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Midwest August Newsletter

August 30, 2016

Online Claims Reprocessing Inquiries Coming Soon

We’re moving claims reprocessing inquiries onto Your Health Alliance for providers.

You’ll be able to track the status on inquiries easily on the site, and it will eliminate tedious and time-consuming paperwork. You can send inquiries for many reasons, including:

  • Timely filing
  • Coding
  • No preauthorization
  • Reimbursement questions

We plan for this feature to launch September 15.

UM Types of Additional Documentation Needed

There are certain types of commonly requested procedures or services that are missing important documentation, which can lead to delays in the preauthorization process. To reduce the delays, we’ve taken the commonly requested preauthorizations and detailed the additional information we need when you’re submitting the request. When requesting these procedures or services, you can submit additional documentation through Clear Coverage (CC) or the Preauthorization tab of Your Health Alliance (YHA) for providers.

Requested Procedure or Services Additional Documentation Needed To Be Submitted Via YHA or CC
Abdominoplasty/ Panniculectomy
  • Color/dated photos showing under the lower abdominal area
  • Conservative treatment with appropriate hygiene and medical therapy x3 months
  • Rashes/infection/ulceration x3 months or more, impairs ambulation/interferes with daily home routine (ADLs)
  • Weight loss greater than 100 lbs x6 months (18 months post-Bariatric)
 YHA
Bariatric
  • (Weight Loss) Bariatric Checklist completed and signed
  • Weights at least 6 months apart and current to date
  • Nutritional and psych assessments within last 6 months
 CC
Blepharoplasty, Eyebrow Lift
  • Dated photos showing visual field limitations (frontal and lateral)
  • Visual field testing showing taped and un-taped eyelids-with measurements
  • Documentation of visual impairment in degrees
 YHA
Bone Growth Stimulators
  • Fresh fracture (less than 14 days) and skeletally mature
  • Risk factors for non-healing, history or future spinal fusion surgeries
  • Imaging study performed x2 (3 months apart)
  • Location of arthrodesis or fracture
 YHA
Cranial Orthotic Device
  • Skull measurements
  • Conservative treatment attempt x2 months with repositioning
  • Conservative treatment – PT/OT, activity modification and how long
 YHA
CTs / MRIs
  • X-rays/imaging
  • Non-Steroidal Anti-inflammatory Drugs(ibuprofen) use and how long
  • Any labs performed
  • Specific diagnosis/what are you ruling out
  • Documentation of symptoms (new/worsening)
 CC
Gynecomastia
  • Dated photos
  • Corrections of underlying causes if related to breast cancer
  • Any past surgical treatment for gynecomastia
  • Classification of Gynecomastia
 YHA
Genetic Testing
  • Prenatal notes
  • Genetic test – What test is being requested
  • Fetal ultrasound
  • Quad screen
  • Family history
 YHA or CC
Home Enteral Feedings
  • Written / signed / dated script
  • Documentation of diagnosis and previous treatment
 YHA
Home Services
  • Disciplines (services) requested, number of visits requesting, dates needed, skilled need
  • Not 485 (Plan of Treatment), but actual notes from visits
 YHA
Infertility
  • (Male) needs 2 semen analysis post vasectomy reversal proving it was successful
 YHA
Lymphedema Pump / Pneumatic Compression Pump
  • Leg measurements-baseline and after conservative treatment or to demonstrate continued need
  • Previous treatment performed with device
  • One or more ulcer failed to heal or recurred after therapy (Chronic Venous Insufficiency)
  • Documentation of 4 week treatment by therapist with significant improvement (Lymphedema)
 YHA
Out-of-Network / Tertiary Referrals
  • Why you’re referring there (member-driven or lack of specialty in primary network)
  • Need documentation from in-net specialist
 YHA
OPAP Devices
  • Completed checklist for OPAP-Attestation Statement
 YHA
Oxygen
  • Pulse oximeter results
  • Written/signed script from last 6 months
  • Current clinical within last 6 months including diagnosis/med necessity
  • Date started oxygen
  • Subsequent requests – Clinic notes documenting continued need
  • Reminder – Follow Medicare guidelines = 3 year rental, then 2 year provider is responsible
 YHA
Radiofrequency Facet Ablation (RFA)
  • 2 Medial Branch Blocks results using pain scale (Visual Analog Scale)
  • Conservative measures / previous treatments performed x3 to 6 months
  • No prior spinal fusion
  • Imaging study performed
  • Symptoms x6 months (limit daily home routine)
 YHA
Skin and Soft Tissue Lesions Removals
  • Why is this being done in a facility
  • Risk factors of bleeding / size / location
 YHA
Spinal Fusion, Lumbar
  • Full radiologist MRI report OR MRI on a disc
  • Levels of fusion being requested
  • 6 months of conservative therapy including physical therapy, activity modification, Non-Steroidal Anti-Inflammatory Drugs (ibuprofen), or acetaminophen use
  • X-rays
  • Symptoms / findings / exacerbations
  • Other conditions causing nerve compression in lower back
  • Documentation of gait difficulties
 CC
Spinal Manipulation (Chiro)
  • Initial visit – Recent history and physical within last 6 months
  • Notes from chiro visits for continued care including plan of treatment
 CC
Wheelchair
  • Written / signed / dated script from MD
  • Home inspection
  • Recent clinical within last 6 months documenting med necessity
 YHA

We Will Discontinue Medicaid-Only Coverage at End of 2016

Health Alliance has notified the Illinois Department of Healthcare and Family Services (HFS) of its desire to terminate its contracts for Medicaid Managed Care services effective December 31, 2016. This contract termination does not affect our Medicare Advantage or Medicare Supplement plans or any commercial lines of business.

The termination of our Medicaid Managed Care contract will not require any change to our provider agreements. You will remain contracted to provide services to our Medicaid members, but there will be no members to serve after December 31, 2016, except for any necessary continuity of care plans.

Affected members will receive information about their options in the coming months. In addition, updates will be forthcoming as we work through the transition process with HFS.

New Contracted Provider Information Change Form

Now, it’s easier than ever to keep us in the loop. Use our new Contracted Provider Information Change/Update Form to notify us of any new information or changes to your current practice structure, including:

  • Location, correspondence, or remit/pay to address change
  • Adding a new location
  • Provider NPI change
  • Provider termination
  • New clinic name
  • Tax ID changes
  • Provider TIN changes
  • Provider panel closed
  • Phone number change
  • PCP status change

Once you’ve filled out your contracted provider information and the details of your change, email your finished form to [email protected].

Visit Provider.HealthAlliance.org to find the form under the Provider Materials, or log into YourHealthAlliance.org for providers to find the form on the Forms and Resources page.

2016 Provider Manuals Available

You can find provider manuals for all of our plans, including Medicare and Medicaid, on the Forms & Resources page of Your Health Alliance. In them, you’ll find more information about:

  • Our Quality Improvement program, including its purpose, goals, objectives, scope, structure, key personnel, and technical resources and systems
  • Our complex case management program and how to refer a member
  • How to access and request our utilization management and pharmaceutical management criteria
  • Affirmative statement about incentives related to UM decision making
  • When decision timeframes begin for nonurgent preservice requests received after business hours
  • How to use our pharmacy management procedures and processes, including our formulary, pharmaceutical classes, tier information, preauthorization, managed dose limitations, step-therapy, generic substitution, pharmacy savings programs, and how to request a medical exception
  • Our disease management programs, including what we do and how you and your patients can access program services
  • A comprehensive list of clinical guidelines, including nonpreventive and preventive, as well as behavioral health
  • Preventive care guidelines for all age groups
  • Members’ rights and responsibilities

New Statin Use and Adherence HEDIS® Measures

The National Committee of Quality Assurance (NCQA) added two new measures to the 2016 HEDIS® audit — Statin Therapy for Patients with Cardiovascular Disease and Statin Therapy for Patients with Diabetes. Both of these measures are administrative measures, which means data is collected via 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 21-75 years and females 40-75 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 members who remained on the statin medication for at least 80% of the treatment period.

Statin Therapy for Patients with Diabetes

Reflects the percentage of members with diabetes between the ages of 40-75 who were dispensed a prescription for a statin during the measurement year. The adherence rate is also measured to show members who remained on the statin medication for at least 80% of the treatment period.

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

To determine if potential exclusions were being submitted via claims, Health Alliance did a review of members meeting criteria for inclusion in the measure, but were not taking a statin medication. Results showed that some members are not on a statin due to muscle pain, or the record simply documented intolerance to statin; however, the intolerance was not reflected in the claim. Most of the allowed exclusions can be coded during the measurement year or the year prior to the measurement year; however, myalgia, myositis, myopathy or rhabdomyolysis need to be coded annually if that is the reason the patient cannot tolerate the statin. See the list of conditions and codes accepted as exclusions by NCQA for muscle pain and muscle disease below. Providers can receive other diagnosis codes accepted as exclusion by contacting the Quality Medical 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
359.4 Toxic myopathy ICD9CM
359.9 Myopathy, unspecified ICD9CM
728.88 Rhabdomyolysis ICD9CM
729.1 Myalgia and myositis, unspecified ICD9CM

 

HEDIS 2016 (Measurement Year 2015) Results

Since these are new measures, national benchmarks are not yet available.

Statin Therapy for Patients with Cardiovascular Disease

Commercial HMO/POS Medicare HMO Medicare PPO Northwest Medicare HMO
Received Statin Therapy – Males 79.33% 76.22% 75.06% 82.29%
Statin Adherence 80% – Males 75.09% 84.40% 83.06% 81.01%
Received Statin Therapy – Female 71.46% 59.04% 64.97% 77.50%
Statin Adherence 80% – Females 68.79% 83.67% 73.91% 80.65%
Received Statin Therapy – Total 77.16% 69.91% 71.97% 80.88%
Statin Adherence 80% – Total 73.48% 84.18% 80.53% 80.91%

 

Statin Therapy for Patients with Diabetes

Commercial HMO/POS Medicare HMO Medicare PPO Northwest Medicare HMO
Received Statin Therapy 60.56% 69.16% 65.12% 70.80%
Statin Adherence 80% 73.33% 82.43% 80.00% 74.58%

Each of the HEDIS guidelines measure care recommended by national guidelines of the American Diabetes Association and the ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. 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.

Committee Completes Annual Clinical Guidelines Review

To support NCQA goals and help practitioners make even better decisions about appropriate health care in specific clinical circumstances, the Health Alliance Quality Improvement Committee annually reviews and updates adopted clinical guidelines.

We adopt evidence-based, nationally recognized sources for clinical guidelines, which are listed below, complete with links to additional information.

You can also find these guidelines, as well as other helpful resources, on Your Health Alliance by choosing Clinical Guidelines from the menu in the footer of the page. If you prefer a paper copy of a guideline, contact our Quality and Medical Management Department at 1-800-851-3379, ext. 8112. Alcohol Misuse

Asthma

Attention Deficit Hyperactivity Disorder

Cholesterol Control

Chronic Obstructive Pulmonary Disease (COPD)

Congestive Heart Failure (CHF)

Coronary Artery Disease (CAD)

Depression in Adults

Diabetes

Hypertension

Migraines and Headaches

Osteoporosis

Potentially Inappropriate Medication (PIM) Usage in Older Adults

Preventive Care

Tobacco Use

Weight Management

Pharmacy Updates

All Plans

Formulary Additions – Effective June 1, 2016

  • Descovy (emtricitabine and tenofovir alafenamide) – Indicated in combination with other antiretroviral agents for the treatment of HIV-1 infection in adults and pediatric patients 12 years of age and older.
    • Commercial – Tier 5 with no PA
    • Medicaid- Covered with no PA
    • Medicare – Tier 5 with no PA
  • Odefsey (emtricitabine, rilpivirine, and tenofovir alafenamide) – Indicated (1) as a complete regimen for the treatment of HIV-1 infection in patients 12 years of age and older as initial therapy in those with no antiretroviral treatment history with HIV-1 RNA less than or equal to 100,000 copies per mL and (2) to replace a stable antiretroviral regimen in those who are virologically suppressed (HIV-1 RNA less than 50 copies per mL) for at least 6 months with no history of treatment failure and no known substitutions associated with resistance to the individual components of Odefsey.
    • Commercial – Tier 5 with no preauthorization (PA)
    • Medicaid- Covered with no PA
    • Medicare – Tier 5 with no PA
  • Taltz (ixekizumab) – Indicated for the treatment of adults with moderate-to-severe plaque psoriasis who are candidates for systemic therapy or phototherapy.
    • Commercial – Tier 5 with PA
    • Medicaid – Covered with PA
    • Medicare – Non-Formulary
  • Tresiba (insulin degludec) – Indicated to improve glycemic control in adults with diabetes mellitus. Note: Not recommended for the treatment of diabetic ketoacidosis.
    • Commercial – Tier 3 with no PA
    • Medicaid – Non-Formulary
    • Medicare – Tier 4 with no PA
  • Vistogard (uridine triacetate) – Indicated for the emergency treatment of adult and pediatric patients following a fluorouracil or capecitabine overdose regardless of the presence of symptoms, or who exhibit early-onset, severe or life-threatening toxicity affecting the cardiac or central nervous system, and/or early-onset, unusually severe adverse reactions (e.g., gastrointestinal toxicity and/or neutropenia) within 96 hours following the end of fluorouracil or capecitabine administration.
    • Commercial – Tier 6 with no PA
    • Medicaid – Covered with no PA
    • Medicare – Tier 5 with no PA
  • Xuriden (uridine triacetate) – Indicated for the treatment of patients with a diagnosis of hereditary orotic aciduria (HOA).
    • Commercial – Tier 6 with PA
    • Medicaid – Covered with PA
    • Medicare – Tier 5 with PA
  • Zepatier (elbasvir/grazoprevir) – Indicated with or without ribavirin for the treatment of chronic hepatitis C virus (HCV) genotypes 1 or 4 infection in adults.
    • Commercial – Tier 5 with PA
    • Medicaid – Covered with PA
    • Medicare – Non-Formulary

Formulary Additions – Effective August 3, 2016

  • Belbuca (buprenorphine) – Indicated for the management of pain severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate.
    • Commercial – Tier 3 with preauthorization (PA)
    • Medicaid- Not Covered
    • Medicare – Tier 4 with quantity limit (QL)
  • Briviact (brivaracetam) – Indicated as adjunctive therapy in the treatment of partial onset seizures in patients 16 years of age and older with epilepsy.
    • Commercial – Tier 3 with step-therapy (ST)
    • Medicaid- Covered with ST
    • Medicare – Tier 4 with ST
  • Nuplazid (pimavanserin) – Indicated for the treatment of hallucinations and delusions caused by Parkinson’s Disease psychosis.
    • Commercial – Tier 3 with PA
    • Medicaid – Covered with PA
    • Medicare – Tier 4 with PA
  • Xtampza ER (oxycodone hydrochloride) – An opioid agonist product indicated for the management of pain severe enough to require daily, around the clock, long term opioid treatment and for which alternative treatment options are inadequate.
    • Commercial – Tier 3 with PA
    • Medicaid – Not Covered
    • Medicare – Non-Formulary

Tier Changes – Effective August 3, 2016

  • Levocetirizine
    • Moved from Excluded to Tier 1 on Commercial
    • Moved from Not Covered to Covered on Medicaid
    • Moved from Non Formulary to Tier 2 on Medicare
  • Desloratadine
    • Moved from Excluded to Tier 1 on Commercial
    • Moved from Not Covered to Covered on Medicaid
    • Moved from Non Formulary to Tier 2 on Medicare
  • Eliquis
    • Moved from Tier 3 to Tier 2 on Commercial
    • Moved from Not Covered to Covered on Medicaid
    • Moved from Tier 4 to Tier 3 on Medicare

Medicare

Tier Change – Effective June 1, 2016

  • Humulin N, Humulin R, and Humulin 70/30 Vials Only – Moved from Tier 3 to Tier 2

New Policy – Effective August 3, 2016

  • Zepatier – Created to establish Medicare D criteria for coverage of Zepatier to meet CMS formulary requirement

Medicaid

New Policy – Effective June 1, 2016

  • Qualaquin (quinine sulfate) – Specified criteria for coverage and clarified that drug is not covered for leg or muscle cramps

Criteria Change – Effective June 1, 2016

  • Diabetes Drug Therapies
    • Removed pioglitazone from policy
    • Added alogliptin, alogliptin-metformin HCl, alogliption-pioglitazone, and Invokamet to policy
    • Clarified step-edit time frames:
      • At least a 90-day supply of specified step therapy drug(s) within the previous 120 days

Tier Change – Effective June 1, 2016

  • Modafinil – Moved from Non-Formulary to Covered

Medicaid & Commercial

New Policies – Effective June 1, 2016

  • Migranal (dihydroergotamine mesylate) Nasal Spray – Specified criteria for coverage and MDL of 8 units per 30 days
  • Orenitram (treprostinil diolamine) – Specified criteria for coverage
  • Spritam (levetiracetam) ODT Step-Edit – Specified step-edit criteria for coverage: a previous paid claim of levetiracetam solution, tablets, or capsules
  • Sucraid (sacrosidase) – Specified criteria for coverage
  • Syprine (trientine hydrochloride) – Specified criteria for coverage

Criteria Change – Effective June 1, 2016

  • Azelaic Acid – Added Azelex to policy

Criteria Changes – Effective August 3, 2016

  • Anticoagulant, Novel – Removed step through warfarin on all novel anticoagulants and moved Eliquis to parity with Xarelto as a preferred novel anticoagulant
    • Commercial – Added Eliquis to Xarelto as a step therapy requirement for Savaysa
    • Medicaid – Added Eliquis to Xarelto as a step therapy requirement for Pradaxa
  • Excluded Drug List – Removed Xyzal and Clarinex from exclusion of non-sedating antihistamines/combinations with an OTC alternative
  • Lyrica – Added criteria for coverage of generalized anxiety disorder (GAD)
  • Smoking Cessation – Chantix: Specified eligibility of 180 days per 365-day period
  • Xolair – Changed asthma diagnosis age requirement to 6 years or older

Tier Change – Effective August 3, 2016

  • Mupirocin Cream
    • Moved from Tier 1 to Excluded on Commercial
    • Moved from Covered to Not Covered on Medicaid
    • Mupirocin ointment available at Tier 1 on Commercial
    • Mupirocin ointment covered on Medicaid

Removed Preauthorization – Effective August 3, 2016

  • Lidoderm

Managed Dose Limit (MDL) Change – Effective August 3, 2016

  • Epinephrine Auto Injectors
    • Added MDL of 4 pens per 30 days
    • Requests for additional quantities would require medical exception

Commercial

Criteria Changes – Effective June 1, 2016

  • Diabetes Drug Therapies – Added Synjardy to policy, clarified step-edit time frames where applicable:
    • At least a 90-day supply of specified step therapy drug(s) within the previous 120 days
  • Medical Exception for Tier 2 Copayment – Clarified that Tier 2 drugs are not eligible for further tier lowering

Criteria Changes – Effective August 3, 2016

  • ARB (angiotensin II receptor blocker) Generic First Step-Edit – Added olmesartan (generic Benicar) to policy with step therapy through preferred generic ARB
  • Erectile Dysfunction Drugs (Exchange only) – Specified QL of 4 tablets per 30 days, which is already coded with Optum
  • Qudexy XR and Trokendi
    • Changed policy from ST to PA
    • Added epilepsy diagnosis to criteria
  • Tysabri – Changed multiple sclerosis prerequisites to two preferred agents

Removed Preauthorization – Effective August 3, 2016

  • Celebrex
  • Movantik

Tier Changes – Effective June 1, 2016

  • Crestor – Moved from Tier 2 to Tier 3
    • Generic rosuvastatin now available at Tier 1
  • Syprine – Moved from Tier 3 to Tier 5
    • Drug qualifies for specialty
  • Orenitram – Moved from Tier 6 to Tier 5
    • PAH drugs sit at Tier 5
  • Lupaneta – Moved from Tier 6 to Tier 5
    • Lupron Depot sits at Tier 5
  • Noxafil Suspension – Moved from Tier 3 to Tier 5
    • This will place it at the same tier as Noxafil tablets and IV
  • Viekira Pak – Moved from Tier 4 to Tier 5
    • Harvoni is available at Tier 4

Tier Changes – Effective October 1, 2016

  • Azor
    • Moved from Tier 2 to Tier 3 on Commercial
    • Generic (olmesartan-amlodipine) will be available at Tier 1 in October 2016
  • Tribenzor
    • Moved from Tier 2 to Tier 3 on Commercial
    • olmesartan (generic launch in October 2016), amlodipine, and hydrochlorothiazide are available separately at Tier 1

 

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