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Midwest December Newsletter

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

 

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