Midwest August Newsletter

Learn About Our New Facility Claims Editor

Health Alliance began using the new iCES Facility Claims Editor in June. It works very similar to the previous Professional Claims Editor in detecting appropriate coding and billing. Here are some things you should know about the new claims editor:

• Venipunctures are disallowed as incidental to lab for Commercial and Medicaid products.
• Health Alliance follows OPPS edits regarding proper coding for all products. We only apply OPPS payment-type edits to products reimbursed based on OPPS.
• Use of modifiers is necessary. Specifically:
  • Modifier 27 will be required for multiple E/M visits on the same date of service.
  • Modifier L1 (ONLY applicable to Medicare Advantage products) – Outpatient laboratory tests that are generally packaged as ancillary services should have Modifier L1 attached if the hospital provides an outpatient lab test on the same date of service as other hospital outpatient services that are clinically unrelated and should be paid separately.
  • Therapy Modifiers.
• Standard multiple procedure modifier reductions (i.e. Modifiers 50, 51, 52, 53, 73, 74).
• Unbundling/Rebundling of services:
  • Lab panel codes should be billed, when appropriate, versus unbundling each lab code. We recognize different requirements for Medicare and Medicaid.
  • NCCI/CCI edits.
• Health Alliance follows Medicare’s MUE published guidelines.
• When reporting CPT 90999 for Dialysis, a modifier for URR (G1-G6 Modifier) must be attached.
• The patient discharge status code must be 30 (still patient) when the frequency digit is the type of bill 2 (Interim – First Claim) or the frequency digit is the type of bill 3 (Interim – Continuing Claim).

Clear Coverage Update

Starting September 1, 2015, Clear Coverage will only require you to have one username and password instead of 2. The process for gaining initial access will not change — providers will still request access through Your Health Alliance.

Helpful ICD-10 FAQ

We know you and your team might have questions about the transition to ICD-10, which goes into effect October 1, 2015. Our coding and CPS teams put together an FAQ to help. To see the whole FAQ, log in to Your Health Alliance and go to the Forms & Resources page.

If you have other ICD-10 questions, please email PSC@healthalliance.org.

• What has Health Alliance done to prepare for ICD-10?

Our design, development, testing and deployment are aligned for the October 1, 2015, ICD-10 compliance date. We have completed all analyses, including gap and system impact inventory, and system remediation. We have engaged the impacted areas of our company in our business assessments. We will be ready for the move from ICD-9 codes to ICD-10 codes.

• How will reimbursement methodology be impacted by ICD-10?

The ICD-10 conversion was not intended to transform payment or reimbursement. However, it may result in reimbursement methodologies that more accurately show patient status and care. We have engaged the impacted areas of our company in business assessments and planning for the move from ICD-9 codes to ICD-10 codes. As a result of this assessment, we will be updating all impacted policies, processes, and systems to be compliant with the ICD-10 code set.

• Will you accept both ICD-9 and ICD-10 code formats after October 1, 2015?

No. Beginning with dates of service/discharge on or after October 1, 2015, only ICD-10 codes will need to be submitted. ICD-9 codes should be submitted for dates of service/discharge before October 1, 2015.

Pharmacy Updates

All Plans

Formulary Additions

• Tanzeum (albiglutide) – GLP-1 receptor agonist indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.
  • Commercial – Tier 3 with Step Therapy (ST)
  • Medicare – Tier 4 with ST
  • Duals – Tier 2 with ST
  • Medicaid – Covered with ST
• Corlanor (ivabradine) – HCN-gated channel blocker indicated to reduce the risk of hospitalization for worsening heart failure in patients with stable, symptomatic chronic heart failure with left ventricular ejection fraction ≤ 35%, who are in sinus rhythm with resting heart rate ≥ 70 beats per minute and either are on maximally tolerated doses of beta-blockers or have a contraindication to beta-blocker use.
  • Commercial – Tier 3 with ST
  • Medicare – Tier 4
  • Duals – Tier 2
  • Medicaid – Covered with ST
• Cresemba (isavuconazonium sulfate) – an azole antifungal indicated for patients 18 years of age and older for the treatment of invasive aspergillosis and invasive mucormycosis.
  • Commercial – Tier 5 with preauthorization (PA)
  • Medicare – Tier 5 with PA
  • Duals – Tier 2 with PA
  • Medicaid – Covered with PA
• Cholbam (cholic acid) – indicated for the treatment of bile acid synthesis disorders due to single enzyme defects (SEDs), and for adjunctive treatment of peroxisomal disorders (PDs), including Zellweger spectrum disorders in patients who exhibit manifestations of liver disease, steatorrhea, or complications from decreased fat soluble vitamin absorption.
  • Commercial – Tier 6 with PA
  • Medicare – Tier 5 with PA
  • Duals – Tier 2 with PA
  • Medicaid – Covered with PA
• Natpara (parathyroid hormone) – a parathyroid hormone (PTH) indicated as an adjunct to calcium and vitamin D to control hypocalcemia in patients with hypoparathyroidism.
  • Commercial – Tier 6 with PA
  • Medicare – Tier 5 with PA
  • Duals – Tier 2 with PA
  • Medicaid – Covered with PA
• Toujeo (insulin glargine, recombinant) – long-acting basal insulin for treatment of diabetes mellitus.
  • Commercial – Tier 2
  • Medicare – Tier 3
  • Duals – Tier 2
  • Medicaid – Covered

Medicaid

Criteria Change

• Hepatitis C – Restricted coverage to only METAVIR score F4, unless hepatic manifestations are present, which is in line with coverage of these medications provided by traditional Medicaid in Illinois.

Medicaid & Commercial

Formulary Additions

• Glyxambi (empagliflozin/linagliptin) – SGLT-2 & DPP-4 inhibitor combination indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus when treatment with both empagliflozin and linagliptin is appropriate.
  • Commercial – Tier 3 with ST
  • Medicaid – Covered with ST
  • Medicare and Duals – Non-Formulary
• Jadenu (deferasirox) – an orally active chelating agent that is selective for iron (Fe3+), indicated for the treatment of chronic iron overload due to blood transfusions (transfusional hemosiderosis) in patients ≥ 2 years of age, and for treatment of chronic iron overload in non-transfusion-dependent Thalassemia Syndromes in patients ≥10 years of age with a liver iron concentration (LIC) of at least 5 milligrams of iron per gram of liver dry weight (mg Fe/g DW) and a serum ferritin greater than 300 mcg/L.
  • Commercial – Tier 5 with PA
  • Medicaid – Covered with PA
  • Medicare and Duals: Non-Formulary

Commercial Tier Changes

• Makena – Move to Tier 5
• Progesterone in Oil – Move to Tier 1 with No PA
• Levemir – Move to Tier 2

Medicaid Tier Changes

• Lanoxin – Move to Non-Formulary
• Bystolic – Move to Non-Formulary
• Inderal XL – Move to Non-Formulary
• Innopran XL – Move to Non-Formulary
• Edarbi – Move to Non-Formulary
• Azor – Move to Non-Formulary
• Edarbyclor – Move to Non-Formulary
• Teveten HCT – Move to Non-Formulary
• Glumetza – Move to Non-Formulary

Criteria Changes

• These specialty drugs no longer include Cimzia in their step therapy:
  • Commercial and Medicaid
    • Entyvio
    • Otezla
    • Remicade
    • Rituxan
    • Stelara
  • Commercial
    • Kineret
    • Orencia
    • Simponi
    • Xeljanz
• Diabetes Drug Therapies
  • Commercial – added Jardiance, Glyxambi, Xigduo, Tanzeum, and Trulicity
  • Medicaid – added Tanzeum, Nesina, Oseni, Kazano, Invokana, and Glyxambi
• Reclast (zoledronic acid) – removed PA
• Prolia – removed PA
• Adempas – added coverage of Pulmonary Arterial Hypertension
• Daliresp Step-Edit – removed Advair and Dulera
• Lidoderm – removed gabapentin step edit and added coverage of post herpetic neuralgia
• Osphena Step-Edit – removed PA due to contracting
• PPI (Proton Pump Inhibitor) Coverage – added quantity limit for Nexium
• Uceris – removed budesonide and Entocort
• Additional Quantities Requests – updated blood glucose test strip MDL and approval period

Commercial

Formulary Additions

• Trulicity (dulaglutide) – GLP-1 receptor agonist indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.
  • Commercial – Tier 3 with PA
  • Medicare, Duals, and Medicaid – Non-Formulary
• Saxenda (liraglutide) – anti-obesity GLP-1 receptor agonist indicated for use as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of ≥ 30 kg/m2 or a BMI of ≥27 kg/m2 in the presence of weight-related comorbidities (e.g., hypertension, diabetes, hyperlipidemia).
  • Commercial – Tier 4 with PA for FEHB plans only
  • Medicare, Duals, and Medicaid – Non-Formulary
• Natesto (testosterone) – the first nasal gel formulation of testosterone indicated for replacement therapy in males for conditions associated with a deficiency or absence of endogenous testosterone.
  • Commercial – Tier 3 with PA
  • Medicare, Duals, and Medicaid – Non-Formulary

Criteria Changes

• Testosterone – Implantable, Topical, Oral, IM, and Nasal – removed oral testosterone requirement from criteria for Testopel. Added Natesto to policy.

New Members’ Secondary/Tertiary Networks

When our members need services that aren’t available from an in-network provider, they might be able to get those services from a provider in their secondary or tertiary network. To help you easily see which providers are in these networks, we’ve added a new link to the member detail page on Your Health Alliance.

Please note that all providers in secondary or tertiary networks require preauthorization. Learn more about easily submitting online preauthorization requests.

Enhanced Web Feature: Preauthorization and Referral Submissions

Are you submitting your preauthorizations and referrals online today? If not, did you know you can? We added this helpful feature to Your Health Alliance this year and have continued to improve it. Now, you can not only submit the form, but also copy and paste the medical record information directly into the form. This makes the process faster because you don’t need to download documents from other programs and upload them into our system. You can track the status of the form each time you log in, and you can also communicate directly with our Quality & Medical Management staff through comments on the submitted request.

This new process helps decrease our processing time and increase our efficiency. If you are not already familiar with the new online preauthorization/referral submission process, log in to Your Health Alliance and take a look. If you have any questions, please contact your provider relations specialist.

ICSI Guideline for Patients with Low Back Pain

Health Alliance is working to decrease the number of medically untimely imaging studies for members with acute low back pain. According to the ICSI guideline for treatment of Adult Acute and Subacute Low Back Pain, imaging is usually not recommended during the first 12 weeks of symptoms.

The HEDIS^® measure, Use of Imaging Studies for Low Back Pain, measures the percentage of members 18–50 years of age who did not have an X-ray, CT or MRI within 28 days of a new episode of low back pain. The measure identifies patients in the outpatient setting, including emergency settings. If there is not a claim with diagnosis code for low back pain in the 6-month period prior to the identified visit, the visit is considered a new episode and the imaging study is considered potentially not necessary.

The recent 2015 HEDIS audit results show Health Alliance’s scores are just above the national average (Health Alliance Commercial HMO/POS is at 76.61% and Commercial PPO is at 76.44%).

Our goal is to improve the scores to at least 79%. Please consider the ICSI guideline when evaluating patients with low back pain.

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

Codes Associated with Rapid Strep Tests

When confirming a diagnosis of acute pharyngitis, acute tonsillitis, or streptococcal sore throat with a rapid strep test, please make sure you are using the correct ICD-9 codes:

• Pharyngitis – 462
• Tonsillitis – 463
• Streptococcal Sore Throat – 034.0
• Strep Test – 87081, 87070–87071, 87430, 87650–87652
• Rapid Strep Test – 87880

Also submit any diagnosis codes for other bacterial infections, like otitis media (382.9) or sinusitis (461.9), if identified.

Diagnosis Codes and Risk Adjustment

All Risk Adjustment models are dependent on diagnosis codes received through claims submission. It is imperative that all claims and associated diagnosis codes are submitted to Health Alliance. Recently, we have identified 2 areas of opportunity related to provider business processes: