Winter 2016 Provider Edition Introducing the NEW rmhp.org RMHP is excited to announce that we have launched our redesigned rmhp.org to provide a better experience for our Members and valued partners. While you still have access to the online tools and resources that help you care for our Members, the look and feel of the new rmhp.org allows you to find the information you need with just a few simple clicks. New features include: Streamlined navigation Straightforward, easy-to-read information Seamless desktop, tablet, and mobile design Improved search ability Updated colors and imagery that exemplify the natural tones and scenery of our beautiful Colorado landscape Know the Navigation Found on every page, the top navigation/ menu area offers easy access to our most requested information. Here, you ll also find I am a Provider. Your personalized section offers access to our secure provider portal, commonly used forms and resources, provider contacts, and more. Access to the provider portal may also be found in the footer on every page of rmhp.org. We invite you to explore the new rmhp.org today!
ProviderNews RMHP Prime and CHP+ Members Rights and Responsibilities The following text is reproduced from the Member Handbook. This information has also been included in the Provider Manual for your information. It Is Your Right To get information about RMHP and its services, doctors, and health care providers and to get information about your rights and responsibilities. To be treated with respect and with recognition of your dignity and right to privacy. To accept or refuse medical treatment to the extent provided by Colorado state law and to participate in making decisions about your health care. To have open discussion with health care providers about appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage, and presented in a manner appropriate to your condition and ability to understand. To make appeals, and to bring complaints to RMHP, the Insurance Commissioner of the State of Colorado, or the Department of Health Care Policy and Financing. To be furnished health care services in accordance with federal health care regulations for access and availability, care coordination and quality. To expect all communications regarding your care to be kept confidential as required by law. To freely exercise your rights without being treated differently. To be free from the use of physical restraint or being isolated. These methods may not be used to make you cooperate, to punish you, for the ease of the caregiver, or as a way of getting back at you. To get family planning services from any Colorado RMHP Prime from any duly licensed provider, in or out of RMHP s provider network. To request and receive your medical records and to have them changed according to federal law. To get a second opinion. To make recommendations regarding RMHP s rights and responsibilities policy. It is Your Responsibility To choose a Primary Care Physician (PCP) for each Member of your family and to let that PCP know of any advance directive regarding your medical care. To let your PCP direct your care with specialists and other health care providers, except in cases of medical emergencies, urgent care when outside the service area, obstetrical or gynecological care, and eye care. To learn about your RMHP health care benefits, procedures, and limitations and to be cooperative and considerate with health care providers and staff. To notify RMHP Customer Service of membership or address changes, marriage, birth of a child, or adoption of a child. To take responsibility for copayments and costs for certain health care services and any services that are not covered by Colorado Medicaid. To provide the health care provider with all information needed for you to receive appropriate care and to follow the care and instructions agreed upon with your provider. To understand your health problems and participate in making treatment goals. To tell RMHP about any other insurance you may have, including Medicare. To file a complaint or grievance, please follow the rules as described in the Appeal and Grievance section of this handbook. 2 Rocky Mountain Health
Balanced Billing Prohibitions for Qualified Medicare Beneficiaries The Qualified Medicare Beneficiary (QMB) program is a benefit that covers Medicare deductibles, coinsurance, and copayments, subject to State payment limits for some Medicare beneficiaries. Federal law, Section 1902(n)(3)(B) of the Social Security Act, bars Medicare providers from billing QMBs for Medicare cost-sharing, regardless of whether the State reimburses providers for the full Medicare cost-sharing amounts. Medicare providers must accept the Medicare payment and Medicaid payment (if any) as payment in full for services rendered to a QMB beneficiary. Medicare providers who violate these billing prohibitions are violating their Medicare Provider Agreement and may be subject to sanctions. Be aware of the following policy clarifications to ensure compliance with QMB balance billing requirements. First, know that all original Medicare and MA providers not only those that accept Medicaid must abide by the balance billing prohibitions. Next, QMB individuals retain their protection from balance billing when they cross state lines to receive care. Providers cannot charge QMB individuals even if the patient s QMB benefit is provided by a different State than the State in which care is rendered. Finally, QMBs cannot choose to waive their QMB status and pay Medicare cost-sharing. Please ensure staff is aware of federal balance billing laws and policies regarding QMB individuals. Online Preauthorization Portal Effective 04/04/2016, all RMHP network providers are required to utilize our online preauthorization portal. It is very important that you select the correct patient/member and validate eligibility. RMHP has multiple individuals with the same first and last name in our system, so please verify the patient/member s date of birth at a minimum to prevent any possibility of HIPAA violations. If your office/facility causes a HIPAA-related event because you did not correctly verify the patient/member, RMHP will inform you of the error. You will be asked to provide RMHP with documentation on how you will ensure future verifications and proof of addressing this issue with the employee who made the error. Rocky Mountain Health 3
ProviderNews Health First Colorado (Colorado s Medicaid Program) EPSDT Provider Information All children and adolescents age 20 and under who receive care under Health First Colorado have a special benefit called EPSDT. EPSDT stands for Early and Periodic Screening, Diagnosis and Treatment (EPSDT). The goal of EPSDT is to ensure that children and adolescents through age 20 receive age-appropriate screening, preventive services, and treatment services that are medically necessary to correct or ameliorate any identified conditions. EPSDT is key to ensuring that children and adolescents receive appropriate preventive, dental, hearing, vision, mental health, developmental, and specialty services. Referral and transportation/scheduling services are also available. More information about EPSDT is available at rmhpcommunity.org/epsdt This link has information about Recommended periodicity schedule Community resources How to refer to services such as oral health and vision services More information about EPSDT, such as what is covered by RMHP and services available through other Health First Colorado providers Other important services, such as lead toxicity screening Ask RMHP if you have questions about EPSDT or how to get medically-necessary services for children and adolescents covered under Health First Colorado. 4 Rocky Mountain Health
HEDIS is Coming HEDIS data collection will begin in early February; however, we are now in the final quarter to impact our results! What is the Provider office s role in HEDIS? HEDIS data is collected year round through claims and data surveys. Accurate coding of all claims is critical, since every HEDIS measure is linked to specific coding criteria. Each spring, NCQA allows plans to collect additional data through medical record review. This is when HEDIS nurses visit your offices. Timely access to your office and medical records helps to ensure we meet the deadlines. Allowing remote access to electronic medical records (EMR) may reduce the need for on-site visits for many provider offices. If you are interested in this, please contact the RMHP Quality Department at 970-263-5552. Below are a few of our key HEDIS measures with some tips for success Adult BMI Assessment (ABA) Height and weight are usually documented, but the BMI is often missing. Work with your EMR vendor to update your system with the calculation. Comprehensive Diabetes Care (CDC) Labs indicating poor control are often not repeated again later in the calendar year. Bring the Member back in for testing. Controlling High Blood Pressure (CBP) When the Member s blood pressure is elevated, be sure to repeat the measurement AND document the new result. The repeat BP is often lower. Medication Reconciliation Post-Discharge (MRP) This HEDIS measure requires that Medicare Members have an outpatient follow up visit or phone call within 30 days of an acute inpatient stay. Documentation must include a notation that discharge medications were reviewed and compared to current medications. Colorectal Cancer Screening (COL) Review all preventive health screenings at each visit. Obtain a copy of the colonoscopy report to ensure the medical record is complete. Cologuard and FIT tests now count. Well Child Visits (W34), Adolescent Well Care Visits (AWC) and Immunizations (CIS) Take advantage of all time spent with Members (well visits, sick visits, sports physical exams, etc.) to meet the criteria for these measures. Document health education and anticipatory guidance, specifying what information was discussed at the visit. Document discussions about nutrition and physical activity. Confirm the BMI percentile is calculated for children less than 20 years of age. If your office uses BMI growth charts, make sure a copy is included in the medical record. Check a Member s immunization status at each visit and administer immunizations as appropriate. Ensure that all immunizations are documented and updated in CIIS. If you would like more information about the HEDIS process, please call the RMHP Quality Department at 970-263-5552. Rocky Mountain Health 5
ProviderNews Clinical Practice Guidelines Update RMHP writes, adopts and reviews evidence-based clinical guidelines to help practitioners and Members make decisions about appropriate healthcare for specific clinical circumstances. Please see below regarding two newly adopted guidelines to support our Disease Management After a Heart Attack Program. GUIDELINE 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes 2013 ACCF/AHA Guideline for the Management of ST- Elevation Myocardial Infarction SOURCE American Heart Association/ American College of Cardiology American College of Cardiology Foundation/ American Heart Association Clinical Guidelines can be found at rmhp.org/learning-center/helpful-resources/qualityimprovement or contact our Quality Improvement Department for a copy at 970-263-5552 or 855-830-1565. Medicare Prescriber Enrollment CMS is delaying enforcement of the Part D Prescriber Enrollment Requirement to January 1, 2019. The revised implementation date will allow additional time for CMS to employ strategies to increase prescriber enrollment and identify and eliminate vulnerabilities to strengthen the Medicare Part D program. In addition, the delay will provide Part D sponsors and pharmacy benefit managers (PBMs) and Medicare Advantage Organizations (MAOs) sufficient time to finalize the system enhancements needed to comply with prescriber enrollment requirements. Further action from Part D prescribers is not required at this time. CMS will implement a multifaceted phased approach which will align enforcement of the Part D Prescriber Enrollment Requirement with other CMS initiatives. Full enforcement of the Part D Prescriber Enrollment Requirement will therefore be January 1, 2019. An Update to Member ID Cards RMHP values the importance of the relationship between a provider and our Members. Having a primary care provider (PCP) is always encouraged to help manage a Member s health through better coordinated, more comprehensive care. RMHP will soon be removing PCP s from our Members ID cards. By doing so, we hope to lessen Member confusion when a provider is automatically assigned to a Member. The change is also a cost-effective one by eliminating the need for a new Member ID card, should a Member change PCPs. The removal of the PCP from the ID card does not prevent a Member from seeking care from their PCP. Members will be notified of this change and encouraged to take an active role in their health care by establishing a medical home. Please contact RMHP with any questions about this change. All practitioners applying to join RMHP have the following rights: The right to review information submitted to support their credentialing application. The right to correct erroneous information obtained from other sources during the credentialing process. The right, upon request, to be informed of the status of their credentialing or recredentialing application. 6 Rocky Mountain Health
Important Information Correction to the RMHP Preauthorization List Providers recently received a CD with the RMHP Clinical Preauthorization List that was effective October 1, 2016. Please discard that copy. Multiple procedures that are considered experimental were inadvertently omitted. Several procedures that were moved from the experimental category to preauthorization required also were omitted. Additionally, only CPT codes 0295T 0298T were listed in the section for prolonged mobile cardiovascular telemetry. The code ranges have been corrected to include 93228, 93229, 93268 93272, 93285, 93290, 93291, 93298, and 93299. A copy of the corrected Clinical Preauthorization List (version 2) can be found on the RMHP website at rmhp.org/i-am-a-provider/provider-resources. You can also obtain a copy by calling RMHP Customer Service or your Provider Relations Representative. Timely Access to Care and Services The table below shows the standards for timely access to care and services for Commercial, RMHP Prime, and CHP+ Members as defined by the Division of Insurance and the State. Please refer to this table when scheduling Members for appointments with your office. Appointment Type Prime CHP+ Commercial Behavioral Health Emergent 24/7 24/7 Routine 14 days 7 days Urgent 24/7 24 hours Non-Emergent, Non-Urgent mental health services 14 days 7 days Non-Emergent, Non-Urgent substance abuse disorder 14 days 7 days Medical Emergent 24/7 24/7 24/7 Routine 7 days 7 days 7 days Urgent 48 hours 48 hours 24 hours Preventive 30 days 30 days 30 days Non-Urgent, Symptomatic 10 days 30 days 7 days Non-Emergent, Non-Urgent 7 days 30 days 7 days Prenatal care 7 days 7 days 7 days Specialty care 60 days 60 days 60 days Adult, well-care physical exam (annual exam) 45 days 30 days Child, well-care physical exam (annual exam) 30 days 30 days Notice of Nondiscrimination Rocky Mountain Health Plans (RMHP) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-346-4643 (TTY: 711). Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-346-4643 (TTY: 711). Rocky Mountain Health 7
PO Box 10600 Grand Junction, CO 81502-5600 PRSRT STD U.S. Postage Paid Grand Junction, CO Permit No. 243 Steve ErkenBrack President and CEO Kevin R. Fitzgerald, MD Chief Medical Officer Front Range and Eastern Plains Professional Relations: 303-689-7372 or 800-823-8356 Western Slope and San Luis Valley Professional Relations: 970-244-7798 or 888-286-3113 Please check out our website rmhp.org for recent changes to the RMHP Medicare Part D Drug Formulary Please route this important information to: q Physicians q Office Manager q Billing Office q Receptionist q Other Find Updated Formulary Information Online To view periodic formulary changes, including new drugs and generics, just visit our website at rmhp.org/i-am-a-provider/provider-resources and select the formulary updates under Prior Authorization for Pharmacy. To view the most up-to-date, complete formulary, visit rmhp.org/formulary or call 970-244-7760 or 800-346-4643 (TTY: 711) and we will mail you a copy of the latest update. @RMHPColorado @RMHP RockyMtnHealthPlans rmhp.org/blog