Provider Newsletter. MedStar Select/Medicare Choice. HEDIS Season

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1 Fourth Quarter 2015 MedStar Select/Medicare Choice Provider Newsletter HEDIS Season Every year, MedStar Health is required to report HEDIS data to the National Committee for Quality Assurance (NCQA). This reporting is also mandated by the Centers for Medicare & Medicaid Services (CMS) for Medicare Advantage plans. MedStar Health has contracted with Datafied to retrieve any medical records necessary for HEDIS. Therefore, in the upcoming months, you may be receiving a call from Datafied requesting MedStar Health member s records. What is HEDIS? The Healthcare Effectiveness Data and Information Set (HEDIS) is used by more than 90 percent of America s health plans to measure performance on important dimensions of care and service. It allows the comparison of health plans in these key areas of measurement: Quality of care, access to care and member satisfaction with the health plan and providers. 4. Is my participation in HEDIS data collection mandatory? Yes. Network participants are contractually required to provide medical record information for the purpose of quality assurance, and this includes HEDIS. 5. What is my office s responsibility regarding HEDIS data collection? You and your office staff are responsible for replying to the request from Datafied in a timely manner and providing access to the requested records either by fax, mail, remote access to EMR or on-site review. We appreciate your help with this annual quality of care and service initiative. 1. When will the collection of these records occur? Medical record reviews can occur from January 25 through May 15, Are all MedStar Health members records needed? No, records are only needed for a random subset of MedStar Health associates who are part of MedStar Medicare Choice, MedStar Medicare Choice Dual Advantage and MedStar Medicare Choice Care Advantage. 3. Does the Health Insurance Portability and Accountability Act (HIPAA) permit me to release records to Datafied for HEDIS data collection? Yes. As a MedStar Health contracted provider, you are permitted to disclose protected health information (PHI) to Datafied, our contracted medical record reviewer. A signed consent from the member is not required under the HIPAA privacy rule for you to release the requested information.

2 Consumer Assessment of Healthcare Providers and systems From February to April of 2016, some MedStar Medicare Choice Health plans members may receive a patient experience survey called the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey from an approved survey firm for the Centers for Medicare & Medicaid Services (CMS). Not all members will be surveyed, and those receiving the surveys are randomly selected. CMS develops, implements and administers member experience surveys. The CAHPS survey makes up a large portion of the Medicare Star rating. The survey is a way to assess member experience with their health plan and their providers. Answers remain anonymous, and the feedback is used to identify ways to improve the member experience. MedStar Medicare Choice Health plans does not receive the names of those surveyed and does not know how a person replied. End of fourth quarter and early first quarter is the time to target CAHPS. Below are some strategies to help improve CAHPS scores: Since members generally remember their experiences in the last 90 days, every touchpoint with our members counts the most now and early in the year. Make sure your staff asks is there anything else I can do for you? Ensure members have a positive experience during every touchpoint. Remember, one member can make a difference. Medical Policies Participating providers should review the medical policies posted on our website, MedStarProviderNetwork.org, for updates. All medical policies are PDFs and can be downloaded. To request hard copies of materials, please contact Provider Relations at , option 5. Member Complaint/Grievance and Appeal Process The MedStar Select and MedStar Medicare Choice complaint/grievance and appeal procedure that members can follow can be found on our website at MedStarProviderNetwork.org and in your provider manual. You may also call our Provider Relations department at , option 5, for a copy of the manual. The process will explain the following: How members can file a complaint, grievance or appeal, and the differences between them How quickly we will respond to the member and the provider What to do if the member does not agree with our decision Providers may not appeal a decision on the member s behalf without written permission from the member. Avoid Timely Filing Denials Quite often, claims are denied because they were not submitted within the required amount of time. A claim must be received by MedStar Select and MedStar Medicare Choice within 180 days (six months) from the date of service. Claims submitted after 180 days will be deemed as untimely and will not be paid. Exception: If a member has both Medicare (primary carrier) and MedStar Select (secondary carrier), the filing must occur within 18 months from the date of the Medicare explanation of benefits (EOB) to be considered timely. It is always required that the provider submit that EOB with the claim once they receive it. When a claim is submitted, please retain the EOB as your proof of timely filing. It is critical for providers to retain EOBs since this is the only acceptable proof that a claim has been filed in a timely manner. Billing system printouts are not acceptable proof that a claim was filed in a timely manner. Providers should make every effort to submit claims as soon as possible. This allows providers additional time to submit corrected new claims within the required 180 day period. For claims inquiries, including verifying receipt of a claim or inquiring about the status of a claim, call Provider Services at or log on to the provider portal at MedStarProviderNetwork.org. For provider online log in requests, call Provider Services at or provider_support@togetherforyourhealth.com. 2

3 Find it on the Web The provider website at MedStarProviderNetwork.org includes resources such as: Medicare Choice Provider Directory Search Pharmacy Directory RAF Training Video SNP Provider Training Provider Manual Medical Policies Payment Policies Pharmacy Prior Authorization Forms Pharmacy Formulary Summary of Benefits Evidence of Coverage EDI Documents Reason Codes Quick Reference Guide [frequently updated] Medical Management Forms How to Become a Participating Provider Ancillary Provider Interest Form MedStar Newsletter Contact Us Laboratory and Radiology Services MedStar Select and MedStar Medicare Choice offer benefits for laboratory and radiology services. Please remember to use and refer members to in-network providers for the services listed below. Laboratory services, refer to: Any MedStar Health laboratory Quest Diagnostics LabCorp Visit MedStarProviderNetwork.org for a complete listing of in-network laboratory services and locations. Radiology services, refer to: Any MedStar Health radiology facility Any contracted radiology provider Visit MedStarProviderNetwork.org for a complete listing of in-network radiology services and locations. MedStar Select Provider Directory Provider Manual Medical Policies Payment Policies Pharmacy Formulary Benefits Booklet EDI Documents Reason Codes Quick Reference Guide [frequently updated] Medical Management Forms How to Become a Participating Provider Ancillary Provider Interest Form MedStar Newsletter Contact Us Credentialing and Re-Credentialing All new providers wishing to participate in the MedStar Select and MedStar Medicare Choice provider networks are required to complete and submit a MedStar Family Choice Council for Affordable Quality Healthcare Medical Data sheet (CAQH Medical Data Sheet) along with a copy of their Disclosure of Ownership and Control Interest statement. We use our CAQH Medical Data sheet to add new providers to our CAQH provider roster. Existing groups that participate in MedStar Family Choice products do not need to complete this form for re-credentialing but must complete our CAQH form and attach a copy of their Disclosure of Ownership and Control Interest statement as part of their request to credential new providers who have joined their group. Provider requests for initial credentialing will not be processed if the request is not on our CAQH Medical Data sheet or if the Disclosure of Ownership and Control Interest statement is missing and/ or incomplete. Providers who are not a member of CAQH can complete the Maryland Uniform Credentialing form (MUCF). Please contact Provider Relations with questions at , option 5. 3

4 Denials and Appeals All denied claims are reported on the explanation of payment (EOP), referred to on the statement as a remittance advice. This indicates whether the provider has the right to bill the member for the denied services and/or if the member is financially responsible for payment. If a provider disagrees with the MedStar Select plan s decision to deny payment of services, the provider must appeal in writing to the appeals coordinator within 90 business days of receipt of the denial notification. The request must include the reason for the appeal and any relevant documentation, which may include the member s medical record. Appeals should be submitted to: MedStar Select Health Plan MSC: MS01 PO Box Atlanta, GA MedStar Medicare Choice Health Plan MSC: MS03 PO Box Atlanta, GA All appeals undergo an internal review process, which meets all applicable regulatory agency requirements. The provider will receive written notification in all situations in which the decision to deny payment is upheld. Corrections or resubmissions of claims due to minor errors or omissions should be sent to the customary claims address. Administrative Appeals An Administrative appeal is an appeal that involves claims that have been denied for reasons other than those related to medical necessity. Examples include: Care not coordinated with a PCP Prior authorization not obtained Administrative Appeals must be submitted in writing within 120 days from the date of the notice. All decisions are final. Medical Necessity Appeals: Medical Necessity appeals must be submitted in writing within 60 days from the date of the notice of denial. The Medical Necessity appeal request should include the reason for the appeal, a clear statement of why and on what basis the provider wishes to appeal, as well as a copy of the medical record or other supporting documentation. A physician will determine if additional information has been presented that supports a reversal of the denial. Expedited Review The provider can request an expedited review if the provider believes a member s life, health or ability to regain maximum function is in jeopardy because of the time required for the usual review process. A decision is rendered as quickly as is warranted by the member s condition but no later than 72 hours after the review is received. An expedited review can be requested by calling Medical Management at Clinical is required. If you have questions about the right to appeal or the procedure to file an appeal, or wish to request a hard copy of this information, please contact your Network Management representative or call Provider Services at Claims Submissions Claims must be submitted within 180 days of the date of service. Providers may submit a claim on paper, through a clearinghouse or directly through the online provider portal. Paper claims should be mailed to: MedStar Select Claims/MedStar Medicare Choice PO Box 1200, Pittsburgh, PA Electronic claims are accepted from clearinghouses, such as Emdeon, Relay Health and Allscripts. The payer ID for MedStar Select/MedStar Medicare Choice claims is 251 MS. Direct submission of claims for MedStar Select or MedStar Medicare Choice is available at MedStarProviderNetwork.org. Providers must sign up for a login to view eligibility, claims, and other patient specific information. If you have additional questions, please contact Provider Services at After claims are successfully submitted and received, payments are dispersed within 15 days. Please contact Provider Services to verify claims receipt, as well as claims status and inquiries, at Inquiries can also be made through the provider portal at MedStarProviderNetwork.org. 4

5 MyHealth Programs: Advising and Transition Care Each patient has a unique approach to accessing and utilizing healthcare services. In a continued effort to provide you with the tools needed to engage patients in better managing their chronic conditions, MedStar Health offers special programs to MedStar Select and MedStar Medicare Choice members. These programs are to include Care Advising and Transition Care. If your patient is enrolled in one of our programs and is admitted to a MedStar or nonmedstar facility, we are able to notify you of the admission, send you records and test results, and provide you with the necessary information and tools needed to follow up and provide optimal care for your patient. This ability to share information and eliminate duplication helps us better manage patients with chronic conditions and decrease readmission rates. MedStar s dedicated care advising and transition care teams help bridge the gaps to improve care coordination. These services help MedStar Select and MedStar Medicare Choice members who need some extra support in managing their health. Whether the patient needs support with a short-term solution, or help with a long-term care plan, Care Advising can offer valuable assistance to your high-risk patients, as well as to Medicare members with a chronic special needs plan (CSNP) or dual special needs plan (DSNP). Care Advising Identified patients engage with a registered nurse care advisor to help them follow their doctor s orders, understand their test results and take their prescribed medication properly. Care advisors can also help set follow-up appointments and coordinate important communication and information between the multiple providers the patient might be seeing. To ensure continuity of care, each enrolled patient and their primary care physician (PCP) will develop and maintain a relationship with the same care team. Care advisors are also supported by a broader care team, including social workers, pharmacists and dietitians, all of whom help support and guide the patient through their personal care plan. Whatever support is needed, you and your patient will have access to services such as nursing, pharmacy, nutrition, dietitians, social workers, and more. Care Advising services and the ongoing support that Care Advising offers can improve the health of these patients and assist providers in managing their most vulnerable patients. The service also promotes active patient engagement, education and understanding. For more information about our Care Advising services, please call Transition Care Transition Care, a hospital transition program, provides members with the necessary tools to get healthy and stay well. Our Transition Care program helps patients decrease their chances of hospital readmission. While in the hospital, a patient is assigned to a transition coach who will educate them on how to successfully adjust from hospital to home. The patient will leave the hospital with a printed care plan, including medication reminders and a list of follow-up appointments. In addition to giving the patient the much needed assistance to make a smooth transition from hospital to home, the transition coach and the care advisor will follow up with the patient to ensure medication adherence and confirm travel arrangements for upcoming physician appointments. If you have a MedStar Select or MedStar Medicare Choice patient who you feel would benefit from Transition Care services, please call

6 MedStar Medicare Choice Vision Benefits and Providers The vision networks for routine and medical vision are managed separately. Our MedStar Medicare Choice Care Advantage plans offer Routine vision care through Superior Vision. Members can be seen by providers within the Superior network for routine visits. Please contact Superior Vision at to confirm member benefits, eligibility and/or provider participation. Members who have medical vision needs must use ophthalmologists who are directly contracted with our plan. We credential these providers and contract them for medical services. Therefore, par ophthalmologists who perform medical procedures are listed on our website at MedStarProviderNetwork.org. Members with diabetes can receive one dilated retinal eye exam per calendar year at no cost to them. Encourage your members with diabetes to schedule their eye exam today. MedStar Select Vision Benefits and Providers Effective January 1, 2016, MedStar Select offers routine vision care through Group Vision. Members can be seen by providers within the Group Vision network for routine visits. Please contact to confirm member benefits, eligibility and/or provider participation at Members who have medical vision needs must use ophthalmologists who are directly contracted with our plan. We credential these providers and contract them for medical services. Therefore, par ophthalmologists who perform medical procedures are listed on our website at MedStarProviderNetwork.org. National Correct Coding Initiative and Outpatient Coding Edits The National Correct Coding Initiative (NCCI) is a program developed by the Center for Medicare and Medicaid Services (CMS) that consists of coding policies and edits. NCCI edits address correct coding combinations submitted by a provider for multiple services in regards to the same patient, on the same anatomic site and on the same date of service. There are two types of edits: procedure to procedure edits and medically unlikely edits (MUEs). Procedure-toprocedure edits make certain that CPT and/or HCPCS codes billed together are eligible for separate reimbursement and medically unlikely edits ensure that the appropriate number of units for a particular service were billed. MedStar Family Choice claims processing center utilizes CCI edit software from Optum so that providers are reimbursed for services in accordance with the NCCI procedure to procedure edits. We also expanded our existing NCCI edits to include the MUEs for professional claims and some types of outpatient facility claims. This logic includes a maximum number of units of service for each HCPCS/CPT code. Claims that do not meet criteria set in the CCI edit software are denied. Instances when a claim is denied because of NCCI procedure to procedure edits include, but are not limited to: Mutually exclusive codes that cannot be reported together were billed Unbundling of codes when a single comprehensive CPT code is available Please keep in mind that many procedure codes have CCI edits associated with them. Providers should use applicable modifiers when services are in fact separate and independent from each other in order for claims to be processed and paid as separate procedures. Since modifiers can be used to bypass CCI edits, MedStar Family Choice monitors their use. Therefore, if a modifier is to be used to bypass CCI edits, it is imperative that providers clearly document and explain the circumstances of the services that were provided in the member s chart. The documentation must clearly show that the procedure code and modifier met the conditions for separate billing. At this time, coding edits affect professional and outpatient claims submitted on CMS-1500 forms, as well as outpatient facility claims submitted on UB-04 (CMS-1450) forms. If you need more information regarding NCCI methodologies and the appropriate usage of modifiers, you can access CMS.gov/MedicaidNCCICoding for the National Correct Coding Initiative Policy manual for Medicaid services as well as the Medicaid National Correct Coding Initiative Edit Design manual at: medicaid.gov/medicaid-chip-program-information/bytopics/data-and-systems/downloads/2014-medicaidncci-edit-design-manual-rev-3/14.pdf. 6

7 MedStar Medicare Choice Pharmacy Benefits The pharmacy benefits manager for MedStar Medicare Choice is Evolent Health. A directory of participating pharmacies, the formulary, and prior authorization forms are available at MedStarProviderNetwork.org. Please utilize these resources to determine if the prescribed drug is on the current formulary, if a prior authorization is required, there are quantity limits, or if step therapy is required. If your patient must take a nonformulary medication, an exception may be available. To request an exception, complete the nonformulary exception form, posted on MedStarProviderNetwork.org under Pharmacy Prior Authorization forms. Please remember, if approved, the medication will be tiered as nonpreferred and may still incur significant costs for the patient. Please call Evolent Health at with questions. Where can MedStar Medicare Choice Members get their Vaccines? Medicare beneficiaries MUST receive most of their vaccinations from a pharmacist at a pharmacy (mandated by the Medicare Part D benefit). If a Medicare beneficiary receives a vaccine that is covered under the Medicare Part D benefit in a physician s office rather than at a pharmacy, the member is responsible for the cost of the drug and the administration of the drug. In this instance, the Medicare beneficiary would have to submit for reimbursement from their Medicare Part D plan administrator. Exception: Influenza, Pneumonia and Tetanus (following an injury) are covered through the member s medical benefit and can be administered at and billed by a pharmacy, a physician s office or an ER. It s flu season! We care about keeping our members healthy. Catching the flu can lead to serious illness and hospitalization. Prevent the flu by reminding your patients to get their flu vaccine at no cost to them. Helping Your MedStar Medicare Choice Patients Afford Their Diabetic Care For many of your patients, caring for their diabetes is not only an emotional challenge, but also a financial challenge. For some, this financial burden has led to medication adherence issues and other complications. If your patient is still struggling financially, patient assistant programs may be available. These programs are typically offered for brand-only medications and are sponsored by the drug manufacturer. The following two websites can help in determining your patient s eligibility for assistance programs: NeedyMeds.org and Medicare.gov/Pharmaceutical-Assistance-Program. Low-income Medicare patients may also contact the Social Security Administration to determine if they qualify for Medicare Extra Help (low income subsidy), which may reduce their prescription costs. More information can be found at SocialSecurity.gov/ExtraHelp or by calling When prescribing for diabetic testing supplies, the covered manufacturers are Lifescan (OneTouch products) and Bayer (Contour products). The quantity limit for blood glucose test strips is 150 strips per 30 days. If more frequent testing is required, a quantity limit exception may be applied. Please complete the prior authorization form found on MedStarProviderNetwork.org. 7

8 MedStar Select Pharmacy Benefits MedStar Select members are covered under a prescription benefit plan administered by Evolent and CVS/Caremark. As a way to help manage healthcare costs, authorize generic substitution whenever possible. Consider prescribing a brand name on the preferred drug list at MedStarProviderNetwork.org if you believe a brand name product is necessary. Please note: Generics should be considered the first line of prescribing. The drug list represents a summary of prescription coverage; it is not inclusive and does not guarantee coverage. The member s prescription benefit plan may have different copay for specific products on the list. Unless specifically indicated, drug list products will include all dosage forms. Log in to Caremark.com to check coverage and copay information for a specific medicine. Where can MedStar Select Members get their Vaccines? Any in-network pharmacy can administer and bill for BOTH the cost of the drug and the administration of the drug through the member s pharmacy benefit. The following seasonal and nonseasonal vaccines are available to MedStar Select members at no additional cost at any participating in-network pharmacy. Seasonal Vaccines: Injectable Flu vaccine (Trivalent and Quadrivalent) Injectable High-Dose vaccine Intranasal Flu vaccine Nonseasonal Vaccines: Pneumonia Diptheria Zoster (Zostavax ) Tetanus Diptheria Toxoids Pertussis Hepatitis A Hepatitis B Haemophilus B Human Papillomavirus (Gardasil ) Meningiococcal, Varicella Inactivated Poliovirus Measles Mumps Rubella Rotavirus Meningococcal Varicella * For drugs covered under the medical benefit that require prior authorization, please refer to An example would be drugs administered in the office would be covered under the medical benefit. Patients are not picking up the prescription at the pharmacy. Please reference the prior authorization list on MedStarProviderNetwork.org. The MedStar Select and MedStar Medicare Choice provider newsletter is a publication of MedStar Health. Submit new items for the next issue to melanie.bodencak@medstar.net King Ave., Suite 400 Baltimore, MD PHONE MedStarProviderNetwork.com Kenneth Samet MedStar Health President & CEO Melanie Bodencak Editor Eric Wagner President 15-MFCMD