InforMED

Midwest February Newsletter

February 14, 2017

Important Update Regarding Preauthorizations

We know many of you are actively attending training and reviewing current workflows in preparation for our upcoming preauthorization requirements. Our partnership with eviCore is progressing as expected, and we’re looking forward to improved turnaround times for our members and providers.

Note:  Your Health Alliance for providers will be ready to process the new preauthorization requests on February 28 for dates of service of March 13 and after. We originally shared that you could begin submitting preauthorizations on February 20, so please note the new date.

Please follow the current processes for preauthorizations today through February 27.

See the December Newsletter for all March 2017 preauthorization changes.

Thank you, and please share this update with all staff responsible for submitting preauthorizations.

Don’t Miss Out on eviCore Preauthorization Online Training Sessions

As we’d previously announced, starting March 1, 2017, we will partner with eviCore, a national specialty benefit management company that focuses on managing quality and use for better outcomes for our patients, providers, and Health Alliance. eviCore will manage some preauthorization services for our commercial and Medicare lines of business to help us address the needs of our expanding complex member populations.

For dates of service on or after March 13, you must request preauthorizations through eviCore on Your Health Alliance 
for providers, which you can access starting February 28.

Anyone who is responsible for submitting preauthorization requests for our members should register for one of these online training sessions:

  • Tuesday, February 7 at 10 a.m. CST
  • Wednesday, February 8 at 1 p.m. CST
  • Thursday, February 9 at 4 p.m. CST
  • Tuesday, February 14 at 10 a.m. CST
  • Wednesday, February 15 at 12 p.m. CST
  • Wednesday, February 22 at 2 p.m. CST
  • Thursday, February 23 at 1 p.m. CST
  • Wednesday, March 1 at 10 a.m. CST
  • Thursday, March 2 at 3 p.m. CST

How To Register

  • Once you’ve picked a session, go to eviCore.webex.com.
  • Choose the Training Center tab from the top menu.
  • Find the date and time of the session you want to attend in the Upcoming tab. All of the training sessions will be named “Preauthorization – Health Alliance Medical Plans.”
  • Choose Register.
  • Enter your registration information.

Attending Your Online Training Session

After you’ve registered, you’ll get an email that includes:

  • The toll-free phone number and pass code you’ll need for the session’s audio
  • A link to the online session
  • The session password

Save this registration email to access your session, and don’t forget to mark your calendar and ensure you’ll be able to fully participate in the session.

You can also access the presentation materials starting February 7 by using the eviCore Resources link in the Forms & Resources section of Your Health Alliance for providers. Or you can get a copy of the presentation slides by emailing ProviderRelations@evicore.com.

May 2017 Preauthorization Changes

Effective May 1, these services will require preauthorization:

  • Genetic testing (which will transition from Your Health Alliance for providers to eviCore)
  • Outpatient medical oncology – Oncology pathway drugs
  • Outpatient radiation therapy
  • Outpatient specialty therapy
    • Chiropractic (which will transition from Clear Coverage to eviCore)
    • Physical, occupational, and speech
  • Musculoskeletal – All joint/spine surgery and pain management

We will have Health Alliance and eviCore webinars in April to help offices with these changes and to help office staff become familiar with eviCore’s processes.

Is Your Info Correct in Our Directories? New Provider Information Change Form

Our provider directories are a key resource for your current and future patients to reach you, and keeping the information in them up-to-date is essential. We depend on you to tell us about changes to addresses, phone numbers, open or closed practices, and to report any errors that may exist.

Check our online directories to make sure that your information is correct. If you need to make an update, use our easy Provider Information Change Form, available in the Forms & Resources section on Your Health Alliance for providers.

If you don’t use this form, the information will be sent back to you, and you’ll be asked to email us a completed version of the correct form. Thank you for your help.

Medicare Outpatient Observation Notices (MOON)

The MOON is mandated by the Federal Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act). The act requires hospitals and critical access hospitals (CAHs) give Medicare beneficiaries receiving observation services as outpatients for more than 24 hours a written notice, and an oral explanation of that notice, no later than 36 hours after observation services start, or sooner if they’re being transferred, discharged, or admitted.

MOON was developed to inform all Medicare beneficiaries when they are an outpatient receiving observation services and are not an inpatient of the hospital or CAH. All hospitals and CAHs must provide this statutorily required notification no later than March 8, 2017.

The notice must include:

  • The reasons the individual is an outpatient receiving observation services
  • The implications of getting outpatient services, such as required Medicare cost-sharing and post-hospitalization eligibility for Medicare coverage of skilled nursing facility services

MOON Resources

Prospective Provider Request Form

Our Prospective Provider Request Form, which providers can use to ask to join our provider network, is now available. By registering with this form, we’ll be able to communicate with you about your request online. If you use the paper form, we will contact you and ask you to complete the online form instead.

Claims Reprocessing Inquiries Reminder

As a reminder, starting January 1, all claims reprocessing inquiries must be submitted through Your Health Alliance for providers. While you can send us inquiries for many reasons, this feature is not what you should use for corrected claims. Corrected claims should be submitted electronically through your clearinghouse or on paper.

Make sure you choose the correct review inquiry reason, coding issue or non-coding issue, which makes sure the inquiry is reviewed by the right team.

HEDIS® Chart Reviews Coming Soon

Each year, Health Alliance collects data to determine how we measure up against national averages for HEDIS® (the Healthcare Effectiveness Data and Information Set). This data collection and analysis indicates where we need to focus our quality efforts and is required for NCQA accreditation.

Successfully generating our HEDIS report depends largely on the cooperation we receive from provider office staff. Health Alliance staff may contact your office between January and May 2017 and ask to review specific medical records or ask you to copy, fax, or mail records to us as part of the audit. All individually identifiable information concerning patients will be kept strictly confidential in compliance with HIPAA regulations.

Results of the HEDIS audit will be available on our website in the fall of 2017. If you have any questions about HEDIS, contact the Quality & Medical Management Department at 1-800-851-3379, ext. 8656.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Changes in Our Provider Relations Team

Christina Dorsett, formerly the liaison in our Southern Illinois service area, will now be the provider relations specialist for all Carle providers and locations, along with providers in Ford, Iroquois, Kankakee, Livingston, and Piatt counties in Illinois, Fayette, Randolph, Union, and Wayne counties in Indiana, and Darke and Preble counties in Ohio.

If you’re a provider in one of these areas, you can reach Christina at 217-337-8007 or Christina.Dorsett@healthalliance.org.

Jill Ducey, formerly the liaison in our local service area, will now be the provider relations specialist for Southern Illinois service area providers in Alexander, Bond, Clay, Clinton, Edwards, Franklin, Gallatin, Hamilton, Hardin, Jackson, Jefferson, Johnson, Lawrence, Marion, Massac, Monroe, Perry, Pope, Pulaski, Randolph, Richland, Saline, St. Clair, Union, Wabash, Washington, Wayne, White, and Williamson counties in Illinois, and all Deaconess providers and locations in Indiana.

If you’re a provider in one of these areas, you can reach Jill at 217-337-4555 or Jill.Ducey@healthalliance.org.

 

Pharmacy Updates

All Plans

Formulary Additions – December

  • Exondys 51 (eteplirsen) – For Duchenne Muscular Dystrophy (DMD).
    • Commercial – Excluded
    • Medicare – Tier 5 with preauthorization (PA)
  • Impavido (miltefosine) – For leishmaniasis.
    • Commercial – Tier 6 with PA
    • Medicare – Non-formulary
  • Ocaliva (obeticholic acid) – Primary biliary cirrhosis.
    • Commercial – Tier 6 with PA
    • Medicare – Tier 5 with PA
  • Zurampic (lesinurad) – For gout.
    • Commercial – Tier 3 with PA
    • Medicare – Non-formulary

Formulary Additions – February

  • Cabometyx (cabozantinib) – For advanced renal cell carcinoma (RCC).
    • Commercial – Tier 5 with PA
    • Medicare – Tier 5 with PA
  • Lartruvo (olaratumab) – For soft tissue sarcoma.
    • Commercial – Tier 5 with PA
    • Medicare – Tier 5 with PA
  • Rubraca (rucaparib) – For advanced ovarian cancer.
    • Commercial – Tier 5 with PA
    • Medicare – Tier 5 with PA
  • Tecentriq (atezolizumab) – For urothelial carcinoma and non-small cell lung cancer (NSCLC).
    • Commercial – Tier 5 with PA
    • Medicare – Tier 5 with PA
  • Venclexta (venetoclax) – For chronic lymphocytic leukemia (CLL).
    • Commercial – Tier 5 with PA
    • Medicare – Tier 5 with PA
  • Vemlidy – For hepatitis B.
    • Commercial – Tier 4 with PA
    • Medicare – Tier 5
  • Natroba – For lice treatment.
    • Commercial – Tier 3 with PA

Medicare

New Policies

  • Cuvitru (immune globulin) subQ – Created policy for line extension
  • Morphine Equivalent Dose DUR Exceptions – Outlines authorization criteria for DUR exceptions to the new 2017 CMS Morphine Equivalent Dose (MED) limits

Medicare 2017 Morphine Equivalent Dose Rejects – Effective January 1, 2017

In an effort to address the nationwide opioid addiction epidemic, CMS is requiring us to put in soft and hard edit limits for pain medications based on daily Morphine Equivalent Dose (MED) thresholds.

  • We have set a soft edit threshold of 120mg per day.
    • Point of sale override after pharmacist has verified with provider.
  • We have set a hard edit threshold of 200mg per day.
    • PA is required. Providers should provide the following to assist with reviews:
      • Diagnosis
      • Notice that the provider is aware of the threshold and of any overlapping prescriptions
      • Notice that the patient has been titrated to requested dose
      • Any other relevant clinical information (pain contract, etc.)
  • OptumRx sent a fax to the pharmacy network on December 1, 2016 with the information about hard and soft edits, including specific point of sale overrides.

Commercial

New Policies

  • Cuvitru (immune globulin) subQ – Created policy for drug line extension
  • Firazyr (icatibant acetate) – Criteria transferred from CVS SGM to HA policy

Criteria Changes – Effective December 7, 2016

  • High Dollar Medication Override – Added HIV, insulin, and specialty drug maximum allowed dollar amount limits. Increased threshold for all other medications.
  • Oncology Agents – Added Hycamtin & Kyprolis to policy.
  • Orkambi (lumacaftor/ivacaftor) – Edited age to 6 years and older.
  • Xifaxan (rifaximin) – Added coverage criteria for SIBO.
  • Xyrem (sodium oxybate) – Added modafinil to prerequisite drug options.
  • Infertility Medications – Added Cetrotide, Ganirelix, Lupaneta, and Novarel to policy. Removed Fertinex, Luveris, and Profasi.
  • IVIG – Added Atgam to policy.

Criteria Change – Effective January 1, 2017

  • Long Acting and Short Acting Opioids – Removed Butrans and Belbuca from policy

Criteria Change – Effective February 1, 2017

  • Behavioral Health – Removed desvenlafaxine as a prerequisite for brand name antidepressants
  • Hepatitis B Treatment – Lamivudine, Hepsera, Baraclude, Tyzeka, & Vemlidy – Added Vemlidy to policy
  • Mandatory Generic Override Review – Edited to include submission of MedWatch form, or if the MedWatch form isn’t available, a description of allergy symptoms and severity
  • Remicade (infliximab) and Inflectra (infliximab) – Added Inflectra to policy

Tier Changes – Effective January 1, 2017

  • Zortress – Moved from Tier 3 to Tier 5 for Exchange members
    • Already sits at Tier 5 on Commercial. No Exchange members currently on Zortress.

Tier Changes – Effective February 1, 2017

  • Drysol – Moved from Tier 3 to Tier 2
    • Drysol is inexpensive
  • EpiPen – Moved from Tier 2 to Tier 3
    • Generic is available at Tier 1
  • Benlysta – Moved from Tier 6 to Tier 5
    • Alternative options are limited. Department receives few requests.
    • Benlysta price aligns with other Tier 5 specialty medications

Tier Changes – Effective March 1, 2017

  • Imatinib Mesylate – Moved from Excluded to Tier 4
    • New discount on generic product makes it more cost effective than cost of brand Gleevec with rebate contract
  • Gleevec – Moved from Tier 4 to Tier 6
    • Generic is available at Tier 4.
    • $72.70 per tablet. Price is in specialty range.
  • Depen Titratabs (penicillamine 250mg) – Moved from Tier 3 to Tier 4
    • $72.70 per tablet. Price is in specialty range.
  • Cuprimine 250mg (penicillamine capsules) – Moved from Tier 2 to Excluded
    • Depen Titratabs (penicillamine tablets) is more cost effective and available at Tier 4
  • Forfivo XL 450mg (bupropion SR 24 HR) – Moved from Tier 3 to Excluded
    • Bupropion ER 150mg and bupropion ER 300mg are available at Tier 1
  • Uceris Foam – Moved from Excluded to Tier 3
    • Price for topical foam is less expensive compared to oral tablet
  • Fluoxetine 60mg tablets – Moved from Tier 1 to Excluded
    • Fluoxetine 20mg tablets are available at Tier 1
  • Fenofibrate 40mg and 120mg (Fenoglide) – Moved from Tier 1 to Excluded
    • Generic Tricor (Fenofibrate 48mg & 145mg tablets) and generic Lofibra (fenofibrate 54mg & 160mg tablets) available at Tier 1
  • Viscous lidocaine 4% – Moved from Tier 1 to Excluded
    • Viscous lidocaine 2% available at Tier 1
  • Long Acting Injectable Atypical Antipsychotic (Abilify Maintena, Aristada, Invega Sustenna, Invega Trinza, Risperdal Consta, and Zyprexa Relprevv) – Moved from General Medical to Tier 4
  • Xifaxan – Moved from Tier 3 to Tier 4
    • Cost per treatment is over $1000 for 14 day supply
    • Committee requested amendment to limit allowed number of re-authorizations per year

Tier Changes – Effective April 1, 2017

  • Amrix – Moved from Tier 3 to Excluded
    • Branded cyclobenzaprine product

MDL Changes – Effective March 1, 2017

  • Lidocaine Cream and Ointment
    • Placed MDL of #50grams per 30 days

FLASH: Preauthorizations for Durable Medical Equipment

February 3, 2017

Starting March 1, 2017, you should submit preauthorization requests for durable medical equipment (DME), home health, and home oxygen through Clear Coverage instead of through our preauthorization forms on Your Health Alliance for providers.

If you need help with Clear Coverage access, contact your provider relations specialist.

FLASH: eviCore Preauthorization Online Training Sessions

January 10, 2017

Starting March 1, 2017, we will partner with eviCore, a national specialty benefit management company that focuses on managing quality and use for better outcomes for our patients, providers, and Health Alliance. eviCore will manage some preauthorization services for our commercial and Medicare lines of business to help us address the needs of our expanding complex member populations.

For dates of service on or after March 1, you must request preauthorizations through eviCore on Your Health Alliance 
for providers, which you can access starting February 20.

Anyone who is responsible for submitting preauthorization requests for our members should register for one of these online training sessions:

  • Tuesday, February 7 at 10 a.m. CST
  • Wednesday, February 8 at 1 p.m. CST
  • Thursday, February 9 at 4 p.m. CST
  • Tuesday, February 14 at 10 a.m. CST
  • Wednesday, February 15 at 12 p.m. CST
  • Wednesday, February 22 at 2 p.m. CST
  • Thursday, February 23 at 1 p.m. CST
  • Wednesday, March 1 at 10 a.m. CST
  • Thursday, March 2 at 3 p.m. CST

How To Register

  • Once you’ve picked a session, go to eviCore.webex.com.
  • Choose the Training Center tab from the top menu.
  • Find the date and time of the session you want to attend in the Upcoming tab. All of the training sessions will be named “Preauthorization – Health Alliance Medical Plans.”
  • Choose Register.
  • Enter your registration information.

Attending Your Online Training Session

After you’ve registered, you’ll get an email that includes:

  • The toll-free phone number and pass code you’ll need for the session’s audio
  • A link to the online session
  • The session password

Save this registration email to access your session, and don’t forget to mark your calendar and ensure you’ll be able to fully participate in the session.

You can also access the presentation materials starting February 7 by using the eviCore Resources link in the Forms & Resources section of Your Health Alliance for providers. Or you can get a copy of the presentation slides by emailing ProviderRelations@evicore.com.

Washington December Newsletter

January 3, 2017

2017 Preauthorization Changes and Clarifications

In our October Newsletter, we notified you that hospitals need to notify us of any observation stays, effective January 1. These details clarify this requirement:

  • For commercial members, Health Alliance must be notified of any observation stays that are longer than 24 hours.
  • For Medicare Advantage members, Health Alliance must be notified of any observation stays that are longer than 48 hours.

In addition to observation stays, non-urgent ambulance (air and ground) will require preauthorization for all members as of January 1. These authorizations should be submitted using the online form on Your Health Alliance for providers.

Effective January 1, 2017, these procedures will no longer require preauthorization:

  • TAVR
  • Therapeutic Plasma Exchange

Effective March 1, this list of services will require preauthorization:

  • Obstetrical Ultrasounds
  • All Diagnostic Ultrasounds
    • Duplex Scans, Transcranial Doppler Study, Non-Invasive Physiologic Studies, Ultrasound B Scan
  • Cardiac Imaging and Procedures
    • ECHO, ECHO Stress, Cardiac Rhythm Implantable Devices, Myocardial Perfusion Imaging, Nuclear Medicine, Diagnostic Heart Catheterization
  • Elective Inpatient Admissions
    • Admitting physician must preauthorize the elective inpatient procedure or surgery.
    • Hospitals must still notify us of an admission within 24 hours of the admission. This process will not change.
  • Experimental and Investigational Services

Online Claims Reprocessing Inquiries

As of January 1, 2017, all claims reprocessing inquiries must be submitted through Your Health Alliance for providers.
You can track the status on inquiries easily on the site, and eliminate tedious and time-consuming paperwork. You can send inquiries for many reasons, including:

  • Timely filing
  • Coding
  • No preauthorization
  • Reimbursement questions

Register or log in to get started today.

Billable Lab Tests

Remember, there are billable lab tests that can be completed in your office, like the HbA1c test and the rapid strep throat culture. Use the code 83037 for the HbA1c test’s billing and 87880 for the rapid strep culture’s billing.

Billing for these tests can both bring in revenue for your office and help collect HEDIS data.

HEDIS® Chart Reviews Coming Soon

Each year, Health Alliance collects data to determine how we measure up against national averages for HEDIS® (the Healthcare Effectiveness Data and Information Set). This data collection and analysis indicates where we need to focus our quality efforts and is required for NCQA accreditation.

Successfully generating our HEDIS report depends largely on the cooperation we receive from provider office staff. Health Alliance staff may contact your office between January and May 2017 and ask to review specific medical records or ask you to copy, fax, or mail records to us as part of the audit. All individually identifiable information concerning patients will be kept strictly confidential in compliance with HIPAA regulations.

Results of the HEDIS audit will be available on our website in the fall of 2017. If you have any questions about HEDIS, contact the Quality & Medical Management Department at 1-800-851-3379, ext. 8656.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Pharmacy Updates

Pharmacy Prior Authorization Reviews

Please be sure to check that medication requests are being directed to our pharmacy department. Requests sent to the medical management department can increase review turnaround times.

All Plans

Medicare & Washington Public Exchange (WA Public) Plans

  • Seebri Neohaler (glycopyrrolate) – Indicated for the long-term, maintenance treatment of airflow obstruction in patients with chronic obstructive pulmonary disease (COPD).
    • WA Public – Tier 3
    • Medicare -Non-formulary, motion to approve
  • Utibron Neohaler (indacaterol/glycopyrrolate) – A combination of indacaterol, a long-acting beta2-adrenergic agonist (LABA), and glycopyrrolate, an anticholinergic (LAMA), indicated for the long-term maintenance treatment of airflow obstruction in patients with chronic obstructive pulmonary disease (COPD).
    • WA Public – Tier 3 with preauthorization (PA)
    • Medicare – Non-formulary
  • Bevespi Aerosphere (glycopyrrolate/formoterol fumarate) – A combination of glycopyrrolate, an anticholinergic, and gormoterol, a long-acting beta2-adrenergic agonist (LABA), indicated for the long-term, once-daily maintenance treatment of airflow obstruction in patients with chronic obstructive pulmonary disease (COPD).
    • WA Public – Tier 3 with PA
    • Medicare – Non-formulary
  • Cinqair (reslizumab) – An anti-interleukin-5 approved as an add-on treatment for adults (18 years and older) with severe asthma and elevated eosinophil levels.
    • WA Public – Tier 5 with PA
    • Medicare – Non-formulary
  • Xiidra (lifitegrast) – The committee was presented the clinical information for Xiidra, which is indicated to improve tear production and reduce dry eye symptoms.
    • WA Public – Tier 3
    • Medicare – Tier 4
  • Epclusa (sofosbuvir/velpatasvir) – Indicated for the treatment of Hepatitis C Virus, genotypes 1 through 6, treatment naïve and treatment experienced, in both patients with and without cirrhosis.
    • WA Public – Tier 4 with PA
    • Medicare – Tier 5 with PA
  • Zinbryta (daclizumab) – Indicated for the treatment of relapsing remitting multiple sclerosis (MS). Note: Because of its safety profile, the use of Zinbryta should be reserved for patients who have had an inadequate response to 2 or more drugs indicated for the treatment of MS.
    • WA Public – Tier 6
    • Medicare – Non-formulary

Commercial

Criteria Changes

  • Xeomin (incobotulinumtoxin A) – Added criteria for coverage of Upper Limb Spasticity
  • Hepatitis C Treatment – Changed criteria to allow for coverage of all METAVIR scores, F0-F4
  • Diabetes Drug Therapies – Added type 2 diabetes mellitus diagnosis requirement to GLP-1 criteria
  • Testosterone, Implantable, Topical, Oral, and Nasal – Edited policy to require fasting testosterone levels to be drawn in the morning
  • Early Refill Policy – Changed name from Vacation Policy to Early Refill Policy

View as PDF

FLASH: Medicare Advantage ABN Process

December 19, 2016

Medicare Advantage members sometimes request procedures that aren’t covered, such as nail trimmings, from their provider’s office. Our providers were requesting members sign Advance Beneficiary Notice (ABN) letters or other waivers of liability, which have members attest that they’ll be financially liable for these non-covered services. CMS does not allow use of these forms prior to the services being rendered for Medicare Advantage plans. As a result of this rule, providers were absorbing the cost of providing non-covered services.

In order for providers to bill members for non-covered services, these steps must be completed:

  1. A preauthorization or Confirmation of Non-Covered Service request must be submitted for the service or procedure prior to the service being rendered and
  2. A notice of denied services to the member is required prior to the services being rendered. Non-clinical staff can issue denials for Confirmation of Non-Covered Services.

The same process is used for services or procedures that are non-covered due to local coverage determinations (LCDs) or national coverage determinations (NCDs) or that exceed quantity or frequency limits.

Submit this request through Your Health Alliance for providers by filling out the Medical form under File at Health Alliance in the Request Preauthorization tab. If you need help finding or completing this form, contact your provider relations specialist.