The Advantage. A Newsletter for Providers. Welcome. What is an MI Health Link Medicare-Medicaid plan?

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1 A Newsletter for Providers Welcome AmeriHealth Caritas VIP Care Plus is pleased to welcome you to the AmeriHealth Caritas VIP Care Plus network of providers. AmeriHealth Caritas VIP Care Plus is an MI Health Link Medicare-Medicaid plan that began providing coverage to members on February 1, AmeriHealth Caritas VIP Care Plus is excited to extend our services to cover the over-21 population, and we are pleased you are on this journey with us. If you are not currently in our network, we invite you to join us and explain how below. What is an MI Health Link Medicare-Medicaid plan? MI Health Link is a demonstration program that provides new options for Michigan residents ages 21 and older who are fully eligible for both Medicare and Medicaid. This program, a collaboration between the Centers for Medicare & Medicaid Services (CMS) and the Michigan Department of Health and Human Services (MDHHS), makes it easier for consumers to get all the services they need. This includes all Medicare and Medicaid benefits, fully managed by a single entity known under the demonstration program as an integrated care organization (ICO). As a contract holder under the demonstration program, AmeriHealth Caritas VIP Care Plus qualifies as an ICO. The integration of Medicare and Medicaid benefits translates to a seamless experience for both members and providers. Members receive all their Medicare (Parts A, B and D) and Medicaid benefits from one plan. Providers only have to submit one claim to the plan for all payments, eliminating the need to submit secondary claims. The overall aim of this demonstration program is providing improved health outcomes, delaying the need for nursing-facility care, reducing inappropriate emergency department use and avoidable hospital readmissions, and decreasing overall health care costs. Who is eligible for MI Health Link? Eligible individuals are: 21 and older. Fully eligible for Medicare Parts A, B and D. Fully eligible for Medicaid. Low-income seniors. Younger persons with disabilities. Living in Wayne and Macomb counties. Winter 2015 Table of contents Welcome...1 What is an MI Health Link Medicare-Medicaid plan?...1 How this plan differs from others: a Model of Care overview...2 The requirement for referrals...3 Contracting and credentialing information...3 Healthcare Effectiveness Data and Information Set (HEDIS )...4 Counting stars, not dollars: Managing CMS s Star Ratings...7 Americans with Disabilities Act (ADA) assessments...9 NaviNet a free provider portal...9 Provider orientation sessions...9 Claims information...10 Is your information current on the CAQH database?...11 Important phone numbers...12 Sign up for Network News alerts...12 Additional resources...12 Just for fun...13 Individuals are ineligible if they are: Currently under hospice care. Enrolled in the MI Choice waiver program or the Program of All-inclusive Care for the Elderly (PACE). If they are enrolled in either of those programs, they must disenroll before enrolling in the MI Health Link program through AmeriHealth Caritas VIP Care Plus. Winter

2 What Is an MI Health Link Medicare-Medicaid Plan? (continued) Verifying eligibility for these individuals will be very important prior to rendering any services, as all dual eligible individuals have the option to change plans each month. Verifying eligibility may be done through various resources: Calling Provider Services at Using NaviNet ( by selecting AmeriHealth Caritas VIP Care Plus from Plan Central and selecting Eligibility and Benefits Inquiry. Using the Web tool available through MDHHS. The result shows whether an individual is eligible for MI Health Link and with which ICO they are enrolled. Consulting CMS eligibility results in the contract number H0192, which denotes AmeriHealth Caritas VIP Care Plus. Using the member identification card. However, a member s ID card is not a guarantee of eligibility! How this plan differs from others: a Model of Care overview There are approximately 9 million individuals in the United States who are eligible for both Medicare and Medicaid. This population, on average, tends to be more sick and frail, accounting for 31 percent of total Medicare costs and 39 percent of total Medicaid costs, while comprising only 21 percent of Medicare s and 15 percent of Medicaid s total populations. Dual eligibles are more likely to suffer from mental disorders, live with a disabling condition and have greater limitations in activities of daily living. More than 50 percent live with three or more chronic conditions. To improve the overall quality of care dual eligibles receive, as well as reduce overall costs, we developed the Model of Care. The Model of Care is a program involving multiple disciplines coming together as a team to provide input and expertise for a member s individualized care plan. This plan is designed to maintain the member s health and encourage the member s involvement in his or her health care. Developing this team begins with a group of personal care connectors, community health navigators and care coordinators from AmeriHealth Caritas VIP Care Plus who gather data on each member. Personal care Connectors work with members over the phone to do an initial health screening, assist with locating providers within our network, quote benefits and help with setting appointments. Community health navigators assist members in person by going to their homes to do initial health screenings, accompanying them to doctor s appointments, linking them to health and social service systems, and helping with other needs (like transportation and shopping). The care coordinator is a clinician who does a comprehensive in-home assessment of the member and their living conditions, develops a plan of care for the member, is the point of contact for the primary care provider (PCP), and is involved in transition-care planning. In addition to the AmeriHealth Caritas VIP Care Plus team, each member is assigned a PCP who is on the member s multidisciplinary team and plays an integral role in coordinating the member s care. The team is also comprised of other health care providers, including specialists, behavioral health providers, home health providers, physical therapists and pharmacists. The member may also include on this team other people who play an important role in their care; this could be a family member, a friend or a pastor. This team varies, based on each member s needs. The multidisciplinary team will develop an individual care plan (ICP) for each member, which all providers can view on NaviNet, our provider portal. The PCP can update the ICP as needed by submitting information to us via NaviNet or contacting a member s care coordinator directly. The care coordinator will update the ICP accordingly, having the changes reviewed and approved by the multidisciplinary team. Members also develop a health action plan to guide them in achieving personal health care goals. This may entail steps they need to take to improve their health so they can attend church, play cards with friends or participate in other activities they enjoy. The 2 Winter

3 The requirement for referrals Because the Model of Care requires a great deal of involvement from both AmeriHealth Caritas VIP Care Plus and the PCP, it is imperative the plan is included where members receive care. Referrals ensure members involve their PCPs in their care, help PCPs cultivate relationships with specialists and ensure members access the appropriate specialists for their conditions. Specialist visits, ambulatory center services and diabetes self-management training are a few services that require a referral. Some services not requiring a referral are outpatient diagnostic procedures, women s specialty services for routine and preventive care, and outpatient behavioral health and substance use treatment. For a complete list of services requiring referrals, please reference the Provider Handbook available on our website at Once a PCP determines a referral is needed, the next step is to locate a provider in our network. Our directory of participating providers is available online, or PCPs may contact Provider Services for assistance. After a participating provider has been located, a PCP may submit referrals electronically via NaviNet, by paper referral or by calling Provider Services at Specialists can view referrals on NaviNet or call Provider Services to ensure a member has the necessary referral on file. If an AmeriHealth Caritas VIP Care Plus member arrives for their scheduled appointment without a referral, contact Provider Services and we will assist you in obtaining a referral so that member care is not interrupted. Contracting and credentialing information AmeriHealth Caritas VIP Care Plus is always looking to expand our network to allow for the greatest access to our members and our referring providers. If your practice is not currently contracted with the AmeriHealth Caritas VIP Care Plus network (which requires a separate contract from AmeriHealth Caritas VIP Care Plus plans) and you are interested in participating, please contact your local network account executive. The Medicare-Medicaid account executive for Wayne county is Patricia Embry, available at or pembry@mibluecrosscomplete.com. Hillary C. Woodruff is the account executive for Macomb and other counties and is available at or hwoodruff@mibluecrosscomplete.com. If you have been credentialed by AmeriHealth Caritas VIP Care Plus, you won t need to submit any credentialing documents to participate in this plan. Internal Medicare credentialing will be done on your behalf. If you have never been credentialed by AmeriHealth Caritas VIP Care Plus, you must complete the credentialing process. The account executive will provide you with the necessary documents and directions to navigate through this process. Winter

4 Healthcare Effectiveness Data and Information Set (HEDIS ) HEDIS is a performance measurement tool administered by the National Committee for Quality Assurance (NCQA). It is used by more than 90 percent of America s health plans and managed care plans that are accredited by NCQA. NCQA performs HEDIS reviews annually. The results of the annual reviews are used to measure performance, identify quality initiatives, and provide educational programs for providers and their patients. This year, AmeriHealth Caritas VIP Care Plus will focus our provider educational programs on improving health outcomes for our members in these key areas: 1. Comprehensive diabetes care HbA1C screenings, eye exams and monitoring for nephropathy. 2. Breast cancer screenings. 3. Colorectal cancer screenings. 4. Medication adherence angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs). Your office can begin to facilitate this process by documenting all care in the patient s record, submitting a claim for each encounter and accurately coding each claim to the highest level of specificity. Below are some examples of what must be included: Measure description Documentation requirements Coding examples Comprehensive diabetes care (CDC) HbA1C testing Members years old with diabetes (type 1 and type 2) who had a hemoglobin A1C (HbA1C) test during the measurement year. Comprehensive diabetes care (CDC) HbA1C adequate control HbA1C poor control Members years old with diabetes (type 1 and type 2) who had the following during the measurement year: Hemoglobin A1C (HbA1C) adequate control = < 8%. Poor control = HbA1C > 9%. CDC Members are identified through any of the following ways during the measurement year or the year prior: Two outpatient, observation or nonacute inpatient visits on different dates with a diagnosis of diabetes. One acute inpatient visit with a diagnosis of diabetes. One emergency department visit with a diagnosis of diabetes. Dispensed insulin or hypoglycemic antihyperglycemics. HbA1C test Documentation in the medical record must include a note indicating the date when the HbA1C test was performed and the result or finding. HbA1C test and level Documentation in the medical record must include a note indicating the date when the HbA1C test was performed and the result or finding. Organizations may count notation of the following in the medical record: A1C, HbA1C, hemoglobin A1C, glycohemoglobin A1C, or HgbA1C during the measurement year. Poor control The most recent HbA1C level (performed during the measurement year) is > 9.0%, is missing or was not performed during the measurement year, as documented through automated laboratory data or medical record review. Note: A lower rate indicates better performance for this indicator (i.e., low rates of poor control indicate better care). Adequate control The most recent HbA1C level (performed during the measurement year) is < 8.0% during the measurement year, as documented through automated laboratory data or medical record review. HbA1C/HbA1C level (Cat II) CPT: Cat II: 3044F 3046F LOINC: , , , , , Diabetes ICD-9: 250, 357.2, , , Winter

5 Healthcare Effectiveness Data and Information Set (HEDIS ) (continued) Measure description Documentation requirements Coding examples Comprehensive diabetes care (CDC) blood pressure (BP) control Members years old with diabetes (type 1 and type 2) who had the following during the measurement year: BP control (< 140/90 mm Hg). Comprehensive diabetes care (CDC) monitoring for nephropathy Members years old with diabetes (type 1 and type 2) who had the following during the measurement year: Medical attention for nephropathy (nephropathy test, evidence of nephropathy, urine microalbumin tests, or at least one ACE inhibitor or ARB dispensing event). Comprehensive diabetes care (CDC) eye exam Members years old with diabetes (type 1 and type 2) who had the following during the measurement year: Eye exam (retinal) performed (year prior to the measurement year is acceptable if exam was negative for retinopathy). The most recent BP reading noted during the measurement year. The member is not compliant if the BP reading is 140/90 or is missing, or if there is no BP reading during the measurement year or the reading is incomplete (e.g., the systolic or diastolic level is missing). Documentation during the measurement year indicating the date when the urine microalbumin test was performed and the results, documentation indicating evidence of nephropathy (i.e., renal transplant, end-stage renal disease, nephrologist visit or positive microalbumin test), or documentation with a note indicating the member received a prescription for ACE inhibitors or ARBs in the measurement year. Common chart deficiencies Incomplete information from consultants in the PCP charts. Incomplete information related to yearly lab testing and results. A note or letter during the measurement year prepared by an ophthalmologist, optometrist, PCP or other health care provider indicating an ophthalmoscopic exam was completed by an eye care provider, the date when the procedure was performed and the results. A chart or photograph of retinal abnormalities indicating the date when the fundus photography was performed and evidence an eye care provider reviewed the results during the measurement year. Documentation of a negative (or normal) retinal or dilated exam by an eye care provider in the year prior to the measurement year, with results indicating retinopathy was not present. BP control Cat II: 3074F, 3075F, 3377F 308F Monitoring for nephropathy CPT: , , Cat II: 3060F 3062F, 3066F, 4010F LOINC: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,9318 7, , , , , Eye exam Optometrist or ophthalmologist CPT: 67028, 67030, 67031, 67036, , 67101, 67105, 67107, 67108, 67110, 67112, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92134, 92225, 99226, 92230, 92235, 92240, 92250, 92260, , Any provider type Cat II: 3072F = negative for retinopathy, 2022F, 2024F, 2026F Winter

6 Healthcare Effectiveness Data and Information Set (HEDIS ) (continued) Measure description Documentation requirements Coding examples Breast cancer screening (BCS) Women years old who had a mammogram to screen for breast cancer during the measurement year or the year prior to the measurement year. Colorectal cancer screening The percentage of members years old who had appropriate screening for colorectal cancer. Administrative claim for a mammogram between Jan. 1, 2014, and Dec. 31, Date and result of one of the following: Fecal occult blood test during Flexible sigmoidoscopy during 2015 or the four years prior. Colonoscopy during 2015 or the nine years prior. CPT: HCPCS: G0202, G0204, G0206 ICD-9: 87.36, Rev: 401, 403 CPT: 82270, 82274, , , 45345, , 44397, 45355, , 45391, CPT Category II code: 3017F HCPCS: G0328, G0104, G0105, G0121 Winter

7 Counting stars, not dollars: Managing CMS s Star Ratings The CMS Five-Star Quality Rating System aims to improve the quality of care provided to patients. AmeriHealth Caritas VIP Care Plus focuses on delivering timely and pertinent information on Star Ratings in the next few issues of The Advantage, beginning with a general overview of the Star Ratings system. Star Ratings help consumers make informed health care choices. Ratings measure the performance and quality of services of a health plan and help determine reimbursement. Consumers in need of a plan can choose from either a Medicare Advantage Plan (MA-PD), which includes Medicare Parts C and D, or a Medicare Part D Plan (PDP). Once they have selected the type of plan best suited to their needs, they can then use the Star Ratings system to pick the higher-rated plans in their area. Plan ratings are determined by evaluating nine domains, broken down into a series of measures. The nine domains are split between Part C and Part D plans, with five domains assigned to Part C plans and four to Part D plans. MA-PD plans encompass all nine domains. The four domains of a PDP plan are: 1. Drug plan customer service. 2. Member complaints, problems getting services and choosing to leave the plan. 3. Member experience with the drug plan. 4. Drug pricing and patient safety. These Medicare Part D domains will house 15 measures for Measures are derived from several sources some come as part of HEDIS measures, others from Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys, the Medicare Health Outcomes Survey or administrative data on plan quality and member satisfaction. All measures are ranked on a five-star scale; however, not all measures are weighted equally. All measures are evaluated on five categories: outcomes, intermediate outcomes, patient experience, access and process. The first two categories weigh three times more than the process category, and the third and fourth categories weigh one-and-a-half times as much as the process category. Once all measures are ranked, the weighted average is determined at the domain level, at the Part C and Part D levels, and at the MA-PD level. While providers are not directly evaluated by the measures, they play an integral part in providing the care that the measures are focused on improving. In addition, the quality bonus payments received by Medicare plans for achieving higher ratings provide additional benefits to enrollees, such as eyeglasses or transportation. Drilling down further, there are five Medicare Part D measures that deal with medication therapy and fall under the intermediate outcomes category, and therefore are triple-weighted. One of these measures, High-Risk Medications in the Elderly (HRM), focuses on ensuring safe medication use. This measure was developed by the Pharmacy Quality Alliance (PQA) and adapted from a HEDIS measure titled, Drugs to be Avoided in the Elderly. It measures the percentage of adults over 65 who receive two or more prescription fills of a medication considered to put the patient at high risk for an adverse drug-related event. The list of medications in this measure was derived from the American Geriatric Society Beers Criteria for Potentially Inappropriate Medications Use in Older Adults and also uses data from 2013 prescription drug event records. The complete list is available on the PQA website at uploads/files/hrm%20measure%202013website.pdf. Some of the more notable drugs on the list include first-generation antihistamines, some tricyclic antidepressants, muscle relaxants, barbiturates, non-benzodiazepine hypnotics, digoxin at doses over 0.125mg/day, long-acting sulfonylureas and nonselective nonsteroidal anti-inflammatory drugs. Plans face challenges ahead in managing this measure. Some patients may not use the same pharmacy for all their medications or may pay out of pocket for certain drugs. It may also be challenging for providers to move patients away from these high-risk medications, in part due to their long availability on the market, proven efficacy and lower price. Patients also may have been taking them before they turned 65 and may be reluctant to switch to a new medication. Each plan must determine how to enforce this measure. A study done by Erickson, et al., found that HRM Star Ratings are weakly correlated with member experience measures during the same time period, meaning more aggressive HRM management may not negatively affect summary ratings for the plan. Whether a plan elects to use more aggressive HRM management or find another method to address this measure will ultimately affect its Star Rating and ranking with CMS. Winter

8 Counting Stars, Not Dollars: Managing CMS s Star Ratings (continued) Since the implementation of Star Ratings, Medicare has made efforts to monitor and revise its measures based on the feedback and data it receives. As more data becomes available on the effect such measures can have on members health, we will see how Star Ratings benefit customers, providers and plans and ultimately improve the delivery of health care. Star Ratings 55 quality measures 37 for Part C 18 for Part D 5 measures are triple-weighed High-Risk Medications in the Elderly Diabetes Treatment Adherence to Oral Diabetes Medications Adherence to RAS Antagonists Adherence to Statins References Erickson SC1, Leslie RS, Patel BV. Is there an association between the high-risk medication star ratings and member experience CMS star ratings measures? J Manag Care Pharm Nov;20(11): Available at: Accessed January 24, Pharmacy Quality Alliance. Use of High-Risk Medications in the Elderly (HRM). Available at: website.pdf. Accessed January 24, American Pharmacists Association and Academy of Managed Care Pharmacy. Medicare star ratings: Stakeholder proceedings on community pharmacy and managed care partnerships in quality. J Am Pharm Assoc. 2014;54:e238 e250. doi: /JAPhA Centers for Medicare & Medicaid Services. Medicare Part C & D Star Ratings: Update for PrescriptionDrugCovGenIn/Downloads/2015_Star_Ratings_User-Call-Slides_v2014_08_04.pdf. Accessed January 23, Centers for Medicare & Medicaid Services. Medicare 2015 Part C & D Star Rating Technical Notes. Accessed January 23, Center for Health Care Strategies. Fact Sheet Star Ratings. Accessed January 23, Winter

9 Americans with Disabilities Act (ADA) assessments CMS and the state require AmeriHealth Caritas VIP Care Plus and its contracted providers to comply with the ADA and the Civil Rights Act of 1964 to promote the success of the ICO model and support better health outcomes for our members. In particular, CMS and the state recognize that successful person-centered care requires physical access to buildings, services and equipment and flexibility in scheduling and processes. The state and CMS will require AmeriHealth Caritas VIP Care Plus to provide members access to contracted providers who demonstrate their commitment and ability to accommodate the physical access and flexible scheduling needs of our members. To meet this requirement, AmeriHealth Caritas VIP Care Plus conducts ongoing site visits of provider offices. If one of our account executives contacts you regarding a site visit, please accommodate their request. In addition, we may administer an independent survey. If you receive a survey, we ask that you complete and return it as soon as possible. NaviNet a free provider portal AmeriHealth Caritas VIP Care Plus offers participating network providers real-time information through our secure provider portal, NaviNet. This free service offers providers real-time access to member eligibility, referrals, prior authorization and claims. Provider orientation sessions AmeriHealth Caritas VIP Care Plus will be hosting training and orientation sessions for participating providers in coming months. Invitations are forthcoming, but please also look for upcoming dates and locations on our website. Training sessions will include information on: Overview of the MI Health Link Dual Demonstration program. Member eligibility. Member benefits. Referrals and prior authorizations. Working with the multidisciplinary team. Model of Care. Reimbursement and claims. This training will introduce clinical and office staff to this new Medicare-Medicaid plan offered by AmeriHealth Caritas VIP Care Plus, so we encourage your offices to allow these employees to attend. As you learn important information about working with AmeriHealth Caritas VIP Care Plus, you ll also fulfill many of the annual provider training requirements. To ensure you are able to access these services for the AmeriHealth Caritas VIP Care Plus plan, please follow the instructions on our website under the link Plan Updates and Changes, available on the Provider Resources tab. Winter

10 Claims information AmeriHealth Caritas VIP Care Plus partners with Emdeon to provide electronic claims submission, electronic funds transfer and electronic remittance advices. The first step is to contact your practice management system vendor or clearinghouse to verify if you are currently signed up with Emdeon or if you need to initiate the process. Emdeon s toll-free number is AmeriHealth Caritas VIP Care Plus payer ID is Paper claims may be submitted to: AmeriHealth Caritas VIP Care Plus Claims Processing Department P.O. Box Richardson, TX Please submit only one claim for both Medicare- and Medicaid-covered services, filing it as you would to Medicare. You will have 365 days from the date of service to submit claims. We will process the Medicare benefit and automatically cross over the claim to process under the Medicaid benefit. Your office will receive one remittance advice and one payment for both benefits. Please review the sample remittance advice below: Example: Remittance advice Example: Remark codes If you have a question regarding the way a claim was processed or adjudicated, you can submit an inquiry request. The provider inquiry form is located on the AmeriHealth Caritas VIP Care Plus website under the Provider Resources tab. Providers should submit all supporting documentation and an explanation why they believe the claim was processed or paid incorrectly. No deductible, coinsurance or copays Members in the AmeriHealth Caritas VIP Care Plus plan are not subject to any deductible, coinsurance or copays for most covered services. Balance billing members for cost-sharing and other contractual write-offs is strictly prohibited by this plan. Should the member file a grievance for balance billing, we will investigate the grievance. If we determine the member was inappropriately billed, we will reimburse the member and request reimbursement from the provider. Winter

11 Is your information current on the CAQH database? This past spring, the Council for Affordable Quality Healthcare (CAQH) launched its new CAQH ProView database. If you are a CAQH user, you may have received notifications on the action items listed below to help prepare you for the transition from UPD to ProView. CAQH alerted providers to the following: Providers with incomplete applications need to complete and attest to any outstanding applications prior to the transition to CAQH ProView. Unattested data will not convert into CAQH ProView. CAQH ProView requires an address for all providers as a primary method of contact. Providers must enter and complete their information online. Paper versions of the credentialing application are no longer accepted. If you have not already done so, please follow CAQH instructions so we may continue to download your information for recredentialing purposes. AmeriHealth Caritas VIP Care Plus access to your current and complete information via CAQH ProView will facilitate a smooth and timely recredentialing process. Winter

12 Important phone numbers Provider Services: Prior Authorizations: (fax) Pharmacy Services: Fraud and abuse hotline: NaviNet: Emdeon: , option 2 Sign up for Network News alerts With the Network News service, you ll be able to: Receive information five to seven days faster than you would via standard mail. Choose to receive information on the topics you care about. Unsubscribe at any time. Keep, retrieve and share information electronically. Link directly to other resources on the Web. Visit the AmeriHealth Caritas VIP Care Plus website and sign up for Network News alerts in the Provider tab under the Provider Communications link. Additional resources Interested in becoming a patient-centered medical home (PCMH)? Please visit our parent company, AmeriHealth Caritas, PCMH website: pcmh.amerihealthcaritas.com/index.aspx. CMS: Michigan Department of Health and Human Services: Free course on health literacy for providers: Winter

13 Just for fun Diabetes word find Y H T L A E H S V P N S E Z M L T T T D O E S R L O I P P A I D I E T T G E K N I D E A N L U O N E L V I I G T E Q E A H S N B U E W L Q Z I H O G G B T A C N M U E X E R C I S E U I O T Y S M I L Q T W A A O D S I G N Z P O Z B U H V R I E O H I E X A M C I N T N E E N E Y E K P N O I T A C U D E Words may be horizontal, vertical or diagonal, forward or backward! CARE COMMUNITY DIABETES DIET EDUCATION EXAM EXERCISE EYE GLUCOSE HEALTHY HEDIS INSULIN MANAGE NUTRITION PREVENTION ACVIPCPMI Winter