Midwest June Newsletter

Primary/Tertiary Network Providers for Out-of-System Referrals

PEDIATRICS

For network questions call 1-800-851-3379, option 3

Note: Referral preauthorization approval is not approval for medical services. If services to be delivered by a tertiary or primary network provider require preauthorization, that request must be submitted separately.

ADULTS

For network questions call 1-800-851-3379, option 3

Note: Referral preauthorization approval is not approval for medical services. If services to be delivered by a tertiary or primary network provider require preauthorization, that request must be submitted separately.

TRANSPLANTS

For network questions call 1-800-851-3379, option 3

Note: Referral preauthorization approval is not approval for medical services. If services to be delivered by a tertiary or primary network provider require preauthorization, that request must be submitted separately.

Provider Network Changes FAQ

Q. Why did Health Alliance change its tertiary provider network?
A.  In the past, Health Alliance used the very broad HealthLink rental network to access providers in the Chicago and St. Louis areas. We have narrowed the tertiary network and moved back to more direct relationships with our network providers to ensure members continue to have access to quality providers outside their primary networks.

Q. What is the difference between primary network and tertiary network?
A. A referral to a provider in the tertiary network requires preauthorization from us. A referral to a provider in a member’s primary network does not require preauthorization from us. The tertiary network providers are specific health systems offering services not available within the primary network, or with more experience in specific services or cases. An additional preauthorization may be required for the services (tests/procedures) to be provided, regardless of whether the provider is in the member’s primary or tertiary network.

Q. How do office staff and physicians know which providers are in the tertiary network?
A. We have created a list that can be viewed through Your Health Alliance. By mid-June, the portal will also offer a searchable tertiary provider directory. We know it’s critical for physicians and office staff to have up-to-date information at their fingertips, and Your Health Alliance is the most efficient way to do that.

Q. Can preauthorization requests for referrals to tertiary providers be completed in Clear Coverage?
A. No. Clear Coverage is used for preauthorizations of medical procedures and tests. We have created an online preauthorization request form for referrals to tertiary providers and other services outside Clear Coverage. You can find the form on Your Health Alliance. Simply follow the instructions to file at Health Alliance. You can upload medical records or notes and track the request through the process.

Q. Who can we call with questions regarding the network?
A. Health Alliance Customer Service reps are ready to help answer any question. Just call 1-800-851-3379, option 3.

Q. How do providers and office managers get access to Your Health Alliance?
A. Just go to Your Health Alliance and register to request access.

Q. Who do we call if there are questions or issues with the website?
A. Health Alliance has a dedicated team of provider service coordinators who can assist you with any website issues or questions. Give them a call at 1-800-851-3379, extension 4668.

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).

Complete an Attestation Form

If you work with our Medicaid members, please fill out the training attestation form on Your Health Alliance. Choose the Forms & Resources tab at the top, then scroll down to ICP, MMAI, FHP section under the forms. You can complete the form electronically and email it to your provider relations specialist or print and mail it to Health Alliance.

Pharmacy Updates

Formulary Additions

• Vitekta (elvitegravir) – A single entity integrase strand transfer inhibitor (INSTI) used in combination with an HIV protease inhibitor co-administered with ritonavir and with other antiretroviral drug(s) indicated for the treatment of HIV-1 infection in antiretroviral treatment-experienced adults.
  • Commercial – Tier 5 with no PA
  • Medicare – Tier 5 with no PA
  • Duals – Tier 2 with no PA
  • Medicaid – Covered with no PA
• Ibrance (palbociclib) – The first drug approved that inhibits cyclin-dependent kinase (CDK) 4 and 6, for use in combination with letrozole for the treatment of postmenopausal women with estrogen receptor (ER)-positive, human epidermal growth factor receptor 2 (HER2)-negative advanced breast cancer.
  • Commercial – Tier 5 with PA
  • Medicare – Tier 5 with PA
  • Duals – Tier 2 with PA
  • Medicaid – Covered with PA
• Lenvima (lenvatinib mesylate) – A new tyrosine kinase inhibitor for the treatment of patients with locally recurrent or metastatic, progressive, radioactive iodine-refractory differentiated thyroid cancer.
  • Commercial – Tier 5 with PA
  • Medicare – Tier 5 with PA
  • Duals – Tier 2 with PA
  • Medicaid – Covered with PA
• Lynparza (olaparib) – The first of a new class of drugs for treating ovarian cancer called the poly (ADP-ribose) polymerase (PARP) inhibitors.
  • Commercial – Tier 5 with PA
  • Medicare – Tier 5 with PA
  • Duals – Tier 2 with PA
  • Medicaid – Covered with PA
• Blincyto (blinatumomab) – The first FDA-approved bispecific T-cell engaging (BiTE) monoclonal antibody construct product, and the first single-agent immunotherapy to be approved for the treatment of patients with Ph-relapsed or refractory B-cell precursor (acute lymphoblastic leukemia) ALL.
  • Commercial – Tier 5 with PA
  • Medicare – Tier 5 with PA
  • Duals – Tier 2 with PA
  • Medicaid – Covered with PA
• Opdivo (nivolumab) – Human monoclonal antibody that binds to the PD-1 receptor, preventing it from binding to its ligands, PD-L1 and PD-L2. Indicated for the treatment of patients with unresectable or metastatic melanoma.
  • Commercial – Tier 5 with PA
  • Medicare – Tier 5 with PA
  • Duals – Tier 2 with PA
  • Medicaid – Covered with PA
• Xofigo (radium Ra 223 dichloride) – A radiopharmaceutical that mimics calcium and forms complexes with the bone mineral hydroxyapatite at areas of increased bone turnover, such as bone metastases; indicated for the treatment of patients with castration-resistant prostate cancer and symptomatic bone metastases.
  • Note: Xofigo will be covered under the medical benefit, but the policy will be housed in Pharmacy.

Medicare

New Policies

• Oncology Agents – Gives coverage criteria for Ibrance, Lenvima, Blincyto, and Opdivo under the specialty benefit

Criteria Changes

• Brand-Name ADHD Medications – Changed title and statement to reflect that coverage criteria apply only to brand-name agents

Medicaid & Commercial

Formulary Addition

• Cosentyx (secukinumab) – A human interleukin-17A antagonist indicated for the treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy or phototherapy.
  • Commercial – Tier 3 with PA
  • Medicaid – Covered with PA

New Policies

• Oncology Agents – Gives coverage criteria for Ibrance, Lenvima, Blincyto, and Opdivo under the specialty benefit
• Oncology and Hepatitis C Split Fill Policy – Defines process in place for dispensing high-cost oncology and Hepatitis C medications in split fills

Criteria Changes

• Additional Quantities Requests – Added quantity limits to dermatological products
• Budesonide, Oral, Products (Uceris, Entocort EC, Budesonide ER) – Added coverage criteria for budesonide for lymphocytic/microscopic colitis
• Entyvio – Added coverage criteria for ulcerative proctitis
• Excluded Drug List – Added nasal corticosteroid sprays and drugs that have not been approved as effective by the Food and Drug Administration, including DESI drugs
• Dymista Nasal Spray – Removed PA and retired policy
• Lotronex – Removed physician requirements
• Xyrem – Added Nuvigil to Step Therapy
• Qudexy XR (topiramate XR) and Trokendi XR (topiramate XR) Step Edit – Added Qudexy XR

Commercial

Formulary Additions

• Belsomra (suvorexant) – The first orexin receptor antagonist approved for the treatment of insomnia.
  • Commercial – Tier 3 with Step Therapy
• Movantik (naloxegol) – Peripherally acting mu opioid receptor antagonist (PAMORA) approved to treat opioid-induced constipation (OIC) in patients with chronic non-cancer pain.
  • Commercial – Tier 3 with PA

Criteria Changes

• PPI (Proton Pump Inhibitor) Coverage – Added Nexium 24 HR OTC to Step Therapy

Star Ratings – How They Work

The Centers for Medicare & Medicaid Services (CMS) uses Star Ratings to rate the quality of medical care and services that Medicare Advantage health plans provide. Our scores come from claims and medical record reviews, member surveys and CMS administrative data.

CMS assigns certain quality metrics a higher weight when determining an overall Star Rating. For example, CMS considers blood pressure reading an outcome measure and weighs it 3x higher than process measures, such as cancer screenings. It’s important for each provider office to use proper technique when checking blood pressure at each visit. If the BP reading is higher than 140/90, please recheck the reading and record all results in the medical record.

CMS also takes diabetes into account in the Star Rating system, using data from the annual HEDIS^®* audit, where A1C tests and levels, eye exams, nephropathy tests, and blood pressure control are measured. Please make sure your office is monitoring your patients with diabetes to ensure required tests are completed annually.

CMS monitors osteoporosis treatment in women who had a fracture and the use of disease-modifying anti-rheumatic medications (DMARD) in patients with rheumatoid arthritis as well. It is important for women over 65 years old who had a fracture to have a bone density test within 6 months of the fracture or to take medication to treat osteoporosis. If the patient had a bone density test within 24 months of the fracture, the test does not need to be repeated 6 months after the fracture. Patients with rheumatoid arthritis should take a DMARD medication to slow progression of the disease.

Despite the difference in weights, we strive to improve each of the 33 Part C and 13 Part D measures.

You can get more information on specific Stars requirements by calling the Health Alliance Stars team at 217-383-8336.

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

Coding is Key

Using the right codes is important for having accurate records of our members, your patients. It helps us know that our members are getting the right care, we’re billing them correctly, and providers are getting the right reimbursement. Many clinics and practices use coding as a quality initiative.

Please make sure to double check codes for every condition a patient has. Here are a few key reminders.

• Rapid strep testing – 87880
• Smoking and tobacco cessation counseling visit (intermediate), longer than 3 minutes but shorter than 10 minutes – 99406
• Smoking and tobacco counseling visit (intensive), longer than 10 minutes – 99407

For more coding information, go to Coding Counts.

Upcoming Coding Meetings

It’s time again for the coding consultant team to meet with our high-volume providers. If you’d like to know if you’re on the list or want to schedule a visit, email CodingCounts@healthalliance.org. And to find out more about risk adjustment, visit Coding Counts.

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