HMSA Welcomes Employees

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1 HMSA s For Participating Medical Practitioners November 2012 What s Inside Got No Time? Go Online! 2 By the Numbers 3 Electronic 3 Procedures 4 Policy News 5 TRICARE 7 HMSA Welcomes Employees of The Queen s Health Systems Effective January 1, 2013, HMSA will administer plan benefits for approximately 4,200 employees of The Queen s Health Systems (QHS) and their family members, for a combined total of 9,000 members. The three-year contract, awarded through a competitive bid process, is a collaborative effort between HMSA and QHS to improve the health and well-being of these members. QHS employees will continue to have their three preferred provider medical plans administered by HMSA. QHS s prescription drug benefits continue to be administered by CVS Caremark. New HMSA membership cards with QHS logos will be issued to members. Provider Update to Include QUEST Notifications HMSA will no longer publish the QUEST Provider Bulletin. QUEST notifications will now appear in HMSA s Provider Update. Member Reviews of Providers More than 380 member reviews of visits with participating providers are posted on hmsa.com. In their reviews, more than 90 percent of HMSA members indicate they would recommend the provider they visited. More than half of the members who rated their visits also left comments, which are moderated in accordance with HMSA s terms of use policy. Each member can write once about a visit and each provider has the opportunity to respond to a member s comment. Members who are looking for a physician can read the reviews to help them decide about choosing a doctor Hawai i Medical Service Association 818 Keeaumoku St. P.O. Box 860 Honolulu, HI Phone: (808) Branch offices located on Hawaii Island, Kauai, and Maui Internet address: hmsa.com Provider Resource Center: hhin.hmsa.com

2 2 Provider Update - Medical Practitioners November 2012 improved provider search on hmsa.com Finding a doctor on hmsa.com just got easier HMSA is excited to introduce our new online provider search. We want to make it easier for members to find the right doctors. HMSA s new provider search is convenient. Just follow these three simple steps: 1. Go to HMSA s website at hmsa.com. 2 From the home page, click on Find a Doctor. 3. In the search bar, type in a doctor s name, specialty, location, or your symptom. For example, need to find a foot doctor in Kailua? Type in foot Kailua. A list of doctors will appear in seconds. Results can be narrowed by: Specialty. Find doctors in different specialties, such as internal medicine, podiatry, or pediatrics. Health center. Find a doctor who participates in your health center. Gender. More comfortable with a female doctor? We ll find one. Languages spoken. Looking for a doctor who speaks Cantonese or Tagalog? We have a list of more than 50 languages to choose from. Results show if the doctor is a primary care provider (PCP) and accepts new patients. Search results show the doctor s phone number and location on Google Maps, so it s easy to call and locate a doctor s office. Your patients can view your credentials and find out which medical school you went to or where you did your residency. The search can also be sorted alphabetically or by best match or patient rating (read related article). If you have comments or suggestions on how to improve the provider search, please let us know. You can give us your feedback on the site.

3 3 Provider Update - Medical Practitioners November 2012 By the Numbers HMSA uses Cozeva as the reporting platform for HMSA s quality programs. Access and supplemental data reporting capabilities on HBIOnline will be discontinued November 30, For more information regarding Cozeva, visit To learn about our $1,000 incentive payment for transitioning to Cozeva and discontinuing the use of HBIOnline, please contact Provider Services at PSInquiries@hmsa.com or call on Oahu or 1 (877) toll-free on the Neighbor Islands. Pay-for-Quality August 2012 Sept 2012 Number of providers 1,026 1,024 Cozeva usage Number of registered providers Number of providers who have submitted supplemental data through Cozeva per month Number of supplemental data submissions through Cozeva per month 7,092 6,170 PCMH Number of physician organizations Total number of providers Level Level Level electronic New HHIN Eligibility Benefit Detail Options Coming soon to HHIN are new and more specific HIPAA service type codes. For example, two new service type codes are: CK Screening X-ray: Includes Bone Density Testing and Abdominal Aortic Aneurism Scan. CN Mammogram, low risk: Includes Screening Mammography. For questions or HHIN training needs, call HHIN Outreach Representative Traci Tabladillo at on Oahu or 1 (800) , ext. 5851, toll-free on the Neighbor Islands.

4 4 Provider Update - Medical Practitioners November 2012 PROCEDURES Claims Processing for Multiple Endoscopy Procedures HMSA processes multiple endoscopy procedures performed on the same day according to Medicare guidelines, with the following exceptions: Unbundle editing is bypassed. Multiple endoscopy processing occurs when the family is billed on the same claim. Bilateral procedures are billed on two lines (refer to hmsa.com/portal/provider/zav_pel.aa.bil.050.htm for more information). Effective February 1, 2013, unbundle edits will be applied. As with all code relationships, use appropriate modifiers (i.e., modifier 59) to identify separate procedures. We will also apply the multiple endoscopy calculation across claims. Please continue to submit bilateral procedures on two separate lines. Claims Processing Errors New Patient Visits Errors in processing for claims of new patient visits were noted in some evaluation and management (E&M) codes. HMSA s processing system used only one year of patient visits when three years are required, and did not note if a member visited the same physician or another physician of the same specialty or subspecialty in the same group practice. HMSA s processing system will be updated to include the three-year criteria by the end of November Errors were found in the following E&M codes: Office or other outpatient services Domiciliary, rest home, or custodial care services Home services Preventive medicine services General ophthalmological services Initial physician evaluation and management of a diabetic patient with diabetic sensory neuropathy G0245. Routine ophthalmological exam S0620. HMSA ICD-10 Translator Tool HMSA has created a convenient tool to help you translate ICD-9 diagnosis codes to the ICD-10 version. This tool is available in the Provider Resource Center under Support Center and also as a direct link on HHIN. This database is modified from the original CMS General Equivalency Maps to filter out many of the unspecified codes when a more appropriate code is available (e.g., for laterality). With CMS s final notice of the new implementation date of October 1, 2014, efforts are underway to complete the transition at HMSA. HMSA has developed an ICD-10 Information and Resources page available in the Provider e-library at: hmsa.com/portal/provider/zav_pel.aa.icd. 100.htm. This page provides a quick link to ICD-10 information in previous Provider Updates, a list of training opportunities for physicians and staff, and general information from sources such as the American Academy of Professional Coders, American Medical Association, and Centers for Medicare and Medicaid Services. Combining Well-Woman Exams and E/M Visits When a well-woman exam and an evaluation and management (E&M) visit occur on the same day, use modifier 25 on the E&M service so HMSA processes both services at full benefit. NOTE: For QUEST members, Med-QUEST will pay for one visit or the other, but will not pay for both. When scheduling the well-woman exam for your patient, discuss the procedures and ask if she has any concerns. Other services provided could change the copayment, so have an up-front discussion to keep the patient informed. HMSA members are encouraged to take control of their health and will often make medical care decisions based on out-of-pocket costs.

5 5 Provider Update - Medical Practitioners November 2012 POLICY NEWS Physician Attestation Review Results Equipment suppliers who dispense certain types of durable medical equipment (DME) or physicians who perform certain diagnostic tests may rely on signed physician attestations certificates of medical necessity (CMN), supplier/physician forms, or letters to ensure that the equipment or service meets HMSA s payment determination criteria. In a recently completed assessment, HMSA reviewed patient medical records against signed attestations submitted with precertification requests for the following services: Hospital beds. Negative pressure wound therapy. Oxygen and oxygen equipment. Polysomnography sleep studies. HMSA evaluated patient medical records to validate that documentation is consistent with signed physician attestation and that payment determination criteria are met. In 20 percent of the reviewed cases, details contained in physician attestations were not supported by or consistent with the patient medical record documentation. What could this mean for you? If your medical record does not support the medical condition or need for the equipment or service, payments you have already received may be recouped from your future payments. Participating physicians should maintain medical records that accurately document the medical necessity of services rendered and billed. If, on review, medical record documentation is determined to be insufficient to support assertions by participating physicians in signed attestations, HMSA s Medical Management department may deny claims for equipment or services, recover payment, and conduct further reviews. For more details on HMSA s medical record documentation requirements, please visit HMSA s Provider E-Library and click on Medical, Providers General Topics, General Reference, then Medical Records. New Policy Drafts Online for Review Drafts of new medical policies are posted online for your review. Please visit hmsa.com/portal/provider/zav_ mm htm in the Provider E-Library for drafts of policies that may affect your practice. Comments should be sent before the due date indicated online and may be ed to medical_policy@hmsa.com or faxed to on Oahu. Questions? Call Provider Services at on Oahu or 1 (800) toll-free on the Neighbor Islands. Annual Review of Medical Policies The following policies have undergone review and have been updated in the Provider E-Library at hmsa.com/ portal/provider/zav_in.mm00_medical_policies_current_ index.htm; copies are available on request. Apnea Monitor for Infants. Hepatitis C Treatment with Protease Inhibitors and Interferons and Ribavirin.* Lipid Risk Factors (Novel) in Risk Assessment and Management of Cardiovascular Disease. Occupational Therapy. Physical Therapy. Preimplantation Genetic Diagnosis (PGD).* * Policies on Hepatitis C Treatment and PGD do not apply to HMSA QUEST members. Archived Policies Archived policies are inactive and not updated. These policies will no longer be used when reviewing requests for coverage and these services will no longer require precertification. The following policy has been archived and will be housed in the archived policy section at hmsa.com/ portal/provider/zav_mm htm: Brachytherapy, Intravascular.

6 6 Provider Update - Medical Practitioners November 2012 POLICY NEWS (CONTINUED) 90-Day Notice for Policy Changes Effective February 2013 The following policies have been updated and will go into effect February 1, Policy Revisions URL Genetic Testing Oncology Criteria/Guidelines hmsa.com/portal/provider/zav_pel.aa.gen.851.htm. Intensity Modulated Radiation Therapy (IMRT) Immune Globulin Therapy Criteria/Guidelines, Limitations/Exclusions, Administrative Guidelines Criteria/Guidelines, Limitations/Exclusions, Administrative Guidelines hmsa.com/portal/provider/zav_pel.aa.int.201.htm. hmsa.com/portal/provider/zav_pel.aa.int.701.htm. New Policies The following policies go into effect February 1, Providers are encouraged to review the criteria before the effective date. Endovascular Procedures (Angioplasty and/or Stenting) for Intracranial Arterial Disease (Atherosclerosis and Aneurysms). Real-Time Intra-Fraction Target Tracking During Radiation Therapy. Please refer to the online policies for precertification requirements at hmsa.com/portal/provider/zav_in.mm00_medical _Policies_Current_INDEX.htm. Precertification Requirements Akamai Advantage The Akamai Advantage policy has been updated to clarify the precertification requirements effective January 1, It can be found at: hmsa.com/portal/provider/zav_pel. aa.aka.501.htm. FDA-Approved Drugs Requiring Precertification The following drugs will require precertification effective February 1, 2013: Code J3490/J3590 J3490/J3590 Description Carfilzomib (Kyprolis) Taliglucerase alfa (Elelyso)

7 7 Provider Update - Medical Practitioners November 2012 TRICARE SmartSheets Now Available on TriWest s Secure Website TriWest Healthcare Alliance (TriWest) has developed a new resource for providers registered to TriWest s secure provider website at TriWest.com that offers clinical support to providers and clinicians at the point of care InterQual SmartSheets criteria. Care Planning SmartSheets provide concise, quick-view checklists of care planning criteria. After logging into the secure provider website, you will see the InterQual SmartSheets link listed under the Referral/ Authorization heading. By clicking on the SmartSheets link, you will have access to some of the most widely searched InterQual criteria information. You may use this Clinical Reference as a resource for medical information. InterQual criteria is intended for use as a screening guideline with respect to the medical appropriateness of health care services and not for final clinical or payment determination concerning the type or level of medical care provided or proposed to be provided to the patient. Here is the list of available SmartSheet topics: Anterior Cervical Discectomy and Fusion. Cervical Hemilaminectomy. Cervical Laminectomy. Cervical Spine Fusion. Computed Tomographic Angiogram Magnetic Resonance Angiogram Brain. Lumbar Discectomy. Lumbar Hemilaminectomy. Lumbar Laminectomy. Lumbar Spine Fusion. Magnetic Resonance Imaging with Contrast Brain. Magnetic Resonance Imaging Brain. Magnetic Resonance Imaging Brain Pediatric. Magnetic Resonance Imaging Cervical Spine. Magnetic Resonance Imaging Lumbar Spine. Magnetic Resonance Imaging Pituitary. Magnetic Resonance Imaging Thoracic Spine. Magnetic Resonance Imaging Lumbar Spine Pediatric. Thoracic Laminectomy. Thoracic Spine Fusion. Total Joint Replacement Knee. When you open a SmartSheet, a list of Indications for the selected condition will appear. For example, the Discectomy and Fusion, Anterior Cervical SmartSheet offers two indications: Cervical disc herniation/sponsylosis (spinal stenosis). Myelopathy (spinal cord compression). Clicking on one of the indications (e.g., cervical disc) presents you with a checklist of diagnoses related to that specific condition to help you rationalize the procedure. Remember, only registered users of the secure provider website at TriWest.com have access to the SmartSheets. If you re not registered, go to Register Now at TriWest.com and complete the online form. Register for a secure account to verify patient eligibility and check benefits, submit referrals/authorizations and claims online, check the status of referrals/authorizations and claims, and more. Once you re registered, you can immediately begin using the SmartSheets. TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved.