InforMED

FLASH: eviCore Issue for DME Providers Resolved

August 10, 2017

Last week, we sent an InforMED flash about issues with submitting preauthorizations for DME providers. This issue has been resolved, and you should be able to submit preauthorization requests online for our members now.

If you have any questions or experience any issues, contact your provider relations specialist.

Reid August Newsletter

August 8, 2017

Submitting Therapy Preauthorization Requests on eviCore

Recently, there’s been some confusion around therapy preauthorization (PA) requests on eviCore. This chart can help make sense of who you need to make preauthorization requests for and the timeframes for those requests:

Physical, Occupational, Massage, Acupuncture, and Chiropractic Therapies

Patient Type When Is PA Through eviCore Required?
Patients currently in treatment plans that began before August 1, 2017

PA is not required through eviCore through 2017 unless there is a change in diagnosis. PA must be obtained for continuing treatment before January 1, 2018.*

Patients who will begin treatment on August 1, 2017 or after

PA is required for all dates of service of August 1, 2017 and after.*

*Note: eviCore will accept PA requests for these therapy programs no more than 14 days before the date of service if requested online through Your Health Alliance for providers. If requested via phone or fax, they will not accept them more than 7 days before the date of service.

Radiation Therapy

Patient Type When Is PA Through eviCore Required?
Patients currently in treatment plans that began before August 1, 2017 PA is not required through eviCore through 2017 unless there is a change in diagnosis. PA must be obtained for continuing treatment before January 1, 2018.
Patients who will begin treatment on August 1, 2017 or after PA is required for all dates of service August 1, 2017 and after.

 

If you have any questions, contact your provider relations specialist.

New Numbers & Medicare Cards Coming in April 2018

Medicare is taking steps to remove Social Security numbers from Medicare cards. People with Medicare will begin receiving new Medicare cards in April 2018, until all cards are replaced by April 2019. These cards will have a Medicare Beneficiary Identifier (MBI) number that is randomly generated.

Medication Reconciliation Post-Discharge Measure

Medication reconciliation after a hospital, skilled nursing facility (SNF), or extended care facility (ECF) stay is an important part of continuity of care and improves the safety of patients. In one study, more than 80% of patients had an error related to or a misunderstanding of their discharge medications, more commonly with the medications that were unrelated to their primary diagnosis.

The measure evaluates if a provider completed a medication reconciliation for Medicare Advantage patients within 30 days of discharge from acute and non-acute settings.

A prescribing provider, registered nurse, or pharmacist can complete medication reconciliation. It can be done at the time of discharge or within 30 days, but it must be clear that any medications the patient had before their admission were compared with their medications at the time of their discharge. Phone call and home visit documentation of a medication review can also be used if the notes are included in the outpatient record.

The National Committee of Quality Assurance (NCQA) recognizes this evidence as meeting compliance for this measure:

  • Billing codes 99495, 99496, and 1111F
  • Discharge summary with documentation that discharge medications were reconciled with the most recent medication list in the outpatient record, which must be filed in the outpatient record within 30 days of discharge
  • Post-discharge hospital follow-up visit with documentation of medication reconciliation or review
  • Documentation of the current medications and a notation that:
    • Discharge medications were reviewed
    • References the discharge medications (e.g., no changes in medications since discharge, same medications at discharge, or discontinue all discharge medications)
    • The provider reconciled the current and the discharge medications
  • Documentation of both current and discharge medication lists and a notation that both were reviewed on the same date of service
  • Notation that no medications were prescribed or ordered upon discharge

Note: If a patient discharges from a hospital to an SNF or ECF, medication reconciliation must be documented in their outpatient record within 30 days of being discharged from the SNF or ECF.

Thank you for your efforts in helping patients understand their medication and how to take them safely.

Statin Use and Adherence HEDIS Measures

Statin Therapy for Patients with Cardiovascular Disease and Statin Therapy for Patients with Diabetes are 2 measures the NCQA included in the 2017 HEDIS audit.

Both of these measures are administrative measures, which means data is collected from claims submitted to us. To get accurate results, claims information must be complete, reflecting the appropriate diagnosis, as well as any conditions or medications that may exclude the member from the denominator.

Statin Therapy for Patients with Cardiovascular Disease

Reflects the percentage of members, males 21 to 75 years and females 40 to 75 years, who have had a diagnosis of clinical atherosclerotic cardiovascular disease and were dispensed at least one high or moderate-intensity statin medication during the measurement year.

The adherence rate is also measured to show the percentage of members who achieved a proportion of days covered (PDC) of at least 80%, beginning with the first prescription fill to the end of the measurement year.

Statin Therapy for Patients with Diabetes

Reflects the percentage of members with diabetes between the ages of 40 to 75 who were dispensed a prescription for a statin during the measurement year.

The adherence rate is also measured to show the percentage of members who achieved a PDC of at least 80%, beginning with the first prescription fill to the end of the measurement year.

 

Members with the following conditions are allowed to be excluded from both measures:

  • Pregnancy
  • Having in vitro fertilization procedure
  • Current prescription for clomiphene
  • End stage renal disease
  • Cirrhosis
  • Myalgia
  • Myositis
  • Myopathy
  • Rhabdomyolysis

Most of the allowed exclusions can be coded during the measurement year or the year before the measurement year; however, myalgia, myositis, myopathy, or rhabdomyolysis need to be coded annually if that’s the reason the patient can’t tolerate the statin.

See the list of conditions and codes accepted as exclusions by the NCQA for muscle pain and muscle disease below. Providers can receive other diagnosis codes accepted as exclusion by contacting the Quality Management department at 1-800-851-3379, ext. 8112.

Code Definition Code System
G72.0 Drug-induced myopathy ICD10CM
G72.2 Myopathy due to other toxic agents ICD10CM
G72.9 Myopathy, unspecified ICD10CM
M62.82 Rhabdomyolysis ICD10CM
M79.1 Myalgia ICD10CM

HEDIS 2017 (Measurement Year 2016) and HEDIS 2016 (Measurement Year 2015) Results

National benchmarks are not available at this time.

Statin Therapy for Patients with Cardiovascular Disease

Commercial HMO/POS
HEDIS 2017 HEDIS 2016
Received Statin Therapy – Males 81.87% 79.33%
Statin Adherence 80% – Males 72.56% 75.09%
Received Statin Therapy – Female 73.40% 71.46%
Statin Adherence 80% – Females 66.44% 68.79%
Received Statin Therapy – Total 79.49% 77.16%
Statin Adherence 80% – Total 70.97% 73.48%
Medicare HMO
HEDIS 2017 HEDIS 2016
Received Statin Therapy – Males 75.00% 76.22%
Statin Adherence 80% – Males 82.81% 84.40%
Received Statin Therapy – Female 70.59% 59.04%
Statin Adherence 80% – Females 66.67% 83.67%
Received Statin Therapy – Total 73.60% 69.91%
Statin Adherence 80% – Total 77.90% 84.18%
Northwest Medicare HMO
HEDIS 2017 HEDIS 2016
Received Statin Therapy – Males 86.11% 82.29%
Statin Adherence 80% – Males 79.57% 81.01%
Received Statin Therapy – Female 80.85% 77.50%
Statin Adherence 80% – Females 78.95% 80.65%
Received Statin Therapy – Total 84.52% 80.88%
Statin Adherence 80% – Total 79.39% 80.91%

Statin Therapy for Patients with Diabetes

Commercial HMO/POS
HEDIS 2017 HEDIS 2016
Received Statin Therapy 61.18% 60.56%
Statin Adherence 80% 74.62% 73.33%
Medicare HMO
HEDIS 2017 HEDIS 2016
Received Statin Therapy 69.15% 69.16%
Statin Adherence 80% 82.05% 82.43%
Northwest Medicare HMO
HEDIS 2017 HEDIS 2016
Received Statin Therapy 74.16% 70.80%
Statin Adherence 80% 72.95% 74.58%

 

Please discuss the benefits of statin use with your patients and, if you have patients who cannot tolerate one of the statins, be sure and code the reason.

 

NCQA is a nonprofit organization dedicated to improving our nation’s health care system. Since its founding in 1990, NCQA has been a central figure in health care improvement, and its seal is a widely recognized symbol of quality and service.

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

Meet with a Coding Specialist

The risk adjustment coding consultants are continuing to request meetings with participating, high-volume provider offices. These meetings are designed to share member-specific examples of coding and quality measure needs and to update providers on the latest efforts to educate on risk adjustment. Along with member specific examples, there is information on yearly risk adjustment data validation (RADV) audits and how provider practice participation is essential in this process.

A member of the coding consultant team is willing to meet with you to discuss any coding or quality questions you may have, or to provide member-specific examples from your panel of members. If interested, contact us at CodingCounts@healthalliance.org.

Pharmacy Updates

All Plans

eviCore Preauthorizations – Effective August 1, 2017

  • All oncology regimens will require PA through eviCore
    • This includes many new medications that did not previously require PA through us
    • Refer to our formulary for more details

Review of P&T Committee Minutes – From April 5, 2017

  • Diabetes Drug Therapies – Added non-preferred insulin step therapy (ST)
    • Novolog and Novolin products require step through Humalog/Humulin

Formulary Additions

  • Rhofade (oxymetazoline hydrochloride) – Indicated for the persistent facial erythema associated with rosacea in adults.
    • Medicare – Non-formulary
  • Eucrisa (crisaborole) – Indicated for the treatment of mild to moderate atopic dermatitis in patients 2 years of age and older.
    • Medicare – Non-formulary
  • Dupixent (dupilumab) – Indicated for the treatment of moderate to severe atopic dermatitis in adults whose disease is not adequately controlled with topical prescription therapies, or when those therapies are not advisable.
    • Medicare – Non-formulary

Medicare

Tier Changes

  • Fluticasone propionate/salmeterol – Moved from Non-Formulary to Tier 2
    • Authorized generic for AirDuo RespiClick
    • Generic version $113 per month versus Advair $435 per month
    • Available strengths include 55/14, 113/14, and 232/14
  • Nitrofurantoin (Macrobid) – Moved from Non-Formulary to Tier 2
    • The American Geriatrics Society 2015 Beers Criteria Update Expert Panel has revised its recommendation to avoid use of nitrofurantoin in renal impairment from patients with a CrCl <60mL/min to those with a CrCl <30mL/min, based on 2 retrospective studies that identified the safety and efficacy of nitrofurantoin in this population
    • Additionally, the increasing resistance to both sulfamethoxazole/trimethoprim and fluoroquinolones gives an advantage to the use of nitrofurantoin

Tier Changes – Effective January 1, 2018

  • Olmesartan Products – Moving from Tier 2 to Non-Formulary
    • Dr. Farasat provided feedback that this would be reasonable given there are several covered alternatives
  • Esomeprazole – Moving from Tier 2 to Non-Formulary
    • Dr. Moy provided feedback that this would be reasonable given there are several covered alternatives

 

View as PDF

FLASH: eviCore Issue for DME Providers

August 3, 2017

eviCore on Your Health Alliance for providers is experiencing issues with letting DME providers submit preauthorizations. If you aren’t able to submit preauthorization requests for C-PAP and BI-PAP machines and supplies through eviCore, you should call them at 844-303-8452 to start cases.

eviCore is working to resolve this issue as soon as possible so that you’ll be able to submit preauthorization requests online for our members.

This is only for DME preauthorizations that go through eviCore. This does not affect DME preauthorizations that are submitted through Clear Coverage.

If you have any questions, contact your provider relations specialist.

Washington August Newsletter

August 1, 2017

Submitting Therapy Preauthorization Requests on eviCore

Recently, there’s been some confusion around therapy preauthorization (PA) requests on eviCore. This chart can help make sense of who you need to make preauthorization requests for and the timeframes for those requests:

Physical, Occupational, Massage, Acupuncture, and Chiropractic Therapies

Patient Type When Is PA Through eviCore Required?
Patients currently in treatment plans that began before August 1, 2017

PA is not required through eviCore through 2017 unless there is a change in diagnosis. PA must be obtained for continuing treatment before January 1, 2018.*

Patients who will begin treatment on August 1, 2017 or after

PA is required for all dates of service of August 1, 2017 and after.*

*Note: eviCore will accept PA requests for these therapy programs no more than 14 days before the date of service if requested online through Your Health Alliance for providers. If requested via phone or fax, they will not accept them more than 7 days before the date of service.

Radiation Therapy

Patient Type When Is PA Through eviCore Required?
Patients currently in treatment plans that began before August 1, 2017 PA is not required through eviCore through 2017 unless there is a change in diagnosis. PA must be obtained for continuing treatment before January 1, 2018.
Patients who will begin treatment on August 1, 2017 or after PA is required for all dates of service August 1, 2017 and after.

 

If you have any questions, contact your provider relations specialist.

New Numbers & Medicare Cards Coming in April 2018

Medicare is taking steps to remove Social Security numbers from Medicare cards. People with Medicare will begin receiving new Medicare cards in April 2018, until all cards are replaced by April 2019. These cards will have a Medicare Beneficiary Identifier (MBI) number that is randomly generated.

Medication Reconciliation Post-Discharge Measure

Medication reconciliation after a hospital, skilled nursing facility (SNF), or extended care facility (ECF) stay is an important part of continuity of care and improves the safety of patients. In one study, more than 80% of patients had an error related to or a misunderstanding of their discharge medications, more commonly with the medications that were unrelated to their primary diagnosis.

The measure evaluates if a provider completed a medication reconciliation for Medicare Advantage patients within 30 days of discharge from acute and non-acute settings.

A prescribing provider, registered nurse, or pharmacist can complete medication reconciliation. It can be done at the time of discharge or within 30 days, but it must be clear that any medications the patient had before their admission were compared with their medications at the time of their discharge. Phone call and home visit documentation of a medication review can also be used if the notes are included in the outpatient record.

The National Committee of Quality Assurance (NCQA) recognizes this evidence as meeting compliance for this measure:

  • Billing codes 99495, 99496, and 1111F
  • Discharge summary with documentation that discharge medications were reconciled with the most recent medication list in the outpatient record, which must be filed in the outpatient record within 30 days of discharge
  • Post-discharge hospital follow-up visit with documentation of medication reconciliation or review
  • Documentation of the current medications and a notation that:
    • Discharge medications were reviewed
    • References the discharge medications (e.g., no changes in medications since discharge, same medications at discharge, or discontinue all discharge medications)
    • The provider reconciled the current and the discharge medications
  • Documentation of both current and discharge medication lists and a notation that both were reviewed on the same date of service
  • Notation that no medications were prescribed or ordered upon discharge

Note: If a patient discharges from a hospital to an SNF or ECF, medication reconciliation must be documented in their outpatient record within 30 days of being discharged from the SNF or ECF.

Thank you for your efforts in helping patients understand their medication and how to take them safely.

Statin Use and Adherence HEDIS Measures

Statin Therapy for Patients with Cardiovascular Disease and Statin Therapy for Patients with Diabetes are 2 measures the NCQA included in the 2017 HEDIS audit.

Both of these measures are administrative measures, which means data is collected from claims submitted to us. To get accurate results, claims information must be complete, reflecting the appropriate diagnosis, as well as any conditions or medications that may exclude the member from the denominator.

Statin Therapy for Patients with Cardiovascular Disease

Reflects the percentage of members, males 21 to 75 years and females 40 to 75 years, who have had a diagnosis of clinical atherosclerotic cardiovascular disease and were dispensed at least one high or moderate-intensity statin medication during the measurement year.

The adherence rate is also measured to show the percentage of members who achieved a proportion of days covered (PDC) of at least 80%, beginning with the first prescription fill to the end of the measurement year.

Statin Therapy for Patients with Diabetes

Reflects the percentage of members with diabetes between the ages of 40 to 75 who were dispensed a prescription for a statin during the measurement year.

The adherence rate is also measured to show the percentage of members who achieved a PDC of at least 80%, beginning with the first prescription fill to the end of the measurement year.

 

Members with the following conditions are allowed to be excluded from both measures:

  • Pregnancy
  • Having in vitro fertilization procedure
  • Current prescription for clomiphene
  • End stage renal disease
  • Cirrhosis
  • Myalgia
  • Myositis
  • Myopathy
  • Rhabdomyolysis

Most of the allowed exclusions can be coded during the measurement year or the year before the measurement year; however, myalgia, myositis, myopathy, or rhabdomyolysis need to be coded annually if that’s the reason the patient can’t tolerate the statin.

See the list of conditions and codes accepted as exclusions by the NCQA for muscle pain and muscle disease below. Providers can receive other diagnosis codes accepted as exclusion by contacting the Quality Management department at 1-800-851-3379, ext. 8112.

Code Definition Code System
G72.0 Drug-induced myopathy ICD10CM
G72.2 Myopathy due to other toxic agents ICD10CM
G72.9 Myopathy, unspecified ICD10CM
M62.82 Rhabdomyolysis ICD10CM
M79.1 Myalgia ICD10CM

HEDIS 2017 (Measurement Year 2016) and HEDIS 2016 (Measurement Year 2015) Results

National benchmarks are not available at this time.

Statin Therapy for Patients with Cardiovascular Disease

Commercial HMO/POS
HEDIS 2017 HEDIS 2016
Received Statin Therapy – Males 81.87% 79.33%
Statin Adherence 80% – Males 72.56% 75.09%
Received Statin Therapy – Female 73.40% 71.46%
Statin Adherence 80% – Females 66.44% 68.79%
Received Statin Therapy – Total 79.49% 77.16%
Statin Adherence 80% – Total 70.97% 73.48%
Medicare HMO
HEDIS 2017 HEDIS 2016
Received Statin Therapy – Males 75.00% 76.22%
Statin Adherence 80% – Males 82.81% 84.40%
Received Statin Therapy – Female 70.59% 59.04%
Statin Adherence 80% – Females 66.67% 83.67%
Received Statin Therapy – Total 73.60% 69.91%
Statin Adherence 80% – Total 77.90% 84.18%
Northwest Medicare HMO
HEDIS 2017 HEDIS 2016
Received Statin Therapy – Males 86.11% 82.29%
Statin Adherence 80% – Males 79.57% 81.01%
Received Statin Therapy – Female 80.85% 77.50%
Statin Adherence 80% – Females 78.95% 80.65%
Received Statin Therapy – Total 84.52% 80.88%
Statin Adherence 80% – Total 79.39% 80.91%

Statin Therapy for Patients with Diabetes

Commercial HMO/POS
HEDIS 2017 HEDIS 2016
Received Statin Therapy 61.18% 60.56%
Statin Adherence 80% 74.62% 73.33%
Medicare HMO
HEDIS 2017 HEDIS 2016
Received Statin Therapy 69.15% 69.16%
Statin Adherence 80% 82.05% 82.43%
Northwest Medicare HMO
HEDIS 2017 HEDIS 2016
Received Statin Therapy 74.16% 70.80%
Statin Adherence 80% 72.95% 74.58%

 

Please discuss the benefits of statin use with your patients and, if you have patients who cannot tolerate one of the statins, be sure and code the reason.

 

NCQA is a nonprofit organization dedicated to improving our nation’s health care system. Since its founding in 1990, NCQA has been a central figure in health care improvement, and its seal is a widely recognized symbol of quality and service.

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

Pharmacy Updates

Medicare & Washington Public Exchange (WA Public) Plans

eviCore Preauthorizations – Effective August 1, 2017

  • All oncology regimens will require PA through eviCore
    • This includes many new medications that did not previously require PA through us
    • Refer to our formulary for more details

Review of P&T Committee Minutes – From April 5, 2017

  • Diabetes Drug Therapies – Added non-preferred insulin step therapy (ST)
    • Novolog and Novolin products require step through Humalog/Humulin

Formulary Additions

  • Rhofade (oxymetazoline hydrochloride) – Indicated for the persistent facial erythema associated with rosacea in adults.
    • WA Public – Tier 3 with PA
    • Medicare – Non-formulary
  • Eucrisa (crisaborole) – Indicated for the treatment of mild to moderate atopic dermatitis in patients 2 years of age and older.
    • WA Public – Tier 3 with PA
    • Medicare – Non-formulary
  • Dupixent (dupilumab) – Indicated for the treatment of moderate to severe atopic dermatitis in adults whose disease is not adequately controlled with topical prescription therapies, or when those therapies are not advisable.
    • WA Public – Tier 5 with PA
    • Medicare – Non-formulary

WA Public Plans

Criteria Changes

  • Cardiology
    • Corlanor
      • Edited policy to allow electrophysiologist to prescribe without restrictions (Diagnosis: Inappropriate sinus tachycardia)
    • Entresto
      • Changed policy from PA to ST
      • Updated to require initiation by a cardiologist or submission of chart notes indicating drug was first ordered by a cardiologist
    • Northera
      • Removed pyridostigmine from ST requirements
    • PCSK9 Inhibitors
      • Added endocrinologist and lipidologist to authorized prescribers
      • Broadened definition of statin failure to include >50% LDL decrease without reaching target
  • Pulmonology
    • All PAH policies
      • Removed conventional therapy ST (oral anticoagulants, diuretics, oxygen, digoxin) as these therapies are not recommended for all patients
    • Revatio (sildenafil)
      • Removed age requirement since this drug is used off label in pediatric PAH
    • Tracleer
      • Removed age requirement since this drug is used in pediatric PAH
    • Adcirca
      • Edited policy to indicate that sildenafil ST can be bypassed if member is using Adcirca in combination with Letairis
    • Adempas, Opsumit
      • Removed ST through sildenafil or Adcirca and ST through Tracleer or Letairis
    • Uptravi
      • Removed ST through sildenafil since guidelines have equal recommendation to support monotherapy as compared to sildenafil for WHO-FC II and III
    • LAMA/LABA
      • Retired policy (removed PA) to reflect 2017 GOLD COPD Guidelines
  • Dermatology
    • Mirvaso Gel
      • Changed policy from ST to PA to allow additional criteria and to match requirements for Soolantra and Rhofade
        • PA for diagnosis
        • Failure on topical metronidazole
        • Failure on oral doxycycline
    • Sklice, Natroba
      • Retired policies
        • Removed permethrin 5% cream ST
      • Both will be covered at Tier 3
      • Both will have MDL of one box per fill

Operational Updates

  • Newly Approved Medications & Indications – Updated title, purpose, and statement to reflect that newly approved indications of currently approved medications will have the same initial PA requirement (for first 12 months from the date of launch) and undergo the same P&T evaluation process as newly approved medications

Tier Changes – Effective August 1, 2017

  • Esomeprazole – Moved from Tier 1 to Excluded
    • Nexium 24 HR OTC is on average $200 less per prescription than the generic prescription version
    • Nexium OTC will remain covered at Tier 1
    • Change reviewed and approved by Dr. Moy in gastroenterology
  • Yosprala – Moved from Tier 3 to Excluded
    • Combo of omeprazole 40mg and aspirin 81mg
    • Omeprazole covered at Tier 1
    • Aspirin available OTC
  • Zyflo, Zyflo CR, Zileuton ER – Moved from Tier 3 to Tier 4
    • $4,000 per month supply
    • Covered on specialty tier
  • Fluticasone propionate/salmeterol – Moved from Excluded to Tier 1
    • Authorized generic for AirDuo RespiClick
    • Generic version $113 per month versus Advair $435 per month
    • Available strengths include 55/14, 113/14, and 232/14
  • Noxifol-D – Moved from Tier 3 to Excluded
    • Folic acid and Vitamin D both available OTC

Medicare

Tier Changes

  • Fluticasone propionate/salmeterol – Moved from Non-Formulary to Tier 2
    • Authorized generic for AirDuo RespiClick
    • Generic version $113 per month versus Advair $435 per month
    • Available strengths include 55/14, 113/14, and 232/14
  • Nitrofurantoin (Macrobid) – Moved from Non-Formulary to Tier 2
    • The American Geriatrics Society 2015 Beers Criteria Update Expert Panel has revised its recommendation to avoid use of nitrofurantoin in renal impairment from patients with a CrCl <60mL/min to those with a CrCl <30mL/min, based on 2 retrospective studies that identified the safety and efficacy of nitrofurantoin in this population
    • Additionally, the increasing resistance to both sulfamethoxazole/trimethoprim and fluoroquinolones gives an advantage to the use of nitrofurantoin

Tier Changes – Effective January 1, 2018

  • Olmesartan Products – Moving from Tier 2 to Non-Formulary
    • Dr. Farasat provided feedback that this would be reasonable given there are several covered alternatives
  • Esomeprazole – Moving from Tier 2 to Non-Formulary
    • Dr. Moy provided feedback that this would be reasonable given there are several covered alternatives

 

View as PDF

Midwest August Newsletter

August 1, 2017

Submitting Therapy Preauthorization Requests on eviCore

Recently, there’s been some confusion around therapy preauthorization (PA) requests on eviCore. This chart can help make sense of who you need to make preauthorization requests for and the timeframes for those requests:

Physical, Occupational, Massage, Acupuncture, and Chiropractic Therapies

Patient Type When Is PA Through eviCore Required?
Patients currently in treatment plans that began before August 1, 2017

PA is not required through eviCore through 2017 unless there is a change in diagnosis. PA must be obtained for continuing treatment before January 1, 2018.*

Patients who will begin treatment on August 1, 2017 or after

PA is required for all dates of service of August 1, 2017 and after.*

*Note: eviCore will accept PA requests for these therapy programs no more than 14 days before the date of service if requested online through Your Health Alliance for providers. If requested via phone or fax, they will not accept them more than 7 days before the date of service.

Radiation Therapy

Patient Type When Is PA Through eviCore Required?
Patients currently in treatment plans that began before August 1, 2017 PA is not required through eviCore through 2017 unless there is a change in diagnosis. PA must be obtained for continuing treatment before January 1, 2018.
Patients who will begin treatment on August 1, 2017 or after PA is required for all dates of service August 1, 2017 and after.

 

If you have any questions, contact your provider relations specialist.

New Numbers & Medicare Cards Coming in April 2018

Medicare is taking steps to remove Social Security numbers from Medicare cards. People with Medicare will begin receiving new Medicare cards in April 2018, until all cards are replaced by April 2019. These cards will have a Medicare Beneficiary Identifier (MBI) number that is randomly generated.

Medication Reconciliation Post-Discharge Measure

Medication reconciliation after a hospital, skilled nursing facility (SNF), or extended care facility (ECF) stay is an important part of continuity of care and improves the safety of patients. In one study, more than 80% of patients had an error related to or a misunderstanding of their discharge medications, more commonly with the medications that were unrelated to their primary diagnosis.

The measure evaluates if a provider completed a medication reconciliation for Medicare Advantage patients within 30 days of discharge from acute and non-acute settings.

A prescribing provider, registered nurse, or pharmacist can complete medication reconciliation. It can be done at the time of discharge or within 30 days, but it must be clear that any medications the patient had before their admission were compared with their medications at the time of their discharge. Phone call and home visit documentation of a medication review can also be used if the notes are included in the outpatient record.

The National Committee of Quality Assurance (NCQA) recognizes this evidence as meeting compliance for this measure:

  • Billing codes 99495, 99496, and 1111F
  • Discharge summary with documentation that discharge medications were reconciled with the most recent medication list in the outpatient record, which must be filed in the outpatient record within 30 days of discharge
  • Post-discharge hospital follow-up visit with documentation of medication reconciliation or review
  • Documentation of the current medications and a notation that:
    • Discharge medications were reviewed
    • References the discharge medications (e.g., no changes in medications since discharge, same medications at discharge, or discontinue all discharge medications)
    • The provider reconciled the current and the discharge medications
  • Documentation of both current and discharge medication lists and a notation that both were reviewed on the same date of service
  • Notation that no medications were prescribed or ordered upon discharge

Note: If a patient discharges from a hospital to an SNF or ECF, medication reconciliation must be documented in their outpatient record within 30 days of being discharged from the SNF or ECF.

Thank you for your efforts in helping patients understand their medication and how to take them safely.

Statin Use and Adherence HEDIS Measures

Statin Therapy for Patients with Cardiovascular Disease and Statin Therapy for Patients with Diabetes are 2 measures the NCQA included in the 2017 HEDIS audit.

Both of these measures are administrative measures, which means data is collected from claims submitted to us. To get accurate results, claims information must be complete, reflecting the appropriate diagnosis, as well as any conditions or medications that may exclude the member from the denominator.

Statin Therapy for Patients with Cardiovascular Disease

Reflects the percentage of members, males 21 to 75 years and females 40 to 75 years, who have had a diagnosis of clinical atherosclerotic cardiovascular disease and were dispensed at least one high or moderate-intensity statin medication during the measurement year.

The adherence rate is also measured to show the percentage of members who achieved a proportion of days covered (PDC) of at least 80%, beginning with the first prescription fill to the end of the measurement year.

Statin Therapy for Patients with Diabetes

Reflects the percentage of members with diabetes between the ages of 40 to 75 who were dispensed a prescription for a statin during the measurement year.

The adherence rate is also measured to show the percentage of members who achieved a PDC of at least 80%, beginning with the first prescription fill to the end of the measurement year.

 

Members with the following conditions are allowed to be excluded from both measures:

  • Pregnancy
  • Having in vitro fertilization procedure
  • Current prescription for clomiphene
  • End stage renal disease
  • Cirrhosis
  • Myalgia
  • Myositis
  • Myopathy
  • Rhabdomyolysis

Most of the allowed exclusions can be coded during the measurement year or the year before the measurement year; however, myalgia, myositis, myopathy, or rhabdomyolysis need to be coded annually if that’s the reason the patient can’t tolerate the statin.

See the list of conditions and codes accepted as exclusions by the NCQA for muscle pain and muscle disease below. Providers can receive other diagnosis codes accepted as exclusion by contacting the Quality Management department at 1-800-851-3379, ext. 8112.

Code Definition Code System
G72.0 Drug-induced myopathy ICD10CM
G72.2 Myopathy due to other toxic agents ICD10CM
G72.9 Myopathy, unspecified ICD10CM
M62.82 Rhabdomyolysis ICD10CM
M79.1 Myalgia ICD10CM

 

HEDIS 2017 (Measurement Year 2016) and HEDIS 2016 (Measurement Year 2015) Results

National benchmarks are not available at this time.

Statin Therapy for Patients with Cardiovascular Disease

Commercial HMO/POS
 
  HEDIS 2017 HEDIS 2016
Received Statin Therapy – Males 81.87% 79.33%
Statin Adherence 80% – Males 72.56% 75.09%
Received Statin Therapy – Female 73.40% 71.46%
Statin Adherence 80% – Females 66.44% 68.79%
Received Statin Therapy – Total 79.49% 77.16%
Statin Adherence 80% – Total 70.97% 73.48%
Medicare HMO
 
  HEDIS 2017 HEDIS 2016
Received Statin Therapy – Males 75.00% 76.22%
Statin Adherence 80% – Males 82.81% 84.40%
Received Statin Therapy – Female 70.59% 59.04%
Statin Adherence 80% – Females 66.67% 83.67%
Received Statin Therapy – Total 73.60% 69.91%
Statin Adherence 80% – Total 77.90% 84.18%
Northwest Medicare HMO
 
  HEDIS 2017 HEDIS 2016
Received Statin Therapy – Males 86.11% 82.29%
Statin Adherence 80% – Males 79.57% 81.01%
Received Statin Therapy – Female 80.85% 77.50%
Statin Adherence 80% – Females 78.95% 80.65%
Received Statin Therapy – Total 84.52% 80.88%
Statin Adherence 80% – Total 79.39% 80.91%

Statin Therapy for Patients with Diabetes

Commercial HMO/POS
 
  HEDIS 2017 HEDIS 2016
Received Statin Therapy 61.18% 60.56%
Statin Adherence 80% 74.62% 73.33%
Medicare HMO
 
  HEDIS 2017 HEDIS 2016
Received Statin Therapy 69.15% 69.16%
Statin Adherence 80% 82.05% 82.43%
Northwest Medicare HMO
 
  HEDIS 2017 HEDIS 2016
Received Statin Therapy 74.16% 70.80%
Statin Adherence 80% 72.95% 74.58%

 

Please discuss the benefits of statin use with your patients and, if you have patients who cannot tolerate one of the statins, be sure and code the reason.

 

NCQA is a nonprofit organization dedicated to improving our nation’s health care system. Since its founding in 1990, NCQA has been a central figure in health care improvement, and its seal is a widely recognized symbol of quality and service.

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

Meet with a Coding Specialist

The risk adjustment coding consultants are continuing to request meetings with participating, high-volume provider offices. These meetings are designed to share member-specific examples of coding and quality measure needs and to update providers on the latest efforts to educate on risk adjustment. Along with member specific examples, there is information on yearly risk adjustment data validation (RADV) audits and how provider practice participation is essential in this process.

A member of the coding consultant team is willing to meet with you to discuss any coding or quality questions you may have, or to provide member-specific examples from your panel of members. If interested, contact us at CodingCounts@healthalliance.org.

Pharmacy Updates

All Plans

eviCore Preauthorizations – Effective August 1, 2017

  • All oncology regimens will require PA through eviCore
    • This includes many new medications that did not previously require PA through us
    • Refer to our formulary for more details

Review of P&T Committee Minutes – From April 5, 2017

  • Diabetes Drug Therapies – Added non-preferred insulin step therapy (ST)
    • Novolog and Novolin products require step through Humalog/Humulin

Formulary Additions

  • Rhofade (oxymetazoline hydrochloride) – Indicated for the persistent facial erythema associated with rosacea in adults.
    • Commercial – Tier 3 with PA
    • Medicare – Non-formulary
  • Eucrisa (crisaborole) – Indicated for the treatment of mild to moderate atopic dermatitis in patients 2 years of age and older.
    • Commercial – Tier 3 with PA
    • Medicare – Non-formulary
  • Dupixent (dupilumab) – Indicated for the treatment of moderate to severe atopic dermatitis in adults whose disease is not adequately controlled with topical prescription therapies, or when those therapies are not advisable.
    • Commercial – Tier 5 with PA
    • Medicare – Non-formulary

Commercial

Criteria Changes

  • Cardiology
    • Corlanor
      • Edited policy to allow electrophysiologist to prescribe without restrictions (Diagnosis: Inappropriate sinus tachycardia)
    • Entresto
      • Changed policy from PA to ST
      • Updated to require initiation by a cardiologist or submission of chart notes indicating drug was first ordered by a cardiologist
    • Northera
      • Removed pyridostigmine from ST requirements
    • PCSK9 Inhibitors
      • Added endocrinologist and lipidologist to authorized prescribers
      • Broadened definition of statin failure to include >50% LDL decrease without reaching target
  • Pulmonology
    • All PAH policies
      • Removed conventional therapy ST (oral anticoagulants, diuretics, oxygen, digoxin) as these therapies are not recommended for all patients
    • Revatio (sildenafil)
      • Removed age requirement since this drug is used off label in pediatric PAH
    • Tracleer
      • Removed age requirement since this drug is used in pediatric PAH
    • Adcirca
      • Edited policy to indicate that sildenafil ST can be bypassed if member is using Adcirca in combination with Letairis
    • Adempas, Opsumit
      • Removed ST through sildenafil or Adcirca and ST through Tracleer or Letairis
    • Uptravi
      • Removed ST through sildenafil since guidelines have equal recommendation to support monotherapy as compared to sildenafil for WHO-FC II and III
    • LAMA/LABA
      • Retired policy (removed PA) to reflect 2017 GOLD COPD Guidelines
  • Dermatology
    • Mirvaso Gel
      • Changed policy from ST to PA to allow additional criteria and to match requirements for Soolantra and Rhofade
        • PA for diagnosis
        • Failure on topical metronidazole
        • Failure on oral doxycycline
    • Sklice, Natroba
      • Retired policies
        • Removed permethrin 5% cream ST
      • Both will be covered at Tier 3
      • Both will have MDL of one box per fill

Operational Updates

  • Newly Approved Medications & Indications – Updated title, purpose, and statement to reflect that newly approved indications of currently approved medications will have the same initial PA requirement (for first 12 months from the date of launch) and undergo the same P&T evaluation process as newly approved medications

Tier Changes – Effective August 1, 2017

  • Esomeprazole – Moved from Tier 1 to Excluded
    • Nexium 24 HR OTC is on average $200 less per prescription than the generic prescription version
    • Nexium OTC will remain covered at Tier 1
    • Change reviewed and approved by Dr. Moy in gastroenterology
  • Yosprala – Moved from Tier 3 to Excluded
    • Combo of omeprazole 40mg and aspirin 81mg
    • Omeprazole covered at Tier 1
    • Aspirin available OTC
  • Zyflo, Zyflo CR, Zileuton ER – Moved from Tier 3 to Tier 4
    • $4,000 per month supply
    • Covered on specialty tier
  • Fluticasone propionate/salmeterol – Moved from Excluded to Tier 1
    • Authorized generic for AirDuo RespiClick
    • Generic version $113 per month versus Advair $435 per month
    • Available strengths include 55/14, 113/14, and 232/14
  • Noxifol-D – Moved from Tier 3 to Excluded
    • Folic acid and Vitamin D both available OTC

Medicare

Tier Changes

  • Fluticasone propionate/salmeterol – Moved from Non-Formulary to Tier 2
    • Authorized generic for AirDuo RespiClick
    • Generic version $113 per month versus Advair $435 per month
    • Available strengths include 55/14, 113/14, and 232/14
  • Nitrofurantoin (Macrobid) – Moved from Non-Formulary to Tier 2
    • The American Geriatrics Society 2015 Beers Criteria Update Expert Panel has revised its recommendation to avoid use of nitrofurantoin in renal impairment from patients with a CrCl <60mL/min to those with a CrCl <30mL/min, based on 2 retrospective studies that identified the safety and efficacy of nitrofurantoin in this population
    • Additionally, the increasing resistance to both sulfamethoxazole/trimethoprim and fluoroquinolones gives an advantage to the use of nitrofurantoin

Tier Changes – Effective January 1, 2018

  • Olmesartan Products – Moving from Tier 2 to Non-Formulary
    • Dr. Farasat provided feedback that this would be reasonable given there are several covered alternatives
  • Esomeprazole – Moving from Tier 2 to Non-Formulary
    • Dr. Moy provided feedback that this would be reasonable given there are several covered alternatives

 

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