Natpara Triumeq Neoral Tier 4 Pradaxa Tier 3 Quantity Limit of 2 per day with a max day supply of 34 and only dispense 1 per 6 months. Unituxin
www.prominencehealthplan.com Page 4 Quality Improvement Program Prominence Health Plan s Quality Improvement (QI) Program is designed to assess and improve the quality of care and service delivered to Plan members. The goal of the QI Program is to monitor the quality and appropriateness of patient care and service and to meet or exceed established local, state and national standards. Methods to achieve this include establishing standards and performance goals for the delivery of care and services, measuring performance outcomes, and development and implementation of action plans to improve outcomes. The Quality Improvement operational functions are under the direct supervision of the Plan Chief Medical Officer. The focus of the QI Program is to improve the overall health status of Plan members through systematic identification of opportunities for improvement and evaluation of processes to achieve improvement. The comprehensive QI Program provides the framework for determining indicators for recommended levels of care and service. Opportunities for improvement are selected through the monitoring of identified quality and performance indicators. The QI Program reflects the Plan s mission, vision and values. It is designed to develop, implement, monitor, evaluate and improve standards of healthcare quality of service and care on an ongoing basis. Quality Improvement functions in conjunction with the Plan s Organizational Structure to promote appropriate system development and implementation to meet the requirements of Plan members, employers, employees and the practitioner/provider network. Additional information regarding the Plan s QI Program and/or program activities is available upon request by accessing Prominence Health Plan s website at www.prominencehealthplan.com. Supporting follow-up treatment after behavioral health hospitalization Timely follow-up treatment after discharge from inpatient behavioral health hospitalization is crucial toward supporting a member s ongoing recovery. Early aftercare treatment (within seven days of discharge) with a behavioral health provider has been demonstrated to improve outcomes and prevent readmission. By contrast, lack of ongoing follow-up has been identified as a predictor of poor outcomes. When a member is hospitalized, it is important to begin aftercare planning as soon as possible after admission. Prior to discharge, key activities that support an effective aftercare plan are: Scheduling the first followup appointment to occur within 7 days of the member s discharge Explaining the benefits of aftercare to the member, so he or she is aware of the importance of keeping follow-up appointments Verifying the aftercare plan is a good fit for the member Involving the member s family to support the aftercare plan Explaining the importance of taking medication and notifying their provider of any side effects For information and support 24 hours/ 7 days a week, please call Magellan Behavioral Health at 800.245.7013. Additional information, self-help tools and other resources are also available online at www.magellanassist.com.
www.prominencehealthplan.com Page 5 Prenatal and postpartum care This HEDIS measure assesses timeliness of prenatal care and postpartum care by measuring the following: Timeliness of Prenatal Care measures the percentage of OB deliveries that received a prenatal visit in the first trimester or within 42 days of enrollment in the Plan. Postpartum Care measures the percentage of OB deliveries that had a postpartum visit on or between 21 and 56 days after delivery. Prenatal and postpartum visits that fall outside these time ranges cannot be used to demonstrate compliance with these measures. You can help by scheduling postpartum visits between 21 and 56 days after delivery as well as encouraging your patients to keep these important appointments for their good health! Colorectal cancer prevention starts with screening As recommended by the U.S. Preventive Services Task Force, Prominence Health Plan encourages members ages 50 through 75 to have periodic colorectal cancer screenings using stool occult blood testing, sigmoidoscopy or colonoscopy. Because the risks and benefits of these screening methods vary, members are encouraged to discuss this recommendation with their clinical practitioner. Now is the ideal time to discuss this very important screening with your patients. For questions related to members benefits or information on plan physicians that provide colonoscopy or sigmoidoscopy, please contact Prominence Health Plan Customer Service through the dedicated phone line for plan providers at 775.770.9311 or 866.500.2741. Appropriate testing for children with pharyngitis Children who are treated as outpatients for acute pharyngitis, acute tonsillitis or streptococcal sore throat and are dispensed antibiotics on or up to three days after the date of the diagnosis need to have a group A streptococcus test for each diagnosed episode. In order to expedite timely and accurate reimbursement, please include the applicable group A streptococcus test code on the member s encounter form. Codes to identify a group A streptococcus test include: * CPT Codes: 87070, 87071, 87081, 87430, 87650 87652, 87880 * LOINC Codes: 626-2, 5036-9, 6556-5, 6557-3, 6558-1, 6559-9, 11268-0, 17656-0, 18481-2, 31971-5, 49610-9, 60489-2, 68954-7 For more information about the treatment of children with pharyngitis, refer to Centers for Disease Control and Prevention recommendations available at www.cdc.gov.
FPO 1510 Meadow Wood Lane Reno, Nevada 89502 Reminder PHP member support from Accolade Accolade s Clinical Health Assistants and Health Assistants work in tandem to help support Prominence Health Plan members and their families with anything related to their healthcare, including: CARE AND CONDITION SUPPORT Health questions and treatment options Medication questions Condition management and lifestyle improvement PROVIDER SEARCHES Doctor, specialist, facility and clinic Other care options Appointment assistance Visit preparation BENEFITS AND CLAIMS SUPPORT Eligibility and coverage Billing questions Benefit enrollment options For questions regarding patient claims, benefits or eligibility, call Prominence Health Plan Customer Service at the dedicated phone line for plan providers at 775.770.9311 or 866.500.2741. www.prominencehealthplan.com Page 6