Midwest December Newsletter 2021

Wishing You a Happy Holidays

It’s hard to believe, but 2021 is almost in the rearview mirror. We simply can’t thank you enough for all you’ve done this past year to help keep our members healthy. You always go above and beyond to provide exceptional care, and we deeply value working with you. We wish you a happy and healthy holidays, and we hope you have an opportunity to rest, recharge, relax – and realize just how much you’ve accomplished this past year. Thank you.

As It Relates to You

Key information for you and your staff.

Continued Gratitude As 2021 Winds Down

From your Provider Relations staff, we wish you all a happy, healthy and prosperous New Year. Each day, you give your patients one of the most important gifts of all – the best health and livelihood possible. Thank you for everything you do!

2022 Ongoing Provider Orientation, Education and Updates

Prior to the COVID-19 pandemic, in an effort to maintain open communication and cascade updates appropriately, our Provider Relations staff conducted in-person visits with providers’ office staff on a regular basis. However, with health and safety in mind, these now can be held virtually. In the upcoming months, please be advised that your provider relations specialist may be contacting your office to set up a time to touch base. We look forward, as always, to talking with you.

New Videos, Digital Tools and Provider Education Guides

The Provider Relations staff have been working hard in the past few months to create helpful resources to educate our providers – including interactive videos and digital tools and resources. The videos are each five to 10 minutes long and give step-by-step instructions to make your job easier. Check out these great resources:

• Preauthorization Overview for Providers and Office Personnel.
• eviCore Resources.
• New Provider Orientation (video).
• Provider Portal Overview (video).

We encourage all our providers to take the time to view these educational materials. They can be found on the Provider Resources page of our provider portal, under the Digital Tools and Guides section. Please reach out to your provider relations specialist if you have any questions.

Important: Items Required for Provider Credentialing

Effective immediately, a copy of your W-9 is required for all credentialing applications. If you use CAQH, please use this form when adding a new provider to your contract. If you don’t use CAQH or aren’t an Illinois MD/DO/DC, please make sure you’re submitting all the required documents noted here. As a reminder, new providers should not be seeing members until their credentialing has been approved and completed. Thank you.

In-Network Referrals

As a reminder, it’s the responsibility of a contracted provider and their office staff to choose contracted, in-network options before referring a patient outside our network. You can search a member’s network on Your Health Alliance for Providers and Office Personnel by attaching to that member. An out-of-network referral should only be done if all other options are exhausted within the member’s network. Thank you for your care and attention to detail.

Remind Your Patients – It’s Not Too Late To Get a Flu Shot

As healthcare providers, you know how important flu shots are to your patients, their families and the community in general. This winter, they’re more essential than ever due to the ongoing COVID-19 pandemic. Flu shots are especially important for those at high risk from influenza, many of whom are also at high risk for contracting COVID-19 or developing serious outcomes if they do.

Remind your patients it’s not too late to get their flu shot. It varies according to health plan, but flu shots are covered at no cost to the member in most cases. Your patients can call the number on the back of their health plan member ID card to learn more about costs and where they can go to get their vaccinations. Together we can help keep our community healthy and well.

Medically Unlikely Edits (MUE) Updates

As of May 2021, we’ve upgraded our system to coincide with CMS guidelines for Medically Unlikely Edits (MUEs). Our previous MUEs would allow the overage, if billed with a modifier, which was incorrect. We were also allowing claims to be processed if the MUE allowed amount was on a different line than the overage amount. Specific indicators are hard daily edits and CMS does not allow the overage, with or without a modifier. We follow CMS MUE guidelines where all lines are summed for a given service and if over the MUE, all lines are denied.

Please see the following supporting information from the CMS website:

D. How are claims adjudicated with MUEs?

MUEs are either claim line edits or date of service edits. If the MUE is a claim line edit, each line of a claim is adjudicated against the MUE value for the HCPCS/CPT code on that claim line. If the UOS on the claim line exceeds the MUE value, all UOS for that claim line are denied. If the same code is reported on more than one line of a claim by using CPT modifiers, each line of the claim is adjudicated separately against the MUE value of the code on that claim line. 

If the MUE is a date of service MUE, all UOS for the HCPCS/CPT code reported by the same provider/supplier for the same beneficiary for the same date of service are summed. The summed value is compared to the MUE value. If the sum is greater than the MUE value, all UOS for the code on the current claim are denied.

We acknowledge that this update will likely impact how you bill claims to us – therefore we’re willing to reprocess denied claims for DOS 5/1/2021 to present to allow the MUE limit. To submit claims for reprocessing, please use the claim inquiry tool via our provider portal. In your submission, it’s important that you clarify if you’re requesting the claim to pay the MUE limit or units over the MUE limit. If requesting units over the MUE limit, supporting documentation must be provided for review by a Medical Director for medical necessity.

If you have any questions or need guidance, you can reach out to your provider relations specialist. Thank you.

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Help Us Move the Needle

Together we can help people live their healthiest lives. Find reminders, tips and more in this section, to guide improvements in patient outcomes. Help us move the needle.

Be Antibiotics Aware:

Help Protect Your Patients, Fight the Spread of Superbugs and More

Did you know that antibiotics are responsible for almost 20% of emergency department visits for adverse drug events? And that they’re the most common cause of these visits for children under 18?

Prescribing antibiotics isn’t always the best choice – and sometimes it can even be harmful. The CDC is urging doctors and other healthcare professionals to only prescribe antibiotics when necessary. This will help combat antibiotic resistance and the spread of superbugs, as well as protect your patients from antibiotic-related adverse drug events.

The CDC encourages you to follow these steps – and to share this information with your fellow healthcare professionals:

• Only prescribe antibiotics when they’re clinically indicated and when they’re needed. You can do harm by prescribing unneeded antibiotics.
• Follow clinical guidelines on how to best evaluate and treat infections.
• Make sure you always prescribe the right antibiotic, at the right dose, for the right duration, and at the right time.
• Educate your patients about why they don’t need antibiotics for viral respiratory infections – and tell them what they should be doing to feel better and how best to seek care in these situations.
• Talk to your patients and their families about possible harms from antibiotics – like allergic reactions, Clostridioides difficile and antibiotic-resistant infections.
• Help educate your patients and their families to recognize the signs and symptoms of worsening infection and sepsis – and to know when they should seek medical care.

Visit this CDC webpage for additional information and resources. And thank you for joining this important initiative.

Key Information About Headaches and Migraines

Not all headaches are the same – here’s what to know about diagnosing, treating, tracking and more, from the experts at Oregon Health & Science University.

Diagnosing

Tension headaches are the most common type. They’re marked by mildly intense, nonpulsating pain and are not associated with nausea or vomiting. Routine physical movement doesn’t worsen the pain, and the patient may be sensitive to sounds or light – but not both.

Migraines are marked by moderate to severe pain that has a throbbing or pulsating quality. Routine physical movement makes the pain worse, and these headaches are associated with nausea and vomiting or sensitivity to light and sounds. A little known fact – many patients who report sinus headaches actually have migraines. Unless there’s evidence of a sinus infection, pain behind the eyes, around the nose or in the frontal sinus area indicates a migraine diagnosis.

Treatment

Treat most tension headaches with over-the-counter medications that contain ibuprofen or acetaminophen.

For acute migraines, first-line agents include NSAIDS or combination analgesics such as Excedrin (aspirin + acetaminophen + caffeine). If the migraine doesn’t respond to first-line agents, try Triptans (sumatriptan, 100 mg), Rizatriptan (10 mg) or Ergotamine (nasal spray).

For patients having more than two migraines a week, try these preventive migraine medications to help cut down their number of headaches: Topiramate (50-200 mg/day), Propranolol (80 mg/day), Metoprolol (50-200 mg/day), Amitriptyline (10-100 mg/day) or Venlafaxine (150 mg/day).

Tracking

Finally, you can help your patients track their headaches – this will give you important information about whether the current treatment plan is working, and it’ll also help prevent overuse of rescue medication. Have your patients use a headache diary to record when they have headaches, the intensity of each one and the medications they take. We provide a sample diary here – feel free to download, print and use.

For much more information – including about migraine rescue plans, when to consider imaging or referring to a headache specialist, lifestyle changes you can help your patients pursue and much more – please visit the original Oregon Health & Science University article.

Tips To Manage and Treat ADHD

Millions of American children have attention deficit hyperactivity disorder (ADHD). Help them – and their families – by learning more about the disorder and following this useful guidance.

You should treat ADHD as a chronic condition, and work to manage the disorder alongside the people most involved in the child or adolescent’s life – including parents or guardians, teachers, coaches and others. Treatment options include behavioral, psychologic and school-based interventions and/or medication.

Behavioral therapy is the first-line treatment in ADHD diagnoses for children under 6. For those 6 and older, the first-line treatment is medication with or without behavioral/psychologic interventions. It’s recommended that patients receiving no medications follow up at least twice a year. Those receiving medication should follow up weekly during titration and every three to six months for maintenance once therapeutic levels are reached. These follow-ups are also dependent upon symptoms, adherence and comorbidities.

Many children and adolescents with ADHD also have other conditions like oppositional defiant disorder, anxiety disorder, learning disabilities, mood disorders and sleep disorders. You’ll need to treat these coexisting disorders too, since they may have an impact on effectively treating the ADHD. One of the most important coexisting conditions is a sleep disorder – a randomized trial found that addressing sleep problems helped improve ADHD symptoms.

Primary care providers can usually manage ADHD in children and adolescents when there are no comorbidities. A referral needs to be made to a specialist if there are coexisting psychiatric, medical or neurologic conditions; or if there’s minimal response to atomoxetine or stimulant therapy.

As a chronic disease, ADHD needs to be monitored regularly to identify any issues with treatment plan adherence, adverse medication effects and overall therapy responses. The team can use daily report cards to monitor progress, relationships, adherence to rules, academic performance and more. If there are concerns with the original treatment plan, there may need to be a reevaluation. This is why it’s so important for patients and their caregivers to follow up with their providers when there’s an ADHD diagnosis.

For more in-depth information, please see the source cited at the end of this article. Thank you for all you do to take such great care of our members and their families.

Educational handouts for caregivers about ADHD medications and treatment:

Patient education: Medicines for attention deficit hyperactivity disorder (ADHD) in children (The Basics) – UpToDate

Patient education: Treatment of attention deficit hyperactivity disorder in children (Beyond the Basics) – UpToDate

Source used for this article:
Krull, K. (2021). Attention deficit hyperactivity disorder in children and adolescents: Overview of treatment and prognosis. UpToDate.

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 The “Big Six” – Specified Heart Arrhythmias

Supporting documentation and accurate coding are key to making sure your patients receive the care they need. Failure to document chronic conditions on an annual basis impacts your patients, fellow providers and our organization. Here are some helpful documentation and coding tips for Specified Heart Arrhythmias, one of the “Big Six” diagnosis categories frequently miscoded or unsupported in documentation.

Make sure you identify the type:

• Atrial fibrillation: paroxysmal, persistent, chronic, permanent or unspecified.
• Arterioventricular block: first degree, second degree (Mobitz type 1 or 2), third degree (complete).
• Atrial flutter: atypical, type I, type II, typical.
• Sick sinus syndrome: sinoatrial node dysfunction, tachycardia-bradycardia syndrome.

Atrial fibrillation (AFib) should be coded as an active diagnosis when a patient is on medication to control rhythm or to prevent thromboembolism. Also, if a patient’s heart arrhythmia is being treated by an internal device, report the arrhythmia in addition to the device status (pacemaker, defibrillator, CRT-P, CRT-D).

When a patient has AFib but is not being treated with medication, report the AFib and document the reason why the patient is not on medication – for example, if the patient has a bleeding risk. A “history of AFib” should only be reported if a patient’s AFib is resolved and not being treated.

Supporting documentation for Specified Heart Arrhythmias should include:

• Signs and symptoms: weakness, syncope, dyspnea, bradycardia, tachycardia.
• Contributing factors: valve abnormalities, sleep apnea, alcoholism, hypertension.
• Treatments: electrical cardioversion, ablation, medications, pacemaker.
• Testing and results: Holter monitor, stress test, echocardiogram.

Thank you for your help with accurate coding and documentation. We’re grateful for how hard you work and all you do for our members’ health. For short videos with coding tips for all of the “Big Six” conditions, click here. For even more helpful tips and resources, visit our Coding Counts page or contact our consulting team at [email protected].

Pharmacy News:
New Pharmacy Authorization Submission Guide

We’re excited to announce that our Pharmacy team has created an online provider portal quick reference guide just for you. The guide is a tool for you and your office staff to use when submitting medication requests through our online provider portal.

The guide is built to specifically meet your needs. Our team worked with Provider Relations to discover what information – and help – you’ve wanted and to identify how we can improve the current resources we have available for you. The quick reference guide includes screenshots of portal screens to clarify the intent of the entry fields and when to use which options. This will hopefully streamline medication requests and allow you to better address your exact needs with each submission. The guide also includes preferred product lists and guideline-based treatment options, based on common disease states that have medications that require certain criteria to be met prior to coverage.

The quick reference guide – along with our other provider resources – is now available on the provider portal. Click here to view the guide. We’re happy to bring you this new tool.

Pharmacy News:
New Auto-Renewal Prior Authorization Process
for Maintenance Medications

In an effort to streamline the prior authorization process for our members, providers and pharmacies, our Pharmacy department will begin implementing a process by which maintenance medications can be automatically reauthorized. We’re setting up coding in the Pharmacy Benefit Manager (PBM) system that’ll allow a claim to adjudicate without a renewed prior authorization when a member has been adherent to therapy with 75% compliance. If a member’s claims history does not show compliance with the medication, the claim will reject as requiring prior authorization. This process will be in effect for all our Commercial and EHB (Essential Health Benefits) plans on 1/1/2022.

Pharmacy News: Specialty Pharmacy Vendor Change

Effective January 1, 2022, our specialty pharmacy vendor will change from CVS/Caremark Specialty Pharmacy to OptumRx Specialty Pharmacy for all non-Medicare plans. We’ve notified all our members currently filling specialty medications of this change, via mailed letter at the end of October. Here’s some more important information:

• Members who currently use CVS/Caremark will be required to transfer to either OptumRx or Carle Specialty Pharmacy.
  • Carle Specialty Pharmacy is able to mail medications to members who live in Illinois or North Carolina. Members outside these two states will need to change to OptumRx.
  • Carle also does not have access to all medications – so before transferring, please call either our own Customer Solutions team or the Carle Specialty Pharmacy to ensure they’re able to dispense that particular medication.
• Carle Specialty Pharmacy
  • You can contact Carle Specialty Pharmacy directly to get the process started at (877) 930-0735 (8 a.m. – 5 p.m. CT, Monday through Friday).
  • You can also reach out by fax at (217) 355-6789.
  • If you have questions, you can also visit org/services/specialty-pharmacy.
• OptumRx Specialty Pharmacy
  • You can reach OptumRx Specialty Pharmacy toll-free at (855) 427-4682.
  • You can also visit https://specialty.optumrx.com.

Pharmacy News:
Biosimilar Medication Crosswalk

Effective November 1, 2021, our claims system now recognizes prior authorization (PA) for a biosimilar medication when there’s a PA already on file for its originator product. Here’s some more important information about this update:

• Going forward, a new PA is not needed to switch a member to a biosimilar.
• A new PA will be needed if a member was originally approved for a biosimilar and now wishes to switch to the originator product.
• At this time, we do not restrict/require specific biosimilars.

In general, biosimilars are on lower copay tiers than their originator products, thus reducing costs for the member.