2015 Comes to an End

Transcription

1 SM Volume 3, Issue 10 November December Comes to an End It s hard to believe that 2015 has come and gone. The International Classification of Diseases, 10th Revision (ICD-10) was much like the falsely predicted technology disaster in the year 2000 (Y2K). Everyone thought all computers would crash after 1999, since many experts believed the computer programmers did not anticipate this change. Of course, nothing drastic occurred. We can say the same for the ICD-10 conversion, which our health plan implemented successfully. After a false start in 2014, we made it through the change in BlueChoice HealthPlan Medicaid is looking forward to a better 2016 in many respects. We value the care you provide our 80,000 members. We know what you do is difficult. We appreciate what you do and pledge that we will make our best efforts to provide you with support, communications and assistance with health plan-related obstacles you may encounter in We hope to develop incentives that will assist your practices, your patients and our members. We will feature a new section in the BlueBlast focusing on the Primary Care Office of the Future. Our health plan has established a relationship with the Connecticut Institute for Primary Care Innovation and encourages you to participate in its pioneering efforts, which may help you navigate the future of health care. The Connecticut Institute for Primary Care Innovation is an independent organization that provides health information on behalf of BlueChoice HealthPlan. Of course, we want to hear from you about what we can do to help make the BlueBlast more informative and useful. Please your comments and suggestions to us at BlueChoiceHealthPlanMedicaid@bcbssc.com. Happy 2016!

2 Consumer Assessment of Healthcare Providers and Systems Survey Shows Opportunities for Improvement in Physician Care Each year, our members receive the Consumer Assessment of Healthcare Providers and Systems (CAHPS ) survey. This survey gives our members an opportunity to share their perceptions about the quality of care and services they receive from our network physicians. All Medicaid Health Maintenance Organization (HMO) plans that undergo accreditation National Committee for Quality Assurance (NCQA) review use CAHPS. The charts compare results from 2015 to those from the previous years. The column on the far right shows the percentiles BlueChoice HealthPlan Medicaid achieved when its scores were compared to those of all other Medicaid plans across the country. Our goal is to achieve at least the 75th percentile in every rating category. As you review these results, we encourage you to focus on ways to address those areas in your own practice that may have room for improvement. Addressing those areas will help ensure our members and your patients have positive experiences that meet their medical requirements and ensure their satisfaction with the quality of services provided BlueChoice Medicaid CAHPS Adult Member Satisfaction Survey Results Survey Question Trend Rating of physician Medicaid Percentile Achieved 4 Rating of personal doctor 79% 79% 81% 50th Rating of specialist seen most often 57% 81% 85% 90th Rating of all health care provided in past 12 months 75% 69% 74% 50th Getting care quickly 2 Got appointment for urgent care as soon as needed 81% 82% 76% <25th Got appointment for non-urgent care as soon as needed Doctor s communication with patients 2 How often personal doctor explained things understandably to you 79% 82% 80% 50th 86% 89% 93% 75th How often personal doctor listened carefully to you 89% 89% 94% 90th How often personal doctor showed respect for what you had to say 89% 91% 93% 50th How often personal doctor spent enough time with you 85% 88% 90% 75th Survey Question Trend 2015 Medicaid Percentile Achieved 4 Shared decision making 3 Doctor discussed reasons to take medicines? 81% 76% 89% DNA Doctor discussed reasons not to take medicine? 58% 55% 64% DNA Doctor asked what you thought was best for you? 68% 75% 74% DNA Continuity of care 2 How often did your personal doctor seem informed about care you received from other health providers? 73% 80% 78% 25th Note: The source of data contained in this report is Quality Compass 2015 and is used with the permission of the NCQA. Quality Compass 2015 includes certain CAHPS data. Any analysis, interpretation or conclusion based on these data is solely that of the authors, and NCQA specifically disclaims responsibility for any such analysis, interpretation or conclusion. Quality Compass is a registered trademark of NCQA. 1 Percent responding 8, 9 or 10 (On a scale of 0-10, with 0 being the worst score and 10 being the best score) 2 Percent responding Usually or Always 3 Percent responding A lot Yes or Some 4 Percentile Definition A score equal to or greater than 75 percent of all those attained on a survey question is said to be in the 75th percentile DNA=Data not available

3 South Carolina Immunization Registry Regulation In May 2013, the South Carolina General Assembly approved regulation , implementing a mandatory S.C. Immunization Registry. The law requires all immunization providers to report all administered immunizations. Mandatory reporting will be phased in over three years and began Jan. 1, 2015, following an age-based, implementation schedule outlined in the regulation. As of Jan. 1, 2017, you must report all immunizations administered in South Carolina to the statewide immunization registry. If you are an immunization provider in South Carolina, you are required to register with the S.C. Department of Health and Environmental Controln (SC DHEC). You may register as an individual immunization provider, or as a facility or other entity provider (i.e., under an entity name or individual provider name). You may also register each specific location or just register once for multiple locations. If you are a health care provider who does not administer any immunizations, you may still register in order to use the registry to retrieve immunization information on your patients. Registration is a simple process. A statewide registry or Immunization Information System (IIS) has benefits for both the patient and the provider. A registry consolidates the vaccination history for patients who visit multiple providers. Having all immunizations in one system reduces over- and under-immunization. Here are methods for reporting to the immunization registry. Direct Data Entry Provider s individual users enter administered doses by manually keying data in the registry. Provider profile for Vaccines for Children Program enrollment can be generated automatically. On-demand printing of the South Carolina Immunization Certificate, DHEC On-demand printing of the immunization administration form, which when signed, may be used in a patient s medical record to document vaccine administration. Electronic Data Submission Provider submits data from Electronic Health Record [EHR] to the registry. Requires practice to have an HL7-capable EHR. Requires practice or EHR vendor to establish an interface with the registry. Eliminates dual-entry. Generate remind/recall lists. South Carolina Health Information Exchange (SCHIEx) Provider submits immunization data through SCHIEx to the registry. Another agency offers a method of data exchange with the immunization registry. Visit SCHIEx for more information on this method. Other methods of reporting may be used only with DHEC approval. If you have questions, please contact (select option 2, Immunization Registry) or by at immunizationregulation@dhec.sc.gov.

4 Telephone Interpreters Available for These Languages Arabic Farsi Spanish Armenian Chinese English Hmong Khmer Korean Russian Tagalog Vietnamese Pilot Program for OB/GYNs and Hospitals BlueChoice HealthPlan Medicaid announces a pilot initiative for all participating OB/GYNs and Hospitals. Effective Oct. 1, 2015, the initiative will focus on early notification of pregnancy and notification of delivery. We will reimburse OB/GYNs $50 for each pregnancy they reported to the plan. We will reimburse hospitals $50 for every delivery they report to the plan. To participate, a provider must compete and fax the Pregnancy Notification Form (PNR) to BlueChoice HealthPlan Mediciad. Once the form has been faxed, he or she can file the incentive on a claim. For more detailed information on this incentive, please contact your provider representative. During business hours, members and providers can call the Customer Care Center at After-hours, call the 24-Hour Nurseline at Give the customer care associate the member s ID number. 2. Explain the need for an interpreter and state the language. 3. Wait on the line while the connection is made. 4. Once connected to the interpreter, the associate or 24-Hour Nurseline will introduce the BlueChoice HealthPlan Mediciad provider and/or member, explain the reason for the call and begin the dialogue. For OB/GYNs 1. Complete and fax in the PNR to within seven days of pregnancy diagnosis date. You can find the form at bluechoice/documents/providers/wlp3375_sc_pnr_ FINAL3.pdf 2. On a separate claim, file CPT code and modifier 32 with a $50 charge amount. For Hospitals 1. Complete and fax in the Newborn Notification Form (NNF) to within three days from date of delivery. You can find this form at medicaid.com/userfiles/bluechoice/documents/ Providers/Newborn_Notification_Form.pdf 2. On a separate outpatient claim, file Type bill 0131, Revenue code 0969, and CPT code with modifier 32 with a $50 charge amount. Service date is the date of delivery.

5 CDC Predicts Another Moderately Severe Flu Season Dominated By Influenza A (H3N2) The Centers for Disease Control and Prevention (CDC) released its report in June on influenza activity during last year s flu season, and announced the composition of the influenza vaccine. According to the CDC, the influenza season was moderately severe overall and especially severe in adults ages 65 and older, with predominant circulation of influenza A (H3N2) viruses. Previous influenza A (H3N2) predominant seasons have been associated with increased hospitalizations and deaths, especially among children under 5 and adults ages 65 and older. Influenza activity peaked during late December, with influenza A (H3N2) viruses predominant early in the season. Influenza B became the predominant virus starting in late February, through the end of flu season in May. The Food and Drug Administration has recommended a change in the influenza A and influenza B components for the influenza vaccine, according to the report. It bases vaccine recommendations on several factors, including global influenza surveillance, genetic characterization, antigenic characterization, antiviral resistance and the candidate vaccine viruses available for production. Since 2010, the CDC has recommended everyone 6 months and older get a flu vaccine annually, with rare exceptions. BlueChoice HealthPlan Medicaid is launching its annual member outreach campaign to encourage high-risk members to visit their providers for flu vaccines. Outreach includes automated outbound telephone calls, text messages and newsletter articles. Providers can expect an increase in phone calls and early appointments for the flu vaccine. Antiviral drugs used to lessen flu duration and symptoms, as well as many cough and cold products, are included on the formulary found at pharmacyinformation.aspx. Flu surveillance and patient education materials are available at the CDC website. For more information about vaccine coverage, contact Provider Services at The CDC is an independent organization that provides health information on behalf of BlueChoice HealthPlan. This link leads to a third party site. That site is solely responsible for the contents and privacy policies on its site.

6 Billing For Well-Child and Sick-Child Visits On The Same Day BlueChoice HealthPlan Medicaid is committed to encouraging quality outcomes and preventive care for our members. Parents and guardians are quick to take a sick child to the doctor for medical care, but not as likely to take a child to the doctor for preventive care. For this reason, BlueChoice HealthPlan Medicaid wants to encourage our providers to perform well-child visits during sick visits. We are encouraging providers to combine sick- and well-child visits. Providers can bill claims for sick-child and well-child visits performed on the same day, effective July 15, This allows us to reimburse our providers for additional services and helps parents avoid extra trips to the doctor s office. Increased well-child visits also lead to better health outcomes for our members, as well as better Healthcare Effectiveness Data and Information Set (HEDIS ) scores. How To Bill Well-Child And Sick-Child Visits Together Use modifier 25 on the line with the well-child evaluation and management code to bill for a sick visit and a well-child visit performed on the same day. Use modifier 25 to document a distinct, separately identifiable reason for the office visit and the well-child visit. Well-child visits with modifier 25 New patient Established patient New patient Established patient Sick-child visits If you are billing vaccines/vaccine administration codes along with these two visit codes, use modifier 25 on both the sick-visit code as well as the well-visit code. For More Information If you have questions, please contact our Customer Care Center at (TTY: )

7 Colds And The Flu Increase Odds For Stroke In Children, Though Risk Is Low Researchers also found children who had all of their vaccinations were less vulnerable Having a cold or the flu may sometimes trigger a stroke in children particularly those with underlying health conditions though the overall risk remains low, a new study indicates. The study compared two groups of more than 350 children one set had suffered ischemic clot-based strokes and the other had not. Researchers found that those with stroke were six times more likely to have had a minor infection the previous week than those who didn t have a stroke. Also, children who had most or all of their routine vaccinations were significantly less likely to suffer a stroke than children who received only some or no vaccinations, according to the study, published online Sept. 30 in the journal Neurology. Study author Dr. Heather Fullerton, a professor of child neurology and pediatric stroke neurologist at University of California, San Francisco (UCSF), Benioff Children s Hospital in San Francisco says, It basically offers some explanation why a stroke may happen on a particular day in a child s life, and offers an opportunity for stroke prevention. You can t change a child s underlying condition, but you can potentially do something about that stroke trigger. The study merely showed an association between minor infections and children s stroke risk, however, but didn t prove a cause-and-effect relationship. Stroke in children is exceedingly rare, occurring in two to 13 out of every 100,000 children annually. Most of those children cope with underlying health conditions, such as congenital heart disease, sickle cell anemia or a blood-clotting disorder. Only about one in 100,000 otherwise healthy children suffer a stroke each year, Fullerton said. In the study, Fullerton and her team reviewed medical charts and conducted parent interviews of 355 children up to age 18 (average age 7) diagnosed with a stroke and 354 stroke-free children of similar ages. The groups hailed from nine countries. Researchers analyzed the children s exposure to infection and their vaccine history. Of all participants, 18 percent of those with stroke had an infection including flu, colds or to a lesser extent, urinary tract or gastrointestinal infections in the prior week. Only 3 percent of the children who didn t have a stroke had had an infection the week before. The association between infection and stroke was short-lived, lasting no longer than a week, experts noted. Meanwhile, children who had received some, few or none of their routine vaccinations were seven times more likely to have a stroke than those who received most or all of their vaccinations. Vaccines are clearly protective, Fullerton said. No matter how we cut the data, vaccines always appear to protect against childhood strokes. In addition to making sure children receive all routine vaccinations, including for flu, parents and teachers can remind children of easy ways to avoid passing along colds and other infections, Fullerton said. Common infection-control measures like hand-washing and covering their mouths are going to be helpful in these kids, she said. Even teaching kids to cough into their elbow[s] rather than their hand[s] can actually make a big difference to protect kids we know to be at increased risk. SOURCES: Heather Fullerton, M.D., professor, children s neurology, pediatric stroke neurologist and director, Pediatric Brain Center, University of California, San Francisco, Benioff Children s Hospital, San Francisco; Sept. 30, 2015, Neurology, online. Neurology is an independent publication that offers health information on behalf of BlueChoice HealthPlan.

8 Provider Education Seminar Questions 2015 This year, over 144 providers attended update meetings in Greenville, Columbia, Rock Hill and Charleston. Providers asked several questions asked during these sessions. We want to share the questions and answers with you. My secondary claims do not always get in to the claims system. Can you explain the process for filing secondary claims? If filing hard copy, submit secondary claims with the primary explanation of benefits to: P.O. Box Columbia, SC You can also submit secondary claims electronically. When physician s assistants file claims under the supervising physician, what is the reimbursement? 100 percent of the Medicaid fee schedule. Does BlueChoice HealthPlan Medicaid require referrals? BlueChoice HealthPlan Medicaid does not require a referral for a member to see an in-network specialist. Can I file a sick visit and a well visit on the same day? In an effort to close gaps in care, PCPs are allowed to file a well visit and a sick visit on the same date of service. File the well visit with a 25 modifier. To which providers can I refer BlueChoice HealthPlan Medicaid members? You can refer members to any in-network provider without a referral. You can find the most up-to-date provider directory on our website at The Provider Directory search option is located on the home page. How do I file rural health center (RHC) claims? RHC claims are based on encounter code T1015. Most RHC claims are filed with the RHC NPI in block 24J and 33A. The individual contract and system setup determines the proper coding for RHC claims. If you are not sure what contract and/or setup your RHC falls under, please contact your provider representative directly. Can I see a member if I am not the primary care physician listed on the member s BlueChoice HealthPlan Medicaid ID card? You can see a member if you are not the physician listed on the card. We do encourage you to have the member update his or her PCP by completing the PCP Selection Form. This form is on our website under Providers > Forms. Members can also call the Customer Care Center at to make a PCP change. What do I do about non-par denials? Should you receive an out-of-network denial for a physician you know has been credentialed, please contact your provider representative directly. Can I provide a roster of my physicians to my provider representative to verify that they are loaded in the system? You can ask your provider representative to review your provider listing to ensure all physicians are loaded properly. How do I file a corrected claim? File corrected claims electronically or via paper. If filed on paper, submit the corrected claim form along with the original claim. Using this form will prevent your corrected claim from denying as a duplicate. How do I remove a member from my roster? For a noncompliant or disruptive member, complete and fax a Member Deletion form into our call center. The call center will contact the member to explain the process and assist with finding another doctor. What is the turnaround time for corrected claims to be processed? Seven to 10 business days. Can I send corrected claims electronically? Yes.

9 Hemophilia Drug Requests Beginning on Nov. 15, 2015, BlueChoice HealthPlan Medicaid must review certain hemophilia drug requests for prior authorization. Please share this information with office staff and other providers in your practice. Prior authorization requirements will be added to these codes: C9136 Factor VIII, fc fusion protein, (recombinant) J7178 Human fibrinogen concentrate J7180 Factor XIII (antihemophilic factor, human) J7181 Factor XIII A-subunit, (recombinant), [Tretten] J7182 Factor VIII, (antihemophilic factor, recombinant), [Novoeight] J7183 Von Willebrand factor complex (human), [Wilate] J7185 Factor VIII (antihemophilic factor, recombinant) [Xyntha] J7186 Antihemophilic factor VIII/von Willebrand factor complex (human), per factor VIII IU [Alphanate] J7187 Von Willebrand factor complex [Humate-P] J7189 Factor VIIa (antihemophilic factor, recombinant) J7190 Factor VIII antihemophilic factor, human, [Hemofil M, Doate DVI, Monoclate-P] J7191 Factor VIII, antihemophilic factor [Porcine] J7192 Factor VIII (antihemophilic factor, recombinant), [Advate, Helixate-FS, Kogenate-FS, Recombinant] J7193 Factor IX (antihemophilic factor, purified, non-recombinant) [AlphaNine SD, Mononine] J7194 Factor IX complex, [Bebulin VH, Profilnine SD] J7195 Factor IX (antihemophilic factor, recombinant), [Benefix] J7198 Anti-inhibitor J7199 Hemophilia clotting factor, [Eloctate] J7200 Factor IX, (antihemophilic factor, recombinant), [Rixubis] J7201 Factor IX, Fc fusion protein (recombinant) Note: Noncompliance with new requirements may result in denied claims. Coding may not reflect the codes that are reimbursed under the benefit. We didn't list all prior authorization requirements here. Detailed prior authorization requirements are available to contracted providers by accessing Non-contracted providers should contact BlueChoice HealthPlan Medicaid by calling the Customer Care Center at BlueChoice HealthPlan Medicaid Provider Operations Manual The BlueChoice HealthPlan Medicaid Provider Operations Manual is always available on our website at Go to Providers > Resources > Manuals & Guides > Provider Manual. Updates to the current version will be coming soon.

10 We re In Your Community! BlueChoice HealthPlan Medicaid was the presenting sponsor of the Annual Death by Chocolate event in Beaufort hosted by The Girl Scouts of Eastern South Carolina. Pictured from left: Loretta Graham, CEO Girl Scouts of Eastern South Carolina; Tiesha Williams, Provider Relations; Amy Bennett, Director, Medicaid Operations; Maggie Brodt, Director, Clinical Quality Management; Chiara Lazarus, Outreach Specialist Sr.; Donna Williams, Marketing & Membership Lead; Daphney Addison, Outreach Specialist Sr.; Diane Smart, Fund Development Manager, Girl Scouts of Eastern South Carolina. Anderson was abuzz as BlueChoice HealthPlan Medicaid hosted an Ultimate Baby Shower. There were many activities including a kids coloring zone, car seat checks and safe sleep classes. Outreach Specialist David Rojas shared health and service information, health tips and more. Over 200 attended the event, where everyone went home with a prize. Charleston, SC was filled with excitement at Marion Square. BlueChoice HealthPlan Medicaid sponsored the Children s Museum Fam Jam. Over 2,500 people were in attendance at the event. BlueChoice HealthPlan Medicaid Outreach Specialist Chiara Lazarus and Donna Williams, marketing manager, conducted an interactive arts and crafts station, shared benefits, service information, health tips and provided give aways. The participants enjoyed music, dancing, inflatable bouncers, and a magic show.

11 Our New Community Activity Transit Our community activity transit (CAT) is a health and wellness interactive system on wheels. CAT has a sitting area that we can use to offer health screenings in private. There is a Nintendo Wii gaming system for families to engage in fitness games/challenges and family fun favorites, such as Connect Four, Checkers and Jenga. We serve fresh, hot popcorn and the staff conducts health awareness sessions based on the theme of the month. CAT is equipped with a sound system and lights, so we can host and support events almost any time. We will use CAT to host and support community activities throughout the state, sharing health and wellness information in a fun-filled, interactive environment. If providers would like to have our CAT at their offices we will need at least a two to three week notice. Let your provider representative know if you are interested! Downtown Greenville was packed with people at the Gospel on Main Event. This was a free concert for everyone to come out and enjoy. Several churches and organizations were on hand to share information with the attendees. Outreach Specialist David Rojas shared health and service information and health tips. Over 700 people were in attendance at the event. BlueChoice HealthPlan Medicaid sponsored CareFIRST's Annual Fall Festival in Hartsville, SC. Outreach Specialist Daphney Addison manned the interactive fun zone and provided health and benefits information. More than 300 participants enjoyed the event filled with bounce houses, food, health screenings and face painting.

12 AX-400-Co1 P.O. Box 6170 Columbia SC PRSRT STD US POSTAGE PAID PERMIT NO 1240 COLUMBIA SC BlueChoice HealthPlan and BlueCross BlueShield of South Carolina are independent licensees of the Blue Cross and Blue Shield Association. Healthy Connections is administered for BlueChoice HealthPlan by WellPoint Partnership Plan LLC, an independent company. Some links in this newsletter lead to third party sites. Those organizations are solely responsible for the content and privacy policies on these sites. In this issue Page Comes to a Close Page 2 3 Consumer Assessment of Healthcare Providers South Carolina Immunization Registry Regulation Page 4 5 Pilot Program for OB/GYNs and Hospitals Telephone Interpreters Available Flu Season Dominated By Influenze A Page 6 7 Billing for Well-Child and Sick-Child Cold and The Flu Increase Odds Page 8 9 Seminar Questions Hemophilia Drug Requests Page We're In Your Community