NETWORK MATTERS August 2014

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1 HPHCURRENT EVENTS Trainings Available for Connecticut Providers Harvard Pilgrim welcomes Connecticut providers to our network. We re offering a series of webinars to introduce you to Harvard Pilgrim and provide you with the information you and your office staff need to start working with us, including how to submit and track claims, receive authorizations, check eligibility, and use our e-transaction tools, such as HPHConnect. Join us for one of the following sessions: Friday, Aug a.m. Tuesday, Aug a.m. Friday, Sept a.m. Thursday, Sept p.m. Tuesday, Oct. 7 3 p.m. Please RSVP at least one week prior to the webinar that you would like to attend by ing the following information to ctprovider_relations@harvardpilgrim.org: Your name and title/role Names of participant (s) Date of session participant(s) would like to attend Practice name and address Phone number address Your confirmation will include the dial-in number, access code, and any other information you ll need to participate in the webinar. You will need a computer with Internet access to view the educational materials presented during the session. If you can t attend one of our webinars, please view this video presentation at your convenience. We also encourage you to visit our website for Connecticut providers for additional tools, resources, and information. Join Us for a Half-Day Mindfulness Conference in November On Friday, Nov. 14, Harvard Pilgrim is hosting a half-day mindfulness conference at our Wellesley headquarters. Don t miss this opportunity to see mindfulness researcher Harvard Pilgrim Health Care 1 Network Matters August 2014

2 Judson Brewer, M.D., Ph.D. and Tara Healey, M.Ed. discuss how training attention through mindfulness can improve productivity, boost creativity, and enhance health and well-being. This program will review recent clinical research and demonstrate a variety of mindfulness meditation techniques. Earn CME/CNE credit. Live web-streaming is also available. Mindfulness: How the Science and Practice of Awareness Improves Well-Being and Performance Location: Harvard Pilgrim Health Care 93 Worcester Street Wellesley, MA Time: 7:30 11:30 a.m. Includes continental breakfast. Fees and registration: Physicians: $175 for live conference. $125 for web conference. Nurses and other professionals: $150 for live conference. $100 for web conference. Space is limited and registration is required. For more information, please visit Accreditation: This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Boston University School of Medicine and Harvard Pilgrim Health Care. Boston University School of Medicine is accredited by the ACCME to provide continuing medical education for physicians. Boston University School of Medicine designates this live activity for a maximum of 3 AMA PRA Category 1 Credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Continuing Nursing Education Provider Unit, Boston University School of Medicine, is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. Contact Hours: 3.25 Harvard Pilgrim Health Care 2 Network Matters August 2014

3 Reminder: Symposium on Emotional Well-Being and Positive Mental Health Learn more about the cultural needs of South Asians seeking behavioral health services by attending a free symposium at Harvard Pilgrim s Wellesley headquarters on Sunday, Sept. 14, The event is being hosted by Saheli, a non-profit organization dedicated to empowering South Asian women and families to lead safe and healthy lives. The goals of the September conference include aiding providers in increasing cultural competency to better meet the needs of the Asian and South Asian community, raising awareness about the mental health needs among South Asians, and removing any associated stigma in order to create an environment where it is acceptable to ask for help. For more information, please visit the Emotional Well-Being Awareness Symposium page on Saheli Boston s website or the Facebook event page. Space is limited. To register, please contact Levelin Chan at Levelin_Chan@harvardpilgrim.org. To learn more about Harvard Pilgrim s collaboration with Saheli Boston and our recently launched Eastern Harmony program, please refer to our May 2014 Network Matters article, as well as the other links provided. CLINICIAN CORNER A Note on Genetic Testing from Michael Sherman, M.D, Chief Medical Officer As our understanding of the human genome deepens, genetic testing technologies have grown rapidly. The NIH Genetic Testing Registry, launched in February 2012, now includes more than 19,000 tests for 4,500 conditions and 3,000 genes, and new discoveries are being made every week. As a 2013 review in the journal Personalized Medicine illustrated, genetic testing is one of the fastest growing segments of the laboratory market, and is expected to rise from $1.5 billion in 2010 to $4 billion in While there is a great deal of excitement about genetic technologies, in some cases the technology precedes the clinical evidence and utility. Health insurers and providers are challenged to keep up with these rapidly evolving technologies to ensure that highquality, high-value care is being delivered to members. Harvard Pilgrim Health Care 3 Network Matters August 2014

4 The right genetic test in the right individual can be of great benefit for example, identifying a medication that's more likely to be effective for the patient or uncovering a higher risk of developing a particular disease, such as breast cancer, and aiding the patient and physician in developing a rigorous early detection and prevention plan. But unnecessary tests where the science can't support the accuracy of test, the person seeking a test isn't a good candidate for the testing, or the test isn't useful in guiding treatment, management, or prevention of a disease can cause a great deal of stress for the member, spur further unnecessary (invasive and costly) testing, and drain healthcare resources that could be better utilized. Given the complexity in the field of genetic testing and the rapidly changing landscape, it is challenging for clinicians to stay abreast of developments and be informed about current consensus guidelines for these tests. At Harvard Pilgrim, we believe there's an opportunity to support our members and provider partners by evaluating common genetic tests and offering a point of view on the validity, clinical utility, and appropriate use of these tests. This fall, Harvard Pilgrim is establishing a clinical medical policy on BRCA genetic testing, which identifies the presence of a BRCA1 or BRCA2 genetic mutation that can substantially increase the risk of breast and ovarian cancer. Since BRCA testing has been available for more than 10 years, Harvard Pilgrim was able to draw on a solid base of clinical evidence and consensus recommendations to develop this comprehensive policy. Additionally, in the last year BRCA testing has been in the media spotlight, with celebrities such as Angelina Jolie discussing the decision to be tested, which may leave some members wondering whether BRCA testing is right for them, too. In the coming year, we will be evaluating other genetic tests and expect to introduce additional clinical guidelines. You can rest assured that, as with our BRCA policy, these clinical guidelines will be supported by strong clinical evidence, and aimed at ensuring that our members receive high-quality, appropriate clinical care. Prior Authorization Required for BRCA Testing For dates of service beginning Nov. 1, 2014, Harvard Pilgrim is requiring prior authorization for all BRCA testing for members of our HMO, POS, and PPO products. Harvard Pilgrim covers medically necessary BRCA1, BRCA2, multi-site BRCA3, or singlesite BRCA1 or BRCA2 testing for members at high risk for breast cancer. Harvard Pilgrim Health Care 4 Network Matters August 2014

5 In creating the medical criteria for BRCA testing, Harvard Pilgrim drew on the best clinical evidence from respected medical societies, clinical journals, and government organizations, such as the U.S. Preventive Services Task Force and the National Comprehensive Cancer Network. For detailed information on the medical criteria that members must meet for BRCA testing to be covered, please refer to the Genetic Testing for Hereditary Breast and/or Ovarian Cancer Medical Review Criteria. To obtain authorization, clinicians must submit documentation showing that the member meets the criteria, the member obtained genetic counseling from a qualified clinician, and any BRCA test results will affect the member s medical management. To request prior authorization, please fax a completed Hereditary Breast/Ovarian Cancers Genetic Testing Prior Authorization Request Form to Harvard Pilgrim at Reminder: Prior Authorization and Quantity Limits for Testosterone Therapy As we noted in the May issue of Network Matters, Harvard Pilgrim requires prior authorization and has set quantity limits on testosterone therapy for all members age 18 and older. This policy was phased in, with an effective date of May 15, 2014 for members beginning testosterone therapy and Sept. 1, 2014 for members currently receiving testosterone therapy. Please refer to our updated Testosterone Clinical Criteria for details on quantity limits, prior authorization requirements, and renewal criteria. In addition, beginning Sept. 1, 2014, injectable testosterone (testosterone cypionate, testosterone enanthate) will be covered under the standard prescription drug benefit, and the member s pharmacy cost share will apply. To obtain prior authorization, please complete the appropriate Medication Request Form and fax it back to MedImpact Healthcare Systems at Harvard Pilgrim Health Care 5 Network Matters August 2014

6 Increase in Painkiller Prescriptions and Overdoses During this current epidemic of overdose deaths from pain prescription medications, it s important for clinicians to understand prescribing patterns and treatment guidelines. The Centers for Disease Control and Prevention (CDC) and other experts point out that an increase in prescriptions for painkillers is a key driver of the increase in prescription opioid overdoses. The CDC reports that: The quantity of prescription painkillers sold to pharmacies, hospitals, and doctors offices quadrupled from 1999 to There are twice as many painkiller prescriptions per person in the U.S. as in Canada. In the U.S., the Northeast had the most prescriptions per person for long-acting and high dose painkillers in The rise in fatalities closely relates to the prescribing behavior of these types of drugs over the past decade. The CDC recommends that when prescribing painkillers, health providers: Recognize that while men are still more likely to die of prescription painkiller overdoses, it is a serious and growing problem among women more than 5 times as many women died from prescription painkiller overdoses in the U.S. in 2010 as in Because women are more likely to be affected by chronic pain than men are, they are often prescribed opioids at higher doses and use them for longer periods of time than men. Additionally, women may become dependent on pain medications more quickly than men do and may be more likely to engage in doctor shopping to obtain multiple opioid prescriptions. Follow guidelines for responsible prescribing, including screening and monitoring for substance abuse and mental health problems. Screening at the primary care level provides an important opportunity for early intervention and better overall health maintenance and improvement. Please refer to the clinical guidelines on Harvard Pilgrim s provider website. Use prescription drug monitoring programs to identify who may be improperly obtaining or using prescription painkillers and other drugs. Individual states offer database programs for providers to track painkiller prescriptions and identify overprescribing. Harvard Pilgrim Health Care 6 Network Matters August 2014

7 Talk with patients about safely storing, using, and disposing of prescription pain medications. For more information on prescription painkiller prescribing trends and overdoses in the U.S., please see the CDC s Vital Signs reports. Additionally, the April 2010 issue of Anesthesiology included practice guidelines for chronic pain management to aid physicians in optimizing pain control, improving function, and enhancing quality of life, while minimizing adverse outcomes. How Optum/UBH can help your patients. For complex clinical situations, Optum/UBH is available to provide consultative assistance. Practitioners can call the Optum/UBH Physicians Consultation Service at To refer a patient for behavioral health services and to facilitate the coordination of care, call Optum at OFFICE ASSISTANT Reminder: Coding for DME Reimbursement When billing for durable medical equipment (DME), placing modifiers in the appropriate field can help ensure that your claim will be processed properly. The modifiers NU, RR, or MS should be used in the first modifier field, while the modifiers LT, RT, or RA should be placed in the second modifier field, when applicable. For more information, please refer to our Durable Medical Equipment Payment Policy. Reminder for EFT Users with Clearinghouses If you are participating in electronic funds transfers and use a clearinghouse, please set up your PaySpan account to automatically direct your 835 files to the clearinghouse, known as a Data Exchange Partner (DEP). The following are the current DEPs that have agreed to accept Harvard Pilgrim 835s through a provider s PaySpan account: Harvard Pilgrim Health Care 7 Network Matters August 2014

8 Allscripts commercial only AthenaHealth Avisena Capario ClaimRemedi Encoda GE Healthcare GHN Online (now Greenway) MD On-Line commercial only MedAssets Navicure Origin Healthcare Solutions PHIcure Inc Practice Insight Quadax Relay Health commercial only Siemens HDX SSI Group Trizetto Provider Solutions Zirmed For details on how to allow your 835 files to be directed to a DEP, please log in to your PaySpan account and visit the Frequently Asked Questions section of the website. Instructions are provided in the section How do I activate an Electronic Mailbox? If you prefer not to use an electronic mailbox, you can retrieve your remittances from PaySpan manually and opt to send your 835 files to the clearinghouse yourself. For more information, providersupport@payspanhealth.com or call PaySpan Provider Services ( , option 1). New Hampshire Health Protection Program Goes Live Aug. 15 Well Sense Health Plan is a participating managed care organization in the New Hampshire Health Protection Program. Coverage, which begins Aug. 15, is for individuals ages that are newly eligible for Medicaid (0-138% of the federal poverty level). As you may remember, Harvard Pilgrim is a business partner of Well Sense. Harvard Pilgrim Health Care 8 Network Matters August 2014

9 From Aug , members who enroll will have fee-for-service coverage administered by the New Hampshire Department of Health and Human Services before transitioning to the participating managed care organizations on Sept. 1. Open enrollment is currently underway. The benefit package reflects the current Medicaid Alternative Benefit Plan with the addition of substance use disorder, chiropractic services benefits, and coverage for Early Periodic Screening and Diagnostic Testing coverage for year olds. For more information, please refer to this Frequently Asked Questions document. Network Matters is a monthly newsletter for the Harvard Pilgrim provider network Eric H. Schultz, President and Chief Executive Officer Richard Weisblatt, Ph.D., Senior Vice President, Provider Network Annmarie Dadoly, Editor Kristin Edmonston, Production Coordinator Read Network Matters online at For questions or comments about Network Matters, contact Annmarie Dadoly at annmarie_dadoly@harvardpilgrim.org or (617) Harvard Pilgrim Health Care 9 Network Matters August 2014