Summer Fall Optima Health News. Industry News. Provider Resources. Authorizations and Medical Policies. Billing and Reimbursement.

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1 Optima Health News 2 FIT Kits for Colorectal Screening Medallion 4.0 Transition Information Industry News 4 New Virginia Law - HB 139 Reminder Complete Your Cultural Competency Training Provider Resources 6 EAP Services Required Medicare and Medicaid Enrollment Participating Reference Laboratories Screening Children and Adolescents for Alcohol Use 2018 Provider Surveys Authorizations and Medical Policies 11 Hysterectomy Member Acknowledgement - Optima Family Care and Optima Health Community Care Billing and Reimbursement 12 Optima EAP Reimbursement Reminder Additional Electronic Claim Submission Option CMHRS Providers Must Complete Field 32 on the HCFA 1550 Claim Form CPT II Codes for Blood Pressure Optima Family Care and Optima Health Community Care Dental Coding Change Pharmacy 14 Quality Improvement 15 October 2018 Formulary Changes Prescribing Statins to Patients Lead Screening Clinical Guidelines Combatting the Opioid Overdose Epidemic What is HEDIS? The National Committee for Quality Assurance and Population Health Management Important Phone Numbers 20 Keep Your Practice Information Up to Date providernews Summer Fall 2018 Any policy changes communicated in this newsletter are considered official and effective immediately unless otherwise indicated, and will be reflected in the next edition of the Optima Health Provider Manual. We have attempted to identify each policy change by placing a red push pin to the left of the corresponding language. 1

2 Optima Health News FIT Kits for Colorectal Cancer Screening The U.S. Multi-Society Task Force of Colorectal Cancer (MSTF), which represents the American College of Gastroenterology, the American Gastroenterological Association, and The American Society for Gastrointestinal Endoscopy, recently published the following recommendations: Colorectal Cancer screening tests are ranked in three tiers based on performance features, costs, and practical considerations. The first-tier tests includes a colonoscopy every 10 years and an annual Fecal Immunochemical Test (FIT). Colonoscopies and FIT are recommended as the cornerstones of screening regardless of how screening is offered. The National Colorectal Cancer Roundtable (NCCRT) has advocated that achieving an 80 percent screening goal could prevent over 200,000 colon cancer deaths within 20 years. Last year, over 2000 Optima Health members over the age of 50, who had a gap in care for colorectal cancer screenings, participated in a program that promoted colorectal cancer screenings by completing a FIT Kit at home. Approximately 140 members had positive results. These results were sent to the members and to their identified Primary Care Providers. Of the members who had a positive FIT test, 33 had pre-cancerous polyps removed and three members had partial colectomies for colon cancer or large polyps. Members are now able to request a FIT Kit directly from the Optima Health website at optimahealth.com/ colonhealth by providing their demographic information and their Primary Care Provider s information. Optima Health is in the final stages of planning the Optima FIT campaign for 2018, which is scheduled to golive on September 26. Optima Health has partnered with the American Cancer Society to promote colorectal cancer screening. Please encourage your patients to complete their FIT screening if they call your office inquiring about the kit they received in the mail. Ensure that your office staff, including nurses and front desk, are also able to encourage the patients to complete the FIT kit screening. Both you and your patient will receive the results of the FIT screening by letter. Patients with positive results will also receive a phone call from a nurse practitioner encouraging them to schedule an appointment with you as soon as possible for further testing 2

3 providernews Fall 2018 Optima Health News Medallion 4.0 Transition Information Optima Family Care has been providing coverage for Virginia Medicaid Members for 24 years and will continue our dedication to being Easy to do Business With through the new Medallion 4.0 product. We invite you to join us and hear our Network Educators go through changes that may impact you, as well as answer any questions you may have. Please join us at one of the regional Optima Health Medallion 4.0 Provider Seminars closest to you. Registration is required and seats are limited. Morning seminars include breakfast and afternoon seminars include lunch. Event Password is required when registering: Optima Rocks! In addition, a condensed version of important transition information you need to know is also offered through weekly WebEx sessions: Medallion 4.0 Provider Weekly Webinar Hosted by AMANDA B EDWARDS Occurs every Tuesday from 12:00 PM to 1:00 PM EST Meeting number: Join by phone Call-in toll number (US/Canada) Access code:

4 Industry News New Virginia Law HB 139 Virginia House Bill 139 is a new law that requires health plans to pay in-network rates to a Provider covered under an existing contract for the time period between when they submit their completed Credentialing application and the date they are approved by the Credentialing Committee. The law applies specifically to doctors of medicine and osteopathic medicine that hold an active license with the Virginia Board of Medicine. It only applies to Providers joining an existing group that already has a fully executed contract with the health plan. Once the Credentialing Committee approves the Provider, claims for services provided during the time the completed application was in process can be submitted and will be reimbursed at the contracted in-network rate. Per the law, if the Provider is not approved by Credentialing, the health plan will not pay for services during that period and the Member may not be billed. This law also requires Providers to provide specific written or electronic notice to Members prior to providing a service if they have not yet been approved by the Credentialing Committee. Reminder Complete Your Cultural Competency Training Being equipped to accommodate the needs of an increasingly diverse population is a growing concern in the healthcare community. Cultural competence and effective communication are keys to understanding a patient s concerns and helping to ensure they understand their healthcare plan. We strongly encourage all providers to complete cultural competency training. The Optima Health provider directory will display Cultural Competence as a feature on all provider profiles, informing members which providers have completed this important training. Please visit the Education section of optimahealth.com/providers for links to cultural competency training opportunities. CME credits are available. Upon completion of training, please complete the Provider Acknowledgement Form for Cultural Competency so we can credit you for this education. 4

5 providernews Fall 2018 Industry News 5

6 Provider Resources EAP Services All Behavioral Health Providers that participate for Optima Health Commercial Products (Fully-Insured, Self- Insured Commercial HMO, POS and PPO) are contractually obligated to provide services for the Employee Assistance Program (EAP), per Exhibit A-1 of the Optima Behavioral Health Provider Agreement unless there is a qualified written exception. A Provider s assessment and referral of EAP services include: Diagnostic assessment, Intervention and/or short term counseling, and Referral to appropriate local resources Providers will receive EAP referrals from employees of Optima Health. Appointments should be offered within 48 hours of the referral with a face-to-face assessment at that time, unless a later date is requested. Required Medicare and Medicaid Enrollment Providers that participate in Optima Family Care and Optima Health Community Care are required to enroll with DMAS and have a Medicaid Provider number at Providers participating with Optima Medicare HMO and Optima Community Complete are required to enroll in Medicare and have a Medicare Provider number at Certification. Participating Reference Laboratories Optima Health requires the use of participating reference laboratories. The Optima Health website provides a current listing of all participating reference laboratories in your area under the category of Find Hospitals and Facilities. Please note that HCA reference laboratories are not contracted with Optima Health. 6

7 providernews Fall 2018 Provider Resources Screening Children and Adolescents for Alcohol Use Research indicates that two age-specific screening questions are powerful predictors of current and future alcohol problems in youth. Below are some useful ways to address this situation with your patients: STEP 1: ASK THE TWO SCREENING QUESTIONS Elementary School (ages 9 11) Ask the friends question Friends: Any drinking? Do you have any friends who drank beer, wine, or any drink containing alcohol in the past year? ANY drinking by friends heightens concern. Patient: Any drinking? How about you have you ever had more than a few sips of beer, wine, or any drink containing alcohol? ANY drinking: Highest Risk Middle School (ages 11 14) Ask the friends question Friends: Any drinking? Do you have any friends who drank beer, wine, or any drink containing alcohol in the past year? ANY drinking by friends heightens concern. Patient: How many days? How about you in the past year, on how many days have you had more than a few sips of beer, wine, or any drink containing alcohol? ANY drinking: Moderate or Highest Risk High School (ages 14 18) Ask the patient question Patient: How many days? In the past year, on how many days have you had more than a few sips of beer, wine, or any drink containing alcohol? Lower, Moderate, or Highest Risk Fr iends: How much? If your friends drink, how many drinks do they usually drink on an occasion? Binge drinking by friends heightens concern. NO Does the patient drink? YE S GO TO STEP 2: GUIDE GO TO STEP 2: ASSESS RISK 7

8 Provider Resources STEP 2: GUIDE PATIENT For patients who DO NOT drink... NO Do friends drink? YE S Neither patient nor patient s friends drink Pa tient does not drink, but friends do Praise choices of not drinking and of having nondrinking friends. Praise choice of not drinking. Consider probing a little using a neutral tone: When your friends were drinking, you didn t drink. Tell me a little more about that. If the patient admits to drinking, go to Step 2 for Patients Who Do Drink; otherwise, continue below. Reinforce healthy choices with praise and encouragement: You ve made a smart decision not to use alcohol. ay alcohol free: So, what led you to the decision to stay away from alcohol? If friends drink, add, especially when your friends have chosen to drink? Possible followup: Those are great reasons and show you really care about yourself and your future. Educate: If your patient is open to input, you may want to help him or her understand, for example ect brain development, which continues into a person s twenties; and (2) drinking at an early age increases the risk for serious alcohol problems later in life. Rescreen next year at the latest. Explore how your patient plans to stay alcohol free when friends drink: Ask patients for their ideas on handling situations where they may feel pressure to drink. You can let them know that often the best response to a drink er is a simple No, thanks ; that, if pressured, ective response is I don t want to ; and that they don t have to give a reason. Advise against riding in a car with a driver who has been drinking or using other drugs. Rescreen at next visit. Screening complete for nondrinkers 8

9 providernews Fall 2018 Provider Resources STEP 2: ASSESS RISK For patients who DO drink... Age 11 On how many DAYS in the past year did your patient drink? 1 5 days 6 11 days days days 52+ days Highest risk Tx: Brief motivational interviewing + possible referral Lower risk Moderate risk 18 Tx: Brief advice Hearing Aids for OHCC Members Tx: Brief advice or motivational interviewing Estimated risk levels by age and frequency in the past year The hearing aid benefit for Optima Health Community Care (OHCC) Members must be provided by the EPIC hearing network of Providers. Information about the EPIC network may be found at epichearing.com or by calling

10 Provider Resources 2018 Provider Surveys This fall, Optima Health staff or our contracted survey vendor will perform several surveys of participating Providers. The results of these surveys help us to identify and prioritize service improvements, allocate resources, and meet NCQA and government regulatory requirements. When possible, Providers that have already been surveyed are eliminated from additional survey samples. Provider Satisfaction Survey: A random sample of Provider offices will receive a mailed survey and/or will be called by our vendor, SPH Analytics, and asked to participate in our Provider Satisfaction Survey. This survey asks you to rate the services we provide to our Providers and is an excellent vehicle for anonymously giving us feedback and making suggestions for every area of the health plan. Appointment Access Survey and After-Hours Survey: We will follow with a required survey to determine how well Providers meet our appointment access standards and after-hours coverage requirements. SPH Analytics will perform the Appointment Access survey during office hours and the After-hours Coverage survey after hours by phone for a random sample of Providers. Current appointment standards are listed in the Optima Health Provider Manual and after-hours coverage requires that a person or recording be in place to immediately direct patients for emergency care. Provider Directory Accuracy Survey: The final survey will ask the person answering the phone in the office to provide basic demographic and product participation information. Their responses will be compared to the information that is currently in the Optima Health directory. This survey will be performed by Optima Health staff and is required by regulations to assess whether Members are receiving the correct information in our Provider Directories for access to care. A random sample of Provider offices will be contacted. We appreciate your time in assisting us with these required surveys. Results will be provided in the Newsletter along with action plans created to address areas of concern. 10

11 providernews Fall 2018 Authorizations and Medical Policies Hysterectomy Member Acknowledgement - Optima Family Care and Optima Health Community Care To obtain hysterectomy pre-authorization for Optima Family Care and Optima Health Community Care members, Optima Health now requires you to submit written member acknowledgement that the procedure will render the member permanently incapable of reproducing. The acknowledgement should be submitted with the necessary clinical documentation to support medical necessity. Optima Health will accept the completed Virginia Medicaid MAP 3005 form. 11

12 Billing and Reimbursement Optima EAP Reimbursement Reminder Please remember that Optima EAP does NOT accept electronic claim submission. All EAP claims must be printed on a HCFA 1500 and submitted to EAP for processing. Please mail or fax EAP claims to: Optima EAP 816 Independence Blvd., Suite 3B Virginia Beach, VA FAX: The Optima EAP phone number is and the hours of operation are Monday Thursday, 8:00 a.m. 7:00 p.m. and Friday, 8:00 a.m. - 5:00 p.m. Additional Electronic Claim Submission Option Optima Health now offers the option of submitting electronic claims through Availity for both batch EDI claims and claims submitted through the Availity portal. Providers can register for the free portal at availity.com. The Optima Health Payer IDs are: Definition Payer IDs Institutional Professional - Medical Professional - Behavioral Health 5415M CMHRS Providers Must Complete Field 32 on the HCFA 1500 Claim Form Field 32 on the HCFA 1500 Form, Service Facility Location Information, provides the name and address of the facility where services were rendered and identifies the site where the service(s) were provided. Completion of this field is required on all CMHRS claims for Behavioral Health Providers in order to determine accurate claims payment. 12

13 providernews Fall 2018 Billing and Reimbursement CPT II Codes for Blood Pressure The National Committee for Quality Assurance has revised the specifications for the HEDIS (Healthcare Effectiveness Data and Information Set) measure Controlling High Blood Pressure to allow for use of CPT II codes to collect this information. Below are the specific codes that may now be used for this purpose. This will reduce the need for onsite medical record reviews or requests to provide records for review. Please utilize these codes for your patients with a diagnosis of hypertension. Definition Systolic Less than 140 Systolic Greater than/equal to 140 Diastolic Less than 80 Diastolic Diastolic Greater than/equal to 90 CPT II Code 3074F, 3075F 3077F 3078F 3079F 3080F Information regarding additional HEDIS measures is available on the Optima Health website: optimahealth.com/providers/quality-improvement/hedis HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). Optima Family Care and Optima Health Community Care Dental Coding Change Effective October 1, 2018 Optima Family Care and Optima Health Community Care will no longer accept Current Dental Terminology (CDT) codes. Practices/facilities should refer to the Current Procedural Terminology (CPT), or the Health Care Common Procedural Coding System (HCPCS) and bill the appropriate code. This change is being made in accordance with DMAS requirements for data transfer as defined by the Accredited Standards Committee (ASC) X12 for claims/encounter data. 13

14 Pharmacy October 2018 Formulary Changes The pharmacy changes effective October 1, 2018 for plans with pharmacy benefits administered by Optima Health are now available at optimahealth.com/providers: select Pharmacy, select Formularies/Drug Lists scroll down to find the Current Quarterly Changes list. Note: Pharmacy changes are made on a quarterly basis with effective dates of January 1, April 1, July 1, and October 1. For Groups without a four-tier pharmacy plan, drugs listed as moving to Tier 4 will remain at Tier 3. These pharmacy changes are specific to commercial plans only and are not applicable to our Medicare plans. 14

15 providernews Fall 2018 Quality Improvement Prescribing Statins to Patients Based on clinical guidelines and quality measures from the American College of Cardiology/American Heart Association (ACC/AHA), Centers for Medicare and Medicaid Services (CMS), and National Committee for Quality Assurance (NCQA), Optima Health recommends that providers prescribe statin therapy to manage cardiovascular disease and diabetes in their patients. Our HEDIS criteria focuses on compliance in receiving statin therapy and at least 80% statin adherence. Statin Therapy for Patients with Cardiovascular Disease ACC/AHA guidelines recommend statin therapy for primary prevention of cardiovascular events for males years of age and females years of age, who have been identified as having clinical atherosclerotic cardiovascular disease (ASCVD). The HEDIS criteria includes: Member was dispensed at least one high or moderate-intensity statin medication during the measurement year. Remained on a high or moderate-intensity statin medication for at least 80% of the treatment period (from initial prescription through the end of the measurement year). Statin Therapy for Patients with Diabetes ACC/AHA guidelines recommend statin therapy for patients years of age with diabetes, who do not have clinical atherosclerotic cardiovascular disease (ASCVD). The HEDIS criteria includes: Member was dispensed at least one statin medication of any intensity during the measurement year. Remained on a statin medication of any intensity for at least 80% of the treatment period (from initial prescription through the end of the measurement year). Lead Screening This HEDIS measure looks at the percentage of children 2 years of age in the Medicaid population who had one or more capillary or venous lead blood tests for lead poisoning by their second birthday. Documentation must include a note indicating the date the test was performed, and the result or finding. A common chart error includes lead screenings done in the office but not documented. Please note that lead assessment does not constitute a lead screening. 15

16 Quality Improvement Clinical Guidelines Optima Health reviews and revises clinical guidelines bi-annually. The most up-to-date, evidenced based clinical guidelines can be found in the Clinical Reference section of optimahealth.com/providers. If you would like a printed copy of these guidelines or have questions, comments, or suggestions about the guidelines, please contact the Optima Health Quality Improvement Department at or Please note: Clinical data in a particular case may necessitate or permit deviation from these guidelines. Optima Health guidelines are institutionally endorsed recommendations and not intended as a substitute for clinical judgment. Combatting the Opioid Overdose Epidemic The morbidity and mortality associated with opioid use has reached epidemic proportions, and is recognized by the Centers for Disease Control and Prevention and the Surgeon General. Optima Health is committed to fighting the opioid overdose epidemic and supporting the communities we serve as we continue work to identify outbreaks, collect data, respond to overdoses, and provide care to those in their communities. Optima Health focuses on: Supporting and improving patient safety. Building resources for our providers and practitioners and supporting the use of evidence-based prevention strategies. Improving our data tools, assessing and analyzing our data collection, improving quality and tracking trends to better understand and respond to the epidemic. Encouraging our members to make safe choices about opioids and raising awareness about prescription opioid misuse and overdose. Long-term daily use of opioids can lead to increased tolerance, addiction, or dependence. Studies suggest a correlation between high opioid dosage and a greater risk of overdoses and fractures. One area of risk related to opioid use is the receipt of opioid prescriptions from multiple prescribers and pharmacies. HEDIS 2019 will begin looking at the Use of Opioids at High Dosage (UOD), defined as average milligram morphine dose [MME] >120mg for 15 or more days during the measurement year; and Use of Opioids From Multiple Providers (UOP), defined as receiving opioid prescriptions from four or more prescribers and/or filling these prescriptions at four or more different pharmacies. Article continued on page 17 16

17 providernews Fall 2018 Quality Improvement Below is a list of medications included in these measures: Buprenorphine (transdermal Butorphanol Codeine patch and buccal film) Dihydrocodeine Fentanyl Hydromorphone Hydrocodone Levorphanol Methadone Morphine Opium Oxycodone Oxymorphone Pentazocine Tapentadol Tramadol Collaboration is essential for success in prevention of opioid overdose deaths. Medical personnel, emergency departments, first responders, public safety officials, mental health and substance abuse treatment providers, community-based organizations, public health, and members of the community all bring awareness, resources, and expertise to address this complex and fast-moving epidemic. Together, we can better coordinate efforts to prevent opioid overdoses and deaths. For more information, see CDC s role in the opioid overdose epidemic. Sources: 1. Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; Available at 2. Seth P, Scholl L, Rudd RA, Bacon S. Increases and Geographic Variations in Overdose Deaths Involving Opioids, Cocaine, and Psychostimulants with Abuse Potential United States, MMWR Morb Mortal Wkly Rep. epub: 29 March Kolodny et al The prescription opioid and heroin crisis: A public health approach to an epidemic of addiction. Annual Review of Public Health, 36, Rudd RA, Aleshire N, Zibbell JE, Gladden RM. Increases in Drug and Opioid Overdose Deaths United States, MMWR 2016, 64(50);

18 Quality Improvement What is HEDIS? HEDIS (Healthcare Effectiveness Data and Information Set) consists of a set of performance measures utilized by more than 90% of American health plans that compare how well a plan performs in these areas: Access to care Quality of care Member satisfaction with the health plan and doctors Why HEDIS is Important HEDIS makes sure that health plans are offering quality preventive care to members. It allows consumers and employers to get a true comparison of the performance of health plans. HEDIS can also help you: Identify gaps in care for members to ensure they receive preventive screenings Understand how you compare with other Optima Health providers as well as with the national average WHAT YOU CAN DO Encourage your patients to schedule preventive exams Remind your patients to follow up with ordered tests Educate members on the importance of medication compliance, when treating acute and chronic conditions HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA) Source: National Committee for Quality Assurance (2018). Technical Specifications for Health Plans. HEDIS Vol. 2. Washington, D.C. Retrieved July 30, 2018 from 18

19 providernews Fall 2018 Quality Improvement The National Committee for Quality Assurance and Population Health Management The National Committee for Quality Assurance (NCQA) is including Population Health Management (PHM) as a new category in its 2018 Health Plan Accreditation (HPA) standards and guidelines. Although Population Health is not new, the PHM category is a shift from treating a member for a single disease toward a cohesive plan of action for addressing member needs across the continuum of care. Our mission is to protect and improve the health of our members and the communities we serve by continuing to focus on: A comprehensive strategy for meeting the care and needs of our member population. Identifying and assessing the needs of members, and connecting them with appropriate programs or services. Delivery System Supports by engaging providers and practitioners across different settings. Identifying members health risks and educating them about patient safety and healthier lifestyles. Managing highest-risk members with complex chronic illnesses. Conducting a comprehensive analysis to determine the effectiveness of our efforts related to: ĔĔ ĔĔ ĔĔ clinical processes or outcomes, member experiences, and cost/utilization. Source: National Committee for Quality Assurance (NCQA) (2018). NCQA Release New Standards Category - Population Health Management. 19

20 Important Phone Numbers Provider Relations or OHCC: Provider Relations Fax Behavioral Health Provider Relations Medical Care Management (Pre-Authorization) Network Educators or or OHCC: or Health and Preventive Services Proprium Pharmacy Proprium Pharmacy Fax Keep Your Practice Information Up to Date Please notify Optima Health of any changes to provider or practice information with 60 days notice, or as soon as possible, especially changes to: provider rosters, panel status, address/phone numbers, and practice address for official communication from Optima Health. Medical providers should contact their Network Educator at with this information; Behavioral Health providers should complete the Provider Update Form. Thank you for your partnership in providing accurate information to our members! 20