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June Newsletter

June 5, 2014

ICD-10 Transition Delayed to 2015

Many of you have already heard about the ICD-10 delay that was embedded in the Protecting Access to Medicare Act of 2014. This act aimed to delay cuts in physicians’ Medicare rates, but it also pushes back implementation of ICD-10 until 2015.

The Centers for Medicare & Medicaid Services released a statement indicating that the U.S. Department of Health and Human Services expects to release an interim final rule soon, which will include a new compliance date requiring the use of ICD-10 beginning October 1, 2015. The rule will also require HIPAA-covered entities to continue to use ICD-9-CM through September 30, 2015. We will update you as we receive more information. You can also check the CMS website for any updates.

Please continue to assess your ICD-10 readiness, and watch your email for ICD-10 Sneak Peek email blasts from Coding Counts, brought to you by the Health Alliance Risk Adjustment coding consultant team. To make sure you’re on our distribution list, email us at CodingCounts@healthalliance.org.

Pharmacy Updates

Medicare

New and Revised Policies

New Medicare Policies

Formulary Change

  • Non-preferred Brand to Preferred Brand
    • Dulera
    • Commercial

Commercial

Formulary Changes

  • Tier 2 to Tier 3 (Members have been notified)
    • Advicor
    • Simcor
    • Diovan

Formulary Additions

  • Anoro Ellipta (umeclidinium/vilanterol) – Tier 3 with Step Therapy through Tudorza, Spiriva, or Serevent
  • Aptiom (eslicarbazepine acetate) – Tier 3 with Step Therapy through oxcarbazepine
  • Duavee (conjugated estrogens/bazedoxifene) – Tier 3
  • Farxiga (dapagliflozin) – Tier 3 with Preauthorization (PA)
  • Luzu (luliconazole) -Tier 3 with Step Therapy through a generic
  • Stendra (avanafil) – Tier 3 with PA
  • Velphoro (sucroferric oxyhydroxide) – Tier 5
  • Vimizim (elosulfase alfa) – Tier 6 with PA
  • Zohydro ER (hydrocodone bitartrate) – Tier 3 with PA
  • Granix (TBO-filgrastim) – Tier 4 with PA

Policy Updates

  • Added Opioids – Long Acting and Short Acting
    • Zohydro ER
    • Butrans
  • Weight Loss Medications – New policy
    • Defines coverage of weight loss medications on FEHB plans only

Think In-Network When Referring

When referring your patients to another provider for consultation or treatment, remember that many of our members’ plans require that provider to be a participating, or in-network, provider. Before referring, please check the member’s network on Your Health Alliance.

  1. Log in at Your Health Alliance*
  2. Choose Attach to a Member, and enter the member’s information.
  3. Enter the member’s information and choose them from the results
  4. View their Member Details to look at their plan type and provider directory

You can also call us at 1-800-851-3379, and we’ll be happy to help you find participating providers for that member’s plan.

Please remind your patients to check with Health Alliance for participating providers. We have an extensive network of providers, and we want to make sure members are staying in-network whenever possible.

*You need to register for an account the first time you visit Your Health Alliance.

Ensuring Accurate Blood Pressure Readings

It’s important to follow proper technique when taking blood pressure readings to get the most accurate measurement. UpToDate®, an evidence-based clinical decision support resource, gives these tips to follow:

  • Use correct cuff size. A cuff that is too small could lead to an over-estimation of the systolic reading by as much as 10-50 mm HG in an obese patient.
  • The patient should sit with their back supported and legs uncrossed. Diastolic blood pressure can be increased by as much as 6 mm HG if the back is not supported. If legs are crossed, the systolic pressure can elevate by as much as 2-8 mm HG.
    The arm should be supported at heart level. If the arm hangs down, the blood pressure reading could be elevated by 10-12 mm HG.
  • The patient should be allowed to rest at least 5 minutes before the blood pressure reading.
  • The patient’s sleeve should not be rolled up, and the cuff should not be placed over thick clothing.
  • Neither the patient nor staff member should talk during the blood pressure reading.
  • Repeat blood pressure reading during the office visit if the first reading is elevated.

This information was last reviewed in April 2014. The same topic was discussed during a recent webinar by Telligen, the Medicare Quality Improvement Organization for Illinois.

During the webinar, the speaker also stressed the importance of choosing medications that are affordable and work with the patient’s lifestyle and work schedule. Patients need to check their blood pressure at home with at least some of the readings done before morning medications.

Request Preauthorization through Clear Coverage or Your Health Alliance

When submitting preauthorization requests, use Clear Coverage for all services that are available through it It allows you to submit an authorization request for some tests and procedures that result in real-time responses to approved requests. Providers who use the Clear Coverage system have reported satisfaction with the program. In the past, requests that can’t go through Clear Coverage have been submitted via fax. We are excited to share that Health Alliance has recently implemented an online preauthorization form that you can use through Your Health Alliance* for providers and office managers.

The form, with any associated documentation, is completed online and submitted via our secure website. This electronic format enhances management of preauthorization requests and gives you confirmation that the request has been received. It also allows you to track the preauthorization process.

Requests that don’t qualify for immediate approval are pended for review. If the request is for urgent care**, the review is completed within 24 hours if all requested information is received. All other types of requests and submissions are processed within 5 to 7 days if all information is received with the request.

You can find a guide for using Your Health Alliance and a Clear Coverage tutorial under Forms and Resources once you’ve logged it.

If you have questions about the preauthorization process or any of the methods available to submit a preauthorization request, please contact your provider relations specialist.

*You need to register for an account the first time you visit Your Health Alliance.

**Urgent care means medical care or treatment where using the timetable for a non-urgent care determination could seriously jeopardize the patient’s life/health or the patient’s ability to regain maximum function or, in the opinion of the attending or consulting physician, would subject the patient to severe pain that could not be adequately managed without the requested care or treatment.

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