HMSA Provider Bulletin

Transcription

1 HMSA Provider Bulletin T H E H M S A P L A N F O R Q U E S T M E M B E R S Bulletin Q09-06 December 1, 2009 Seasons greeting to you and your staff! As the holidays approach, we look forward to the many joys of the season. We hope yours is a happy, healthy and safe holiday season. IN THIS ISSUE: A Message from Our Medical Director EPSDT Matters Screening Tools Revised EPSDT Form 8015 Claims Filing Information Outpatient Anesthesia Services Anesthesia by Surgeon- Mod 47 Drug Formulary Changes Benefit Policies Outpatient Surgical Procedure Related Group List Update Sterilizations Provider Handbook Updates If you have any comments, questions or suggestions for our Bulletin, please call us at on Oahu or 1 (800) toll-free on the Neighbor Islands. A MESSAGE FROM OUR MEDICAL DIRECTOR Novel H1N1 Immunizations At the forefront of this year s flu season are concerns about the spread of the novel H1N1 influenza virus. The H1N1 vaccine was made available by the Hawaii Department of Health in the fall and providers were urged to vaccinate patients according to the criteria developed by the Centers for Disease Control and Prevention (CDC). Because of availability concerns, initial recipients of the vaccine were those who were at higher risk for infection, starting with pregnant women, caregivers for children younger than six months of age, health care and emergency medical services personnel, people age 6 months through 24 years, and then those ages 25 through 64 with health conditions associated with higher risk. When the demand to vaccinate the prioritized groups has been met, everyone from age 25 through 64 years of age should be vaccinated. The CDC website at is a valuable resource for information on the virus. It includes breaking news on the virus, vaccines, situation updates, reports and publications, and social media tools. The H1N1 vaccine is a benefit for our QUEST members. Information on how to bill for the vaccinations was included in our last Bulletin, under Claims Filing Information. Thank you for your efforts in immunizing those at risk and playing an important part in stemming the spread of this disease. EPSDT MATTERS Screening Tools You Can Use Frank Smith, M.D. Here are links to websites that provide screening tools. If you use any of these tools or any other developmental screening tools other than PEDS or ASQ, be sure to list the tools you used for the screening in the Other field of the Screening Done Today section of the EPSDT form P. O. B o x , H o n o l u l u, H I O a h u N e i g h b o r I s l a n d s 1 ( )

2 EPSDT MATTERS (continued) DHS Revised Form 8015 The DHS Med-QUEST Division revised the EPSDT Form 8015 and When available, the forms can be obtained through ACS by calling or 1 (800) tollfree. You can also your request to ACS at hi.providerrelations@acs-inc.com or fax your request to them at (Oahu) or 1 (800) (Neighbor Islands). DHS Med-QUEST will also provide access to an electronic version of the DHS 8015 that can be completed and submitted electronically. Details regarding accessing the electronic form can also be obtained by contacting ACS as noted above. The revised paper forms have retained the familiar red color and we will continue to scan the forms for data collection. However, the paper forms no longer contain a duplicate page and data fields have been modified, shifted or updated, based on comments and suggestions on previous versions. These revised forms will replace all previous versions of the EPSDT form. Providers will be notified when the use of the new form will be required. At that point, only these new versions of the forms, whether paper or electronic, will be acceptable for documenting EPSDT exams. We highly recommend that you begin any necessary revisions to your procedures to accommodate the new forms. CLAIMS FILING INFORMATION Outpatient Anesthesia Services As announced in HMSA s October 2009 Provider Update for facilities, beginning Jan. 1, 2010, outpatient anesthesia codes that do not have established fees will be paid based on a percentage of charge for covered items billed. Claims should be billed with type of bill (TOB) 13x and include revenue code 370, 371, 372 or 379. Anesthesia by Surgeon Mod 47 Payment is made for anesthesia by surgeon when general anesthesia or a regional block is provided. This applies only to the selected procedures listed in the QUEST Provider Handbook. It does not apply to local anesthesia, which is included in the global fee for the surgery and should not be billed separately. Claims for anesthesia by surgeon should be billed with a service line for the surgical procedure, followed immediately by the service line showing the surgical procedure with mod 47. 2

3 DRUG FORMULARY UPDATES The following changes to the HMSA QUEST and CCS formularies were originally included in HMSA s announcement of formulary changes to pharmacies in January. The following items will be added to the QUEST formulary effective Jan. 1, Generic Name Brand Name Reason Bicalutamide Generic Casodex New generic Desmopressin, nasal and oral Generic DDVAP, nasal and oral New generic Levetiracetam XR 750 Keppra XR 750 New strength Levonorgestrel Generic Plan B New generic Liothyronine Generic Cytomel New generic Milnacipran Risperidone, ODT Sevelamer carbonate powder Savella Generic Risperdal M-tab Renvela powder New agent for fibromyalgia New generic, Brand DAW-1 New dosage form Stavudine Generic Zerit New generic Tacrolimus Generic Prograf New generic Ursodiol Generic Urso, Urso Forte New generic Varenicline tartrate Chantix Smoking cessation agent The following items will be deleted from the QUEST formulary effective Jan. 1, Generic Name Brand Name Reason Bicalutamide Casodex New generic available Desmopressin, nasal and oral DAVP, nasal and oral New generic available Liothyronine Cytomel New generic available Metoprolol succinate Toprol XL Generic supply restored Propranolol, long acting Propranolol LA Generic supply restored Renal multivitamins/ minerals Renal-tabs No NDC number for pharmacies to adjudicate for payment Ursodiol Urso, Urso Forte New generic available 3

4 BENEFIT POLICIES Outpatient Surgical Procedure Related Group (PRG) List Update Effective Jan. 1, 2010, the list of procedures was updated to include additional procedure codes and the surgical group assigned to the code. A hyperlink to the list is located in the Provider Resource Center, QUEST Provider Handbook, QUEST Outpatient Surgical Procedure Related Group (PRG). Sterilizations We are only able to reimburse for sterilization procedures when the federally mandated consent form (Sterilization Required Consent Form 1146) is properly completed and signed. We are not able to reimburse if the required form is not properly completed. This requirement includes claims from the surgeon, assistant surgeon, co-surgeon, anesthesiologist and facility. We are not able to accept substitutions of the form because federal requirements mandate that we can only accept this particular form. Details for informed consent are available in the QUEST Provider Handbook, QUEST Sterilizations. Please review the requirements whenever a patient has requested a sterilization procedure. The form is required even if the patient has other insurance that is primary to QUEST. The form is available by faxing a request to DHS Med-QUEST at on Oahu. Include your name, address, telephone number, and the name of the form being requested. Or, you may call on Oahu. PROVIDER HANDBOOK UPDATES Benefit Policies QUEST Bevacizumab (Avastin) (updated) QUEST Carotid Artery Stenting (updated) QUEST Clinical Trials (updated) QUEST Codes That Do Not Meet Payment Determination Criteria QUEST FDA Approved Drugs that Require Precertification (updated) QUEST Kyphoplasty and Vertebroplasty (updated) QUEST Lenalidomide (Revlimid) (updated) QUEST Modifier Code 47 (new) QUEST Never Events (new) QUEST Off-label Drug Use (updated) QUEST Outpatient Surgical Procedure Related Group (PRG) List (updated) QUEST Panitumumab (Vectibix) (updated) 4

5