PROVIDER BULLETIN Fall 2013

Transcription

1 Alameda Alliance for Health 1240 South Loop Road Alameda, CA Fall 2013 PROVIDER BULLETIN MAKE THE SWITCH TO THE NEW PROVIDER PORTAL The Alliance s new Provider Portal launched in November 2013 and offers you these great tools: New Options View authorizations View pharmacy claims View and download your member roster to a spreadsheet Download forms through the Help Center Update your account information online Improved Features Enhanced searches let you view and download multiple results to a spreadsheet for: - Eligibility status based on member ID, CIN number or SSN - Claims status based on NPI, member ID, or claim number - Pharmacy claims based on NPI - Authorization status based on authorization number, member ID, CIN number or SSN View member eligibility and PCP history Register by December 1 Current Provider Portal users need to re-register on the new Provider Portal before December 1, New users who sign up for an account get quick and easy access to member eligibility, claims, authorizations and more. NOTE: If there will be multiple users in one office location, please have each user register for their own account. IN THIS ISSUE: Efforts to Improve HEDIS Scores... 2 Antidepressant Medication Management... 2 How Providers Can Help Improve HEDIS Rates... 3 Improvements & Areas to Focus on... 4 Phone Reminders about HEDIS Screenings... 5 NEW Credentialing Vendor... 5 New Mental Health & Substance Abuse Vendor... 5 NEW Pharmacy Benefits Manager... 6 Psychotropic Drug Intervention Program... 7 Flu Shots... 7 Pertussis Cases on the Rise... 8 New Staying Healthy Assessment... 9 Claims Corner... 9 Free Language Service & Medical Transportation Rights & Responsibilities Fraud, Waste, & Abuse Contact Info... 11

2 PROVIDER BULLETIN Alameda Alliance for Health Fall 2013 ALLIANCE EFFORTS TO IMPROVE HEDIS SCORES The Alliance is launching several quality initiatives to assist its primary care physicians (PCPs) with ensuring that their patients receive recommended preventive care screenings and managing their chronic condition(s). These initiatives will help us to improve the quality of care delivered to our members. If you have any questions about these initiatives, please contact the Alliance Provider Services department at ANTIDEPRESSANT MEDICATION MANAGEMENT HEDIS MEASURE: Opportunity for Improvement Major Depression is Treatable According to the National Institute of Mental Health, major depression affects about 6.7% of the U.S. population over age 18. Depression, even the most severe cases, can be effectively treated. Thank you for your efforts to care for Alameda Alliance for Health (Alliance) members experiencing depression with the best treatment possible. The Alliance would like to ensure that members on an antidepressant medication treatment remain on their antidepressant medication as clinically indicated. The Alliance s recent rates on the Antidepressant Medication Management (AMM) HEDIS measure indicate we have an opportunity for improvement in this area. The AMM HEDIS measure looks at members who meet the following criteria: 18 years of age and older Diagnosis of major depression Newly treated with antidepressant medication For this population the HEDIS measure looks at how long the member remained on an antidepressant medication treatment. There are two rates reported for this measure: Effective Acute Phase Treatment The percentage of newly diagnosed and treated members who remained on an antidepressant medication for at least 84 days (12 weeks). Effective Continuation Phase Treatment The percentage of newly diagnosed and treated members who remained on an antidepressant medication for at least 180 days (6 months). As your partners in striving to improve both the mental and physical health of our members, Alameda Alliance for Health (Alliance) and Beacon Health Strategies/CHIPA (see Page 5) offer tools to support your patients who have a diagnosis of major depression. Behavioral and mental health clinical practice guidelines are available for your use on the Beacon Health Strategies/CHIPA website: beaconhealthstrategies.com/private/provider/tools. Please use the plan name AAH for access. HOW PROVIDERS CAN HELP IMPROVE HEDIS RATES Just weeks remain to encourage your patients who are missing key HEDIS 2013 services to schedule appointments for preventive screenings and regular tests. The Alliance is enlisting your help to improve our HEDIS rates. HEDIS tools and tips for providers are posted on the Alliance website at tinyurl.com/hedis-tips. The Alliance would like to remind providers about the specific HEDIS measures below. MEASURE Care for Older Adults Functional Status Assessment Care for Older Adults Pain Assessment Comprehensive Diabetes Care PROVIDER REMINDER For members 65 years and older, documentation in the medical record must include evidence of a complete functional status assessment and the date when it was performed. Notations for a complete functional status assessment must include one of the following: Notation that Activities of Daily Living (ADL) were assessed (includes bathing, dressing, using toilet, walking) Notation that Instrumental Activities of Daily Living (IADL) were assessed (includes shopping for groceries, driving or using public transportation, housework) Result of assessment using a standardized functional status assessment tool Notation that at least three of the following four components were assessed: - Cognitive status - Ambulation status - Sensory ability (including hearing, vision and speech) - Other functional independence (e.g., exercise, ability to perform job) For members 65 years and older, documentation in the medical record must include evidence of a pain assessment and the date when it was performed. Notations for a pain assessment must include one of the following: Documentation that the patient was assessed for pain (may include positive or negative findings for pain). Result of assessment using a standardized pain assessment tool, not limited to: - Numeric rating scales (verbal or written) - Face, Legs, Activity, Cry Consolability (FLACC) scale - Verbal descriptor scales (5 7 Word Scales, Present Pain Inventory) - Pain Thermometer - Pictorial Pain Scales (Faces Pain Scale, Wong-Baker Pain Scale) - Visual analogue scale - Brief Pain Inventory - Chronic Pain Grade - PROMIS Pain Intensity Scale - Pain Assessment in Advanced Dementia (PAINAD) Scale Please encourage your diabetic patients missing the following lab tests or exams to get them completed before the end of the year: - HbA1c test (most recent result should be <8.0%) - LDL test (most recent result should be <100) - Nephropathy monitoring (microalbumin test or evidence of nephropathy) - Retinal eye exam - Blood pressure <140/90 (most recent result) Thank you for your continued support of our HEDIS and quality improvement efforts. If you have any questions, please contact the Alliance Provider Services department at Page 2 Page 3

3 ALLIANCE HEDIS RATES: Improvements Achieved and Areas of Focus The Alliance thanks our providers for your hard work to help significantly improve our HEDIS rates. The Alliance s goal is to reach the National Committee for Quality Assurance (NCQA) national 75th percentile performance HEDIS benchmark and achieve a CMS 4-Star quality rating for Medicare measures. The tables below show our achievements in 2012 as well as areas for improvement. Measures at or Above the National HEDIS 75th Percentile Childhood Immunizations Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis Use of Imaging Studies for Low Back Pain Medical Attention for Nephropathy Appropriate Treatment for Children With Upper Respiratory Infection MEDI-CAL Areas to Improve Cervical Cancer Screening Controlling High Blood Pressure Diabetes Care Retinal Eye Exam Diabetes Care Blood Pressure <140/90 Annual Monitoring for Patients on Persistent Medications (ACE/ARB and Diuretics) Children and Adolescents' Access to Primary Care Practitioners Prenatal and Postpartum Care Well-child Visits in the Third, Fourth, Fifth and Sixth Years of Life Children with Pharyngitis Follow-up Care for Children Prescribed ADHD Medication MEDICARE ALLIANCE COMPLETECARE (HMO SNP) Measures at or Above 4 Stars Cholesterol Screening for Patients with Heart Disease Diabetes Care Nephropathy Screening Areas to Improve Adult BMI Assessment Care for Older Adults Functional Status Assessment Care for Older Adults Pain Assessment Diabetes Care HbA1c <9% Rheumatoid Arthritis Management PHONE REMINDERS ABOUT HEDIS SCREENINGS Throughout October, the Alliance has been conducting Interactive Voice Response (IVR) calls to Alliance CompleteCare members who have not received a glaucoma screening exam or a diabetes retinal eye exam this year. These automated calls remind members to receive the services by the end of Please ask your Alliance CompleteCare members to schedule appointments for these eye exams by calling March Vision Care directly at IVR calls will soon remind Alliance CompleteCare members who have not yet received a mammogram or appropriate colorectal cancer screening within the recommended time frames. If your patient has not been adequately screened for breast and colorectal cancer, please remind them to get the recommended tests. Alliance CompleteCare and Alliance Group Care members who call the Alliance Nurse Line will be reminded by the nurse to get screened for breast cancer, colorectal cancer, and glaucoma. NEW CREDENTIALING VENDOR Gemini Diversified Services, Inc. (GDS) is an NCQA-accredited credentialing company recently contracted by Alameda Alliance for Health to provide credentialing services. These services include processing of recredentialing applications every three years and periodic requests for updated information such as malpractice, license, and board certification. Using GDS will streamline the credentialing process and assist the Alliance in updating credentialing information. For more information, please contact the Alliance Credentialing department at NEW MENTAL HEALTH AND SUBSTANCE ABUSE Service Partner for Alliance Group Care Members Effective January 1, 2014 the Alliance will change to Beacon Health Strategies/CHIPA Outpatient Mental Health Provider, our new partner to administer mental health and substance abuse benefits for Alliance Group Care members. We have informed Alliance Group Care members that we are changing to this new partner. We also have been letting members know there will be no change to their mental health and substance abuse benefits. Beacon/CHIPA hopes to maintain members with their current, established therapist(s). If a member's current therapist is not contracted with Beacon/CHIPA, there is a process in place for continuity of care with the existing provider. Starting January 1, 2014, please access mental health and substance abuse services for Alliance Group Care members by calling: Beacon Health Strategies (TTY for hearing impaired callers: ) 8:30 a.m. - 5 p.m., Monday - Friday. If you have any questions about this change, please contact the Alliance Provider Services department at Page 4 Page 5

4 NEW PHARMACY BENEFITS MANAGER (PBM) New PBM The Alliance has contracted with PerformRx to provide pharmacy services to all Alliance members beginning January 1, New Pharmacy Prior Authorization (PA) Phone and Fax Numbers Starting January 1, 2014, providers will be able to submit Prior Authorization requests using the phone and fax numbers below. ALLIANCE COMPLETECARE MEDI-CAL AND ALLIANCE GROUP CARE (IHSS) ALLIANCESELECT & ALLIANCESELECT DIRECT Phone Fax New Pharmacy PA Form Our new Prior Authorization request form can be found at alamedaalliance.org under the provider tab. Please contact Provider Services at with any questions. PSYCHOTROPIC DRUG INTERVENTION PROGRAM The Alliance and our behavior health partner, Beacon Health Strategies/CHIPA, are pleased to launch the Psychotropic Drug Intervention Program (PDIP) effective November 1, Our goal is to improve member safety and health outcomes by providing primary care physicians (PCPs) with timely and relevant PDIP information, promoting communication among providers, and ensuring efficient use of limited resources. This program will serve all Alliance members. The PDIP includes several components that support the specific care you provide to your patients. Notifications will inform you of prescribing and medication refill patterns that would be useful to review and evaluate. The PDIP benefits both providers and patients by: Informing prescribers about best prescribing practices with timely, relevant, and evidence-based information Alerting providers to potential problems in medication adherence, dosing, and polypharmacy for individual members Supporting PCP prescribers decision-making through telephonic availability of consulting psychiatrists If you have questions regarding the program, please call Susan Cooke, Assistant Director, PDIP at Members and providers with questions regarding a PDIP intervention letter may call Beacon/CHIPA at PROVIDERS KEY TO MEMBERS GETTING FLU SHOTS The flu season is here again. In the United States it can start as early as October and continue to as late as May. Please start sharing information about the benefits of flu vaccination with your patients now. Why? Your advice and encouragement can make the difference in your patients willingness to get their flu shot. Many patients still see the flu shot as only important for the very young, elderly, or those at risk. However, the CDC recommends that everyone at least six months of age get the flu vaccine, with certain exceptions*. Talking Points for Doctors By getting the vaccination, they will protect those around them who are more vulnerable to the flu. - Getting the flu shot, even for healthy people, helps prevent a miserable flu and time absent from work or school. - Even healthy people have had severe cases of the flu that led to hospitalization or even death. - Alliance members can get their flu vaccines at their PCP office or their pharmacy. Thank you for counseling patients about the importance of flu vaccines and helping them find the most convenient location to get theirs today! * keyfacts.htm Page 6 Page 7

5 PERTUSSIS CASES ON THE RISE Protect vulnerable infants from pertussis and immunize mothers with Tdap during every pregnancy Pertussis is a continuing threat to Californians. Over 9,100 cases of pertussis were reported in California during 2010, the most in more than a half-century. Consistent with historical cycles of 3-5 years between years of higher incidence, cases are likely to increase between 2013 and Infants at Highest Risk of Severe Pertussis Early evidence suggests that maternal immunization with Tdap during the third trimester of pregnancy can prevent pertussis in young infants. Infants younger than two months of age are most susceptible to hospitalization or death from pertussis, but immunization against pertussis is not recommended until at least 6 weeks of age. However, infants can be protected by maternal antibodies that are transferred through the placenta. Optimal Timing of Maternal Tdap Administration To maximize protection of young infants, the federal Advisory Committee on Immunization Practices (ACIP) recommends that all women should be administered Tdap during every pregnancy, preferably between 27 and 36 weeks gestation. If Tdap is not administered during pregnancy, it should be given immediately postpartum. Other Close Contacts Everyone (e.g., parents, siblings, grandparents, childcare providers, and healthcare personnel) who anticipates close contact with an infant younger than 12 months of age should receive Tdap if they have not already done so. ACIP is currently considering whether Tdap boosters are indicated for people in contact with infants. References 1. California Department of Public Health. Pertussis summary reports. ca.gov/programs/immunize/pages/pertussissummaryreports.aspx 2. CDC. Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccine in Pregnant Women-Advisory Committee on Immunization Practices, MMWR, 2013; 62 (7): Available at: preview/mmwrhtml/mm6207a4.htm 3. Healy CM, Rench MA, Baker CJ. Importance of timing of maternal Tdap immunization and protection of young infants. Clin Infect Dis 2013;56: Credits: CDPH Immunization Branch NEW STAYING HEALTHY ASSESSMENT (SHA): Implement by April 1, 2014 Thank you to the providers who responded to our recent survey regarding the Staying Healthy Assessment! All providers need to implement the Department of Health Care Services' (DHCS) new and improved Staying Healthy Assessment by April 1, This must be done either in paper form or by integrating them into Electronic Health Record (EHR) systems. Please prepare for the new SHA by going to the DHCS SHA website for forms and instructions at TinyURL.com/DHCS-SHA. Here is what s coming: Web-based and in-person training on the SHA requirements required for each provider office A CD with all SHA materials, created especially for those who can t access the forms or resources through the Web Updated resources on the Alliance website for providing health education and referrals Scoring of the SHA portion of the Medical Record Review will resume on April 1, 2014 Stay tuned for fax blasts or s with training opportunities. Need more information? Please contact Provider Services at or providerservices@ alamadaallaince.org. CLAIMS CORNER Claims System Updates A new claims system is being installed at the Alliance on January 1, We are moving from Diamond to a new state-of-the-art platform called HEALTHsuite from RAM Technologies. We are also installing a new authorization system from CaseNet called TruCare. These new systems will allow us to serve you more efficiently in the future. New member and provider ID numbers will be issued as part of the process, but not to worry, we will still be able to handle the old ID numbers. There are two new interfaces for HEALTHsuite: ClaimCheck from McKesson and EasyGroup PPS from Optum. In addition, printed RAs will have a slightly different format, but there will be no information loss and they will print the provider ID and TIN. Look for future communications from us about these changes. We will also offer webinars in November, and then post recordings of the presentations on our website. NOTE: As part of these system updates, all Alliance members will receive a new ID card by January 1, Page 8 Page 9

6 Free Language Service and Medical Transportation The Alliance offers free interpreter services and medical transportation. Please remember to recommend that members use professional medical interpreters and not family members or friends. If a member declines the use of a professional medical interpreter please note that in their medical record. For an in-office, face-to-face interpreter: call Member Services at , Monday Friday, 8:00 a.m. 5:00 p.m. For telephone and after-hours phone interpreter service: call , 24 hours a day, seven days a week. Non-emergency transportation may be covered when the member needs to go to a scheduled medical appointment and return home. FRAUD, WASTE, & ABUSE The Alliance is committed to complying with all applicable federal and State laws addressing false claims, including the Federal False Claim Act, the California False Claims Act and the Deficit Reduction Act of The Alliance fosters a culture that promotes prevention, detection, and resolution of situations that do not conform to these laws. If you have concerns about possible fraud, waste, or abuse, possible unethical business practices or potentially illegal activity regarding our health plan, our providers, vendors, or members, please report this information by contacting: Alameda Alliance for Health Compliance Hotline: Alameda Alliance for Health Compliance department: compliance@alamedaalliance.org For Medi-Cal: Call the Department of Health Care Services Medi-Cal Fraud Reporting Line: ALAMEDA ALLIANCE FOR HEALTH OFFICES Headquarters: South Loop Road, Alameda, CA Downtown Oakland: th Street, Suite 730, Oakland, CA Ed Roberts Campus: Adeline Street, Suite 160, Berkeley, CA ALLIANCE DEPARTMENT PHONE FAX Authorizations Mon Fri, 8:30 a.m. 5 p.m. (provider use only) Claims , option Compliance Eligibility (24-hour automated line) Member Services Mon Fri, 8 5 (eligibility, provider assignment, schedule interpreters) Pharmacy Services Provider Services providerservices@alamedaalliance.org Alliance Member Rights and Responsibilities Alliance members have rights and responsibilities. We encourage you to be familiar with our members rights and responsibilities and we expect that you will abide by these rights. The complete Alliance s Member Rights and Responsibilities statement is posted on the Alliance website at alamedaalliance.org/ members/member-materials/. If you would like a paper copy of the statement, please contact Provider Services at For Medicare, call the US Department of Health and Human Services Office of Inspector General: or the Centers for Medicare and Medicaid Services: ALLIANCE PROVIDERS PHONE Alameda County Behavioral Health Beacon Health Strategies/CHIPA Children First Medical Group Community Health Center Network MedImpact (pharmacy benefit manager) through 12/31/ Denti-Cal March Vision Care Optum Behavioral Health (Call Center) physician consultation member referral Quest Diagnostic outpatient lab services WE RE ON THE WEB: Page 10 Page 11