InforMED

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.

Midwest December Newsletter

December 6, 2016

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.

Runout for Medicaid Claims

In our October Newsletter, we announced that all Health Alliance Connect Medicaid coverage will end as of December 31, 2016.

To expedite the transition process, we are requesting that all 2016 claims or claim inquiries/appeals be submitted no later than April 1, 2017.

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).

Meet with a Coding Specialist

The risk adjustment coding consultants are making their rounds to high-volume participating provider offices sharing member-specific examples of coding and quality measure needs. A member of the team is happy 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

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

Formulary Additions

  • Seebri Neohaler (glycopyrrolate) – Indicated for the long-term, maintenance treatment of airflow obstruction in patients with chronic obstructive pulmonary disease (COPD).
    • Commercial – Tier 3
    • Medicaid – Non-formulary
    • 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).
    • Commercial – Tier 3 with preauthorization (PA)
    • Medicaid – Non-formulary
    • 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).
    • Commercial – Tier 3 with PA
    • Medicaid – Non-formulary
    • 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.
    • Commercial – Tier 5 with PA
    • Medicaid – Non-formulary
    • 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.
    • Commercial – Tier 3
    • Medicaid – Non-formulary
    • 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.
    • Commercial – Tier 4 with PA
    • Medicaid – Covered 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.
    • Commercial – Tier 6
    • Medicaid – Non-formulary
    • Medicare – Non-formulary

Medicaid

Members Terming

  • Health Alliance Connect members that term October 31, 2016 may transition to a new plan with a 4-prescription limit.
  • Pharmacies have been notified of best practices for obtaining PA approval without having to contact providers.

Criteria Change

  • Hepatitis C Treatment – Changed criteria to be consistent with HFS and allow for coverage of METAVIR scores F3-F4

Medicaid and Commercial

Criteria Change

  • Xeomin (incobotulinumtoxin A) – Added criteria for coverage of Upper Limb Spasticity

Commercial

Criteria Changes

  • 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

Washington October Newsletter

October 17, 2016

2017 Preauthorization and Notification Changes – Effective January 1, 2017

  • In addition to notifying Health Alliance for inpatient admission, facilities will need to begin notifying us of any observation stays.
  • You must notify us within 24 hours, or the next business day if it’s a holiday.

Online Claims Reprocessing Inquiries

We’ve moved claims reprocessing inquiries onto 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.

S2900 Billing Clarification – Robotic-Assisted Surgery

This code is not payable under our coverage. You can only bill for tracking purposes with no billed amount.

Health Alliance follows the Medicare coding standards for robotic-assisted surgery.

BMI Requirements

HEDIS® requires a biannual calculation of body mass index (BMI). BMI is calculated by dividing a person’s weight in kilograms by the square of height in meters. By current standards for adults, if the BMI is:

  • Less than 18.5, it falls within the underweight range
  • 18.5 to 24.9, it falls within the healthy weight range
  • 25.0 to 29.9, it falls within the overweight range
  • 30.0 or higher, it falls within the obese range

Make sure you’re meeting this requirement by getting a height and weight from patients at least once a year.

In some cases, such as those with a high muscle mass, more than a BMI may be required to accurately diagnose obesity. Waist circumference is one measure that could help in these situations.

Importance of the Health Outcome Survey

The Star Rating system from Centers for Medicare and Medicaid Services (CMS) gives consumers the opportunity to compare Medicare Advantage plans each fall during the Annual Enrollment Period. The Health Outcome Survey (HOS) is an important part of that rating system.

Each spring, CMS mails the survey to a sampling of members from each Medicare Advantage contract. It asks the member questions to evaluate their physical and mental health, plus their day-to-day activities. If a member responds to a baseline survey, they will be surveyed again in 2 years to evaluate their health status over that time period.

Many of the questions in the survey can be addressed during yearly physicals. For example, the survey asks, “In the past 6 months, have you experienced leaking of urine?” If the member answers yes, they’re asked “Have you ever talked with a doctor, nurse, or other health care provider about leaking urine?”

The survey also asks about treatment, “There are many ways to control or manage the leaking of urine, including bladder training exercises, medication, and surgery. Have you ever talked with a doctor, nurse, or other healthcare provider about any of these approaches?”

Other questions in the survey focus on activity level, fall risk assessment, and monitoring for depression at office visits. The HOS survey is an opportunity to evaluate how our members view their current health status, and if they address those concerns with their health care provider.

Please keep these questions in mind during annual visits with Medicare members.

ACA Coverage of Tobacco Cessation

In a medical record review, we’ve noted that in discussions of tobacco cessation, members have told providers that they couldn’t afford the medications.

The Affordable Care Act (ACA) requires health insurers to cover FDA-approved tobacco cessation products for 90 days per quit attempt (for up to 2 quit attempts per year), without cost to the member. Prescriptions are required for this coverage.

We not only cover OTC Nicotine patches, gum, lozenges (with a prescription), but also Bupropion and Chantix. Free counseling over the phone without enrollment is also offered to better prepare our members for success. Many members might not be aware of this coverage to take advantage of the opportunity to quit tobacco use.

If you have questions about this, contact Penny Shaw, RRT, Quality Improvement Coordinator, at 1-800-851-3379, ext. 3409, or email Penny.Shaw@healthalliance.org.

Updated 2015 Beers Criteria for Potentially Inappropriate Medication Use in Older Adults

Last year, the American Geriatrics society updated the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Use the guideline for detailed changes, but here is a brief overview of changes:

  • Desmopressin – Avoid for treatment of nocturia and nocturnal polyuria.
  • Proton-Pump Inhibitors – Avoid for more than 8 weeks duration, unless for high-risk patients, erosive esophagitis, Barrett’s esophagitis, pathologic hyper secretory condition, or demonstrated need for maintenance treatment.
  • Eszopiclone and Zaleplon – Added to the list of drugs to avoid in dementia or cognitive impairment.
  • Opioids – Added to list of drugs to avoid in patients with a history of falls.
  • Nitrofurantoin – Removed recommendation to avoid in CrCl<60 mL/min. The new recommendation is to avoid in individuals with CrCl<30 mL/min, and to continue to avoid long-term use due to potential pulmonary toxicity.
  • Amiodarone – Avoid as first line unless the patient has heart failure or significant left ventricular hypertrophy.
  • Dronadarone – Avoid in permanent atrial fibrillation or with severe or recently decompensated heart failure.
  • Digoxin – Avoid as first line in atrial fibrillation and heart failure. Avoid doses greater than 0.125 mg/day.
  • Non-Benzodiazepine Hypnotics – Changed from avoid use over 90 days to avoid use regardless of duration.
  • Meperidine – Avoid use, especially in those with chronic kidney disease.
  • Antipsychotics – Added to drugs to avoid in delirium. Antipsychotics should be avoided for patients with dementia if non-pharmacologic options have failed or are not possible.
  • Indomethacin and Ketorolac – Indomethacin is more likely than other NSAIDs to have adverse CNS effects. Of all the NSAIDs, indomethacin has the most adverse effects, such as increased risk of gastrointestinal bleeding, peptic ulcer disease, and acute kidney injury in older adults.

Please keep these guidelines in mind when prescribing medication for seniors and when reviewing current medications they already take.