www.unicare.com February 2018 PROVIDER NEWSLETTER Table of Contents Levoleucovorin calcium, elosulfase alfa, histrelin acetate, idursulfase and fulvestrant to require prior authorization Availability of utilization management criteria Page 2 Page 3 Access to Utilization Management staff Page 3 Access to case management Page 4 2017 Provider Satisfaction Survey results Medical Policies and Clinical Utilization Management Guidelines update Page 4 Page 6 UWV-NL-0088-18 February 2018
Levoleucovorin calcium, elosulfase alfa, histrelin acetate, idursulfase and fulvestrant to require prior authorization Effective April 1, 2018, levoleucovorin calcium, elosulfase alfa, histrelin acetate, idursulfase and fulvestrant will require prior authorization (PA) from Federal and state law, as well as state contract language (this includes definitions and specific contract provisions/ exclusions) take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with the new requirements may result in denied claims. PA requirements will be added to the following codes: J0641 Injection, levoleucovorin calcium, 0.5 mg J1322 Injection, elosulfase alfa, 1mg J1675 Injection, histrelin acetate, 10 mcg J1743 Injection, idursulfase, 1 mg J9395 Injection, fulvestrant, 25 mg Please note: These drugs may not be covered in all states. Providers must review their specific state for coverage because not all drugs in this update will apply to the state in which you participate. Please use one of the following methods to request PA: Phone: 1-866-655-7423 Fax: 1-855-402-6983 Web: https://www.availity.com UWV-NL-0084-17 Page 2 of 7
Availability of utilization management criteria If a (UniCare) medical director denies your service request, both you and the member will receive a Notice of Action letter. This letter includes the reason for denial, notes the criteria/guidelines used for the decision and explains the appeal process and member rights. If you d like to speak with a medical director about the service request denial, call our Peer to Peer line at 1-866-902-4628. You must call within 24 hours (one business day) of the denial notification in order for a reconsideration to take place. To request a copy of the specific criteria/ guidelines used for the decision, please call 1-866-655-7423 or write to: Medical Management 200 Association Drive, Suite 200 Charleston, WV 25311 To search for specific policies, visit: www.unicare.com for UniCare Medical Policies and Clinical Utilization Management Guidelines or http://www.aimspecialtyhealth.com/marketing/ guidelines/185/index.html for AIM Specialty Health guidelines. Access to Utilization Management staff (UniCare) ensures availability of Utilization Management (UM) department staff at least eight hours per day during normal business hours to answer questions and return UM-related calls. Staff are identified by name, title and organization name when initiating or returning calls regarding UM issues. You can submit precertification requests 24/7 by: Sending a fax to 1-855-402-6983. Using the Interactive Care Reviewer on https://www.availity.com. Do you have questions about utilization management decisions or the UM process in general? Contact our UM team at: UM phone: 1-866-655-7423 UM fax (pre-service reviews): 1-855-402-6983 UM fax (current inpatient reviews): 1-855-402-6985 Our hours are Monday to Friday from 8 a.m. to 5 p.m. Eastern time. Page 3 of 7
2017 Provider Satisfaction Survey results Access to case management Did you know that, in addition to our disease management programs, we offer a complex case management program for our high-risk members? Using claims and utilization data, we can identify the diseases for which members are most at risk and to which they are most susceptible Our case managers use evidence-based guidelines to coordinate care with the member, his or her family, physicians, and other health care providers. They work with everyone involved in the member s care to help implement a case management plan based on the member s needs. We provide education and support to our members and their families to help improve their health and quality of life. If you have a high-risk member you would like to refer to this program, please call us at 1-800-782-0095. Additionally, members can be referred to complex case management through the nurse line, Disease Management, Utilization Management or a discharge planner. (UniCare) contracted with DSS Research to conduct provider satisfaction surveys. This research can be used to provide rational direction for efforts to strengthen provider relationships. The survey was designed for mail, telephone and internet administration and administered July to September 2017. Sample size 1,000 Total undeliverble records 50 Undeliverable conversions to complete Completes 322 Response rate 32.2% Adjusted response rate 33.9% UniCare targeted approximately 1,000 providers per market/service delivery area in both 2016 and 2017. The adjusted response rate in 2017 was 33.9% compared to about 9.5% in 2016. The per market survey sample was proportioned as follows: 50% primary care physicians 30% specialists 10% OB/GYNs 10% behavioral health 5 Page 4 of 7
2017 Provider Satisfaction Survey results (cont.) Provider Satisfaction Survey results Overall Satisfaction with UniCare UniCare s goal is 90% overall satisfaction. Satisfaction with UniCare increased slightly among providers in West Virginia. Although UniCare scored lowered than the 90% goal, there was a 3% increase in satisfaction among providers from 2016 to 2017. Q21. Please rate your overall satisfaction with UniCare. Provider satisfaction with the overall utilization management process showed a sizable increase, as did obtaining precertification and/or authorization for UniCare members. Composite Summry Provider satisfaction with the overall utilization management process showed a sizable increase, as did obtaining precertification and/or authorization for UniCare members. Page 5 of 7
Medical Policies and Clinical Utilization Management Guidelines update Medical Policies update On November 8, 2017, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies for UniCare Health Plan of West Virginia, Inc. (UniCare). These policies were developed or revised to support clinical coding edits. Several policies were revised to provide clarification only and are not included in the below listing. We made these Medical Policies publicly available on our website on the effective date listed below. Visit www.unicare.com/medicalpolicies/search.html to search for specific policies. Existing precertification requirements have not changed. Please share this notice with other members of your practice and office staff. Medical Policy effective date Medical Policy number Medical Policy title Revised or new 9/27/17 DRUG.00110 Inotuzumab ozogamicin (Besponsa ) New 9/27/17 MED.00124 Tisagenlecleucel (Kymriah ) New 9/27/17 DRUG.00043 Tocilizumab (Actemra ) Revised Page 6 of 7
Medical Policies and Clinical Utilization Management Guidelines update (cont.) Clinical Utilization Management Guidelines update On November 8, 2017, the MPTAC approved the following Clinical Utilization Management (UM) Guidelines for UniCare. These guidelines were developed or revised to support clinical coding edits. Several guidelines were revised to provide clarification only and are not included in the below listing. The Clinical UM Guidelines on this list represent those adopted by the Medical Operations Committee for the Government Business Division on October 19, 2017. We made these guidelines publicly available on the Medical Policies and Clinical UM Guidelines page on the effective date listed below. Visit www.unicare.com/medicalpolicies/search.html to search for specific guidelines. Existing precertification requirements have not changed. Please share this notice with other members of your practice and office staff. Effective date Clinical UM Guideline number Clinical UM Guideline title Revised or new 9/27/17 CG-LAB-11 9/27/17 CG-MED-59 Screening for Vitamin D Deficiency in Average Risk Individuals Upper Gastrointestinal Endoscopy for Diagnosis, Screening or Surveillance New New 9/27/17 CG-SURG-59 Vena Cava Filter New 9/27/17 CG-DME-31 UWVPEC-0740-17 Wheeled Mobility Devices: Wheelchairs Powered, Motorized, With or Without Power Seating Systems and Power Operated Vehicles (POVs) Revised Page 7 of 7