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Reid April Newsletter

eviCore Online Enhancements to Improve Clinical Consultations

eviCore understands that the consultation process takes valuable time away from your patients. After reviewing feedback they’ve received, eviCore has developed educational materials to help you during the consultation scheduling process.

They’ve developed a Consultation Reference Guide for you to use when scheduling a consultation on eviCore.com. It provides a visual of what information needs to be included on each field of the consultation request form.

And don’t forget, if you feel the patient has a condition that’s a risk to their life, health, or ability to regain full function, or is experiencing severe pain, eviCore will allow you to get an urgent clinical consultation with a director or therapist reviewer within the first hour of the case initiation.

Note: Preauthorization requests that do not meet those criteria should schedule consultations with supporting clinical information before eviCore will make a final determination.

If you have any more questions, email ClientServices@evicore.com.

Continuity of Care When Providers Leave Network

When a primary care provider or specialist leaves our network, we take steps to make sure our affected members continue to have access to the care they need.

Any member who is in an ongoing course of treatment may be eligible to continue care with the termed provider (if certain criteria are met) during a 90-day transitional period. Any member in the 13th week or more of pregnancy may be eligible to continue care with the termed provider through post-partum care.

Members with prescription coverage can also fill any remaining prescription refills after the prescribing provider leaves the network.

If you have questions, contact your provider relations specialist.

Preauthorizations for Oncology Clinical Trials

Preauthorization requests for oncology clinical trials should be submitted through Health Alliance’s pharmacy form on the Request Preauthorization tab of Your Health Alliance for providers. These requests aren’t reviewed through eviCore, and providing this information to Health Alliance ensures timely review of your request.

When you’re submitting your request, make sure you note on the form that the member is on a clinical trial for oncology. Include the clinical trial number and a description of the medications provided by the trial. This will help us get your preauthorization reviewed correctly and minimize delays.

If you have any questions, contact your provider relations specialist.

Opioids Pharmacy Criteria Change New Effective Date

The criteria change for opioids, long-acting and short-acting, we told you about in October will now be effective starting on May 1, 2018.

Learn more about Morphine Equivalent Dose (MED) and opioid prescribing in this article from our December newsletter.

Welcoming Dr. Smith

We’re pleased to announce that Michael Smith, MD, FAEMS, has been named as an Associate Medical Director for Health Alliance.

Dr. Smith will focus on the inpatient utilization and serve as medical director for the Reid Health Medical Center in Richmond, Indiana.

Dr. Smith is an Emergency Physician at Carle and serves in leadership capacities including as the EMS Medical Director for Carle Regional EMS and Arrow Ambulance Service and the University of Illinois EMS and Fire Service Institute. He earned a MD from the University of Illinois College of Medicine in Peoria and completed an Emergency Medicine Residency at St. Vincent Medical Center in Toledo, Ohio. Mike is a Clinical Assistant Professor of Surgery at the University of Illinois College of Medicine.

Prior to coming to Carle, Dr. Smith served as a staff physician and EMS Medical Director at Reid Health. His experience with their health system will be invaluable as he works with them on behalf of us and Carle.

Please join us in congratulating Dr. Smith and supporting his expanded role as our Associate Medical Director.

Women’s Health Screenings

Part of our ongoing work is to increase appropriate preventive care for your Health Alliance patients. Recently, we’ve focused on women who receive breast and cervical cancer screenings, as reflected by HEDIS results.

HEDIS measure specifications for breast and cervical cancer screenings are based on U.S. Preventive Services Task Force recommendations. While our 2017 HEDIS results are above the national average for these screenings, we’re continuing to work toward our goal of the 90th percentile for our members.

We’ve entered member care gaps into our system so that we can automatically alert those who haven’t had breast cancer screenings for that year. We also sent out mailers to remind women to get breast and cervical cancer screenings and their preventive care in February. We appreciate your responsiveness in ordering and scheduling these screenings.

Check out the U.S. Preventive Services Task Force recommendations for the most recent guidelines for breast cancer screenings and cervical cancer screenings. We appreciate your partnership by encouraging and ordering these screenings for your patients.

If you have access to the Quality Dashboard on Tableau, you can also use this tool to investigate your member care gaps with interactive HEDIS data.

Ongoing Efforts to Improve Star Ratings

Star Ratings measure the quality of care given to our members and how satisfied members are with the medical care and services provided by our Medicare Advantage plans. We strive to be a 5-star plan and are working to continuously improve all measures and create a high quality, high member satisfaction plan through various reporting and communication tools. Our team will be working with provider partners and departments across Health Alliance to implement improvement strategies to improve the overall health of our members.

We’re committed to contracting with high-performing providers, and our quality ratings are directly tied to this population’s care. Please continue to strive for high quality results, and check our current Star Ratings and HEDIS results to stay informed about our current performance and progress as we advance towards a 5-star rating.

Meet with a Coding Specialist

The risk adjustment coding consultants are continuing to request meetings with participating, high-volume provider offices. These meetings are designed to share member-specific examples of coding and quality measure needs and to update providers on the latest efforts to educate on risk adjustment. Along with member specific examples, there is information on yearly risk adjustment data validation (RADV) audits and how provider practice participation is essential in this process.

A member of the coding consultant team is willing 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.

 

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