Informed

2019 Memorial Health System Employee Plan Changes

January 4, 2019

Chiropractic Services

Effective January 1, 2019, Memorial Health System will bring a chiropractic network to the Memorial Health System employees through an agreement with Empower. Memorial employees will have specific chiropractic care benefits, with limits. Here are some key points:

  • A referral to a chiropractor must be in place and must come from the member’s primary care provider (PCP).
  • If no referral is in place, the claim will be denied to the member.
  • A specific referral form must be used, which is posted in the Forms & Resources section of Your Health Alliance for providers.
  • PCP offices can either fax referral forms to 217-902-9777 or email them to our claims support team at *Team-ClaimsSupport@healthalliance.org.
  • Claims must be coded with a chiropractic CPT code and a neuromusculoskeletal ICD-10 code.

Non-Emergent High-Cost Procedures and Outpatient Surgeries

Effective January 1, 2019, non-emergent high-cost procedures (HCP) and outpatient surgery (OPS) for Memorial Health System employees are required to be performed at a Memorial Health System facility to qualify for in-network benefits. Here are some key points:

 If an in-network provider who is not a Memorial Health System provider performs these services, the claim will be paid as out-of-network. Please review the CPT code list for HCP.

MHS In-Network Facility Provider List

  • Memorial Medical Center
  • Passavant Area Hospital
  • Taylorville Memorial Hospital
  • Abraham Lincoln Memorial Hospital

Please contact the Health Alliance Customer Service Department or your provider relations specialist for more details.

 

View as PDF

FLASH: Upcoming eviCore Therapy Forums

January 2, 2019

The eviCore therapy program launched in August has generated many questions among provider offices. We are hosting online therapy program forums for anyone responsible for submitting PT/OT/ST preauthorization requests for Health Alliance members. We’ll discuss the program, answer questions and solicit feedback.

Please register for one of the following forums. Each session will last about one hour.

  • Wednesday, January 9 at 9 a.m. CST
  • Wednesday, January 9 at 2 p.m. CST
  • Friday, January 11 at 9 a.m. CST

To register:

  • Go to webex.com.
  • Choose “Webex Training.”
  • Find the session you want to attend in the Upcoming tab. All sessions are named HAMP eviCore Therapy Program Forum.
  • Choose “Register.”
  • Enter your registration information.

After you register, you’ll receive an email with the information you need to join the forum.

Contact your provider relations specialist with any questions.

 

View as PDF

Reid December Newsletter

December 11, 2018

As It Relates to You

Reminder: Use New Provider Forms

Please remember to use our new forms to update provider information or add a provider to your practice. You’ll find the forms in the Forms & Resources section of Your Health Alliance for providers.

If adding providers to a currently contracted practice, please use the Provider Addition Form, not the Prospective Provider Form. If you have any questions, contact your provider relations specialist.

Use Internet Explorer to Access EviCore

When using eviCore, please use Internet Explorer as your web browser for best results.

We’ve heard that several providers have received error messages when using eviCore in other web browsers, like Google Chrome. According to eviCore, their system is intended to be used in Internet Explorer only. Please keep this is mind when using eviCore.

Focus on High Blood Pressure

A message from Dr. Good, our chief medical officer:

To all providers: Treat high blood pressure. We continue to find that at least 30 percent of all people with a diagnosis of hypertension continue to have blood pressures over 140 systolic. We know that high blood pressure is the No. 1 treatable cause of coronary artery disease, kidney and heart failure, and stroke. Our non-treatment is adding to the CV statistics.

Prehypertension starts at 120 mm and usually many years before a diagnosis is made. Damage to the vascular system is already occurring at the prehypertension stage. Diet and lifestyle changes should start at this time

Hypertension is generally straightforward in treatment. Although white coat hypertension exists, it can be easily ruled out with verifiable home blood pressure readings. However, published studies suggest that people with white coat hypertension also have increased risk of vascular disease.

Thank you for your cooperation in addressing this serious health issue.

Updates to HEDIS Measures for 2019

  • Controlling High Blood Pressure. NCQA has revised this measure to reflect a new blood pressure target of < 140/90 mm Hg for all adults ages 18–85 with hypertension in accordance with updated clinical recommendations. NCQA has also updated the approach to allow for more administrative methods to collect the measure and added telehealth encounters to satisfy certain components of the measure.
  • Excluding Members With Advanced Illness. Quality measures that were designed and intended for a general adult population may not always be appropriate for those with limited life expectancy or advanced illness and frailty. As such, NCQA is implementing cross-cutting exclusions across selected HEDIS measures to help focus on the population that is most likely to benefit from the measured services.

For HEDIS 2019, the following nine measures exclude individuals 65+ who have an advanced illness and frailty or who live long-term in nursing home settings.*

  • Breast Cancer Screening
  • Colorectal Cancer Screening
  • Comprehensive Diabetes Care
  • Controlling High Blood Pressure
  • Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
  • Osteoporosis Management in Women Who Had a Fracture
  • Persistence of Beta-Blocker Treatment After a Heart Attack
  • Statin Therapy for Patients with Cardiovascular Disease
  • Statin Therapy for Patients with Diabetes

* Members with these conditions may not be excluded during HEDIS chart review.

HEDIS® Chart Reviews Coming Soon

Each spring, 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. Our representatives may visit your office in the spring 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 2019. If you have any questions about HEDIS, contact the Quality Management Department at 1-800-851-3379, ext. 28947.

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

Coding Reminders

Both the Medicare Advantage and commercial Marketplace condition category models are dependent on us receiving accurate diagnosis codes through claims submission. All claims submitted to us must have associated diagnosis codes. There are two areas of opportunity we need your assistance in addressing:

  • Code truncation, or systems limits on the number of diagnosis codes per claim submission
  • Claims that are not submitted at all (e.g., claims for capitated, custodial care, etc.)

These scenarios leave gaps in accurate reflections of the overall risk of the population and may inadvertently omit members from being included in care management programs directed at assisting with health outcomes for their chronic conditions. Please assess your billing practices at an organizational and provider level to ensure these situations don’t apply to you.

If you identify these issues or have concerns that the above applies to your system, contact us at CodingCounts@healthalliance.org, and we’ll reach out to help with a solution.

For useful information on documentation and code reporting,subscribe to our coding e-newsletter.

Statins for Patients with Diabetes

Studies show that statin use in people with diabetes can reduce major cardiovascular events by 35 percent and strokes by 48 percent.

“Statin use in Patients With Diabetes” is a Star measure that follows the American Diabetes Association recommendation that people with diabetes ages 40–75 take a statin medication. This specific measure reflects the percentage of members who have filled at least two prescriptions for diabetes medication and have filled a prescription for a statin.

This Star measure is an administrative HEDIS measure, which means data is collected from claims submitted to Health Alliance. To get accurate results, claims information must be complete, reflecting accurate diagnosis and any conditions that may exclude a member from the denominator. Members with end-stage renal disease and members enrolled in hospice are excluded from the data.

Please discuss the importance of statin use with your patients who have diabetes.

Encourage Chlamydia Screening

Please discuss chlamydia screenings with patients and the parents of teen/young adult patients. 2017 marked the fourth year in a row in which the number of infections nationwide increased.

Eligible population for screening: Women 16–24 years as of December 31 of the measurement year.

One way to reduce the stigma associated with this screening is to encourage getting it as a preventive measure rather than framing it as a sexual-related issue.

Chlamydia is treatable with antibiotics, but it can have long-term consequences when undetected or untreated. Chlamydia can also cause infertility in women.

The national screening average is 50.2 percent. Our 2017 final screening rates are as follows.

  • Commercial HMO/POS: 34.4%
  • Marketplace HMO: 34.5%
  • Marketplace POS: 31.3%

Procedure codes for chlamydia screening:

  • 87270
  • 87320
  • 87490–87492
  • 87810

End-of-Year Screening Reminders

As we wrap up 2018, ensure patients are getting appropriate preventative services to identify any issues or gaps in care.

All Patients

  • Colorectal cancer screening
  • Controlled blood pressure reading
  • Medication review

Women

  • Breast cancer screening
  • Osteoporosis screening in women with a fracture

Patients with Diabetes

  • Controlled A1c readings
  • Nephropathy testing
  • Diabetic eye exams

Children/Adolescents

  • Document counseling for nutrition
  • Document counseling for physical activity

As a reminder, we have health coaching and care coordination services that can help our members better manage their conditions at no extra cost. These services can help improve their health outcomes between visits to your office.

Encourage Physical Activity in Winter

Physical activity is important for all ages and in all seasons. The American Heart Association recommends at least 150 minutes of moderate exercise or 75 minutes of vigorous exercise (or a combination of both) per week, and it doesn’t make exceptions for winter.

Staying active in the winter can be difficult for many. Talk to your patients about ways they can stay active in the winter, including:

  • Going to an exercise class
  • Working out at home with a DVD or free online tutorial
  • Walking around the local mall
  • Joining a gym

Pharmacy Updates

Medicare

Formulary Additions

  • Jynarque (tolvaptan)
    • Vasopressin antagonist indicated to slow the progression of autosomal dominant polycystic kidney disease (ADPKD)
    • Formulary placement recommendations:
      • Commercial—Tier 5 with preauthorization (PA)
      • Medicare—Tier 5 with PA
  • Luxturna (voretigene neparvovec)
    • One-time treatment approved for children and adults with retinal dystrophy due to a mutation of the retinal pigment epithelial 65 kDa protein (RPE65) gene, which causes severe visual impairment beginning in infancy
    • Formulary placement recommendations:
      • Commercial—Tier 6 with PA; change to criteria point #5 noted above
      • Medicare—Part B only
  • Mepsevii (vestronidase alfa-vjbk)
    • The first and only enzyme replacement therapy available to treat mucopolysaccharidosis VII (MPS VII, Sly syndrome)
    • Formulary placement recommendations:
      • Commercial—Tier 6 with PA
      • Medicare—Part B only
  • Palynziq (pegvaliase-pqpz)
    • Phenylalanine-metabolizing enzyme indicated to reduce blood phenylalanine concentrations in adult patients with phenylketonuria who have uncontrolled blood phenylalanine concentrations greater than 600 micromol/L on existing management
    • Formulary placement recommendations:
      • Commercial—Tier 6 with PA; update Continued Approval section as noted above
      • Medicare—Non-Formulary

Criteria Changes

  • Kuvan
    • Exclusion section states that we will not cover concurrent use of Kuvan and Palynziq
  • Spinraza
    • Updated baseline motor milestone scores criteria

Tier Changes

  • Desvenlafaxine ER (Pristiq)—moved from Tier 4 to Tier 2
    • This places it on the same copay tier as desvenlafaxine ER (Khedezla)

 

View as PDF

Northwest December Newsletter

December 11, 2018

As It Relates to You

Reminder: Use New Provider Forms

Please remember to use our new forms to update provider information or add a provider to your practice. You’ll find the forms in the Forms & Resources section of Your Health Alliance for providers.

If adding providers to a currently contracted practice, please use the Provider Addition Form, not the Prospective Provider Form. If you have any questions, contact your provider relations specialist.

Use Internet Explorer to Access EviCore

When using eviCore, please use Internet Explorer as your web browser for best results.

We’ve heard that several providers have received error messages when using eviCore in other web browsers, like Google Chrome. According to eviCore, their system is intended to be used in Internet Explorer only. Please keep this is mind when using eviCore.

Focus on High Blood Pressure

A message from Dr. Good, our chief medical officer:

To all providers: Treat high blood pressure. We continue to find that at least 30 percent of all people with a diagnosis of hypertension continue to have blood pressures over 140 systolic. We know that high blood pressure is the No. 1 treatable cause of coronary artery disease, kidney and heart failure, and stroke. Our non-treatment is adding to the CV statistics.

Prehypertension starts at 120 mm and usually many years before a diagnosis is made. Damage to the vascular system is already occurring at the prehypertension stage. Diet and lifestyle changes should start at this time

Hypertension is generally straightforward in treatment. Although white coat hypertension exists, it can be easily ruled out with verifiable home blood pressure readings. However, published studies suggest that people with white coat hypertension also have increased risk of vascular disease.

Thank you for your cooperation in addressing this serious health issue.

Updates to HEDIS Measures for 2019

  • Controlling High Blood Pressure. NCQA has revised this measure to reflect a new blood pressure target of < 140/90 mm Hg for all adults ages 18–85 with hypertension in accordance with updated clinical recommendations. NCQA has also updated the approach to allow for more administrative methods to collect the measure and added telehealth encounters to satisfy certain components of the measure.
  • Excluding Members With Advanced Illness. Quality measures that were designed and intended for a general adult population may not always be appropriate for those with limited life expectancy or advanced illness and frailty. As such, NCQA is implementing cross-cutting exclusions across selected HEDIS measures to help focus on the population that is most likely to benefit from the measured services.

For HEDIS 2019, the following nine measures exclude individuals 65+ who have an advanced illness and frailty or who live long-term in nursing home settings.*

  • Breast Cancer Screening
  • Colorectal Cancer Screening
  • Comprehensive Diabetes Care
  • Controlling High Blood Pressure
  • Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
  • Osteoporosis Management in Women Who Had a Fracture
  • Persistence of Beta-Blocker Treatment After a Heart Attack
  • Statin Therapy for Patients with Cardiovascular Disease
  • Statin Therapy for Patients with Diabetes

* Members with these conditions may not be excluded during HEDIS chart review.

HEDIS® Chart Reviews Coming Soon

Each spring, 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. Our representatives may visit your office in the spring 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 2019. If you have any questions about HEDIS, contact the Quality Management Department at 1-800-851-3379, ext. 28947.

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

Coding Reminders

Both the Medicare Advantage and commercial Marketplace condition category models are dependent on us receiving accurate diagnosis codes through claims submission. All claims submitted to us must have associated diagnosis codes. There are two areas of opportunity we need your assistance in addressing:

  • Code truncation, or systems limits on the number of diagnosis codes per claim submission
  • Claims that are not submitted at all (e.g., claims for capitated, custodial care, etc.)

These scenarios leave gaps in accurate reflections of the overall risk of the population and may inadvertently omit members from being included in care management programs directed at assisting with health outcomes for their chronic conditions. Please assess your billing practices at an organizational and provider level to ensure these situations don’t apply to you.

If you identify these issues or have concerns that the above applies to your system, contact us at CodingCounts@healthalliance.org, and we’ll reach out to help with a solution.

For useful information on documentation and code reporting,subscribe to our coding e-newsletter.

Statins for Patients with Diabetes

Studies show that statin use in people with diabetes can reduce major cardiovascular events by 35 percent and strokes by 48 percent.

“Statin use in Patients With Diabetes” is a Star measure that follows the American Diabetes Association recommendation that people with diabetes ages 40–75 take a statin medication. This specific measure reflects the percentage of members who have filled at least two prescriptions for diabetes medication and have filled a prescription for a statin.

This Star measure is an administrative HEDIS measure, which means data is collected from claims submitted to Health Alliance. To get accurate results, claims information must be complete, reflecting accurate diagnosis and any conditions that may exclude a member from the denominator. Members with end-stage renal disease and members enrolled in hospice are excluded from the data.

Please discuss the importance of statin use with your patients who have diabetes.

Encourage Chlamydia Screening

Please discuss chlamydia screenings with patients and the parents of teen/young adult patients. 2017 marked the fourth year in a row in which the number of infections nationwide increased.

Eligible population for screening: Women 16–24 years as of December 31 of the measurement year.

One way to reduce the stigma associated with this screening is to encourage getting it as a preventive measure rather than framing it as a sexual-related issue.

Chlamydia is treatable with antibiotics, but it can have long-term consequences when undetected or untreated. Chlamydia can also cause infertility in women.

The national screening average is 50.2 percent. Our 2017 final screening rates are as follows.

  • Commercial HMO/POS: 34.4%
  • Marketplace HMO: 34.5%
  • Marketplace POS: 31.3%

Procedure codes for chlamydia screening:

  • 87270
  • 87320
  • 87490–87492
  • 87810

End-of-Year Screening Reminders

As we wrap up 2018, ensure patients are getting appropriate preventative services to identify any issues or gaps in care.

All Patients

  • Colorectal cancer screening
  • Controlled blood pressure reading
  • Medication review

Women

  • Breast cancer screening
  • Osteoporosis screening in women with a fracture

Patients with Diabetes

  • Controlled A1c readings
  • Nephropathy testing
  • Diabetic eye exams

Children/Adolescents

  • Document counseling for nutrition
  • Document counseling for physical activity

As a reminder, we have health coaching and care coordination services that can help our members better manage their conditions at no extra cost. These services can help improve their health outcomes between visits to your office.

Encourage Physical Activity in Winter

Physical activity is important for all ages and in all seasons. The American Heart Association recommends at least 150 minutes of moderate exercise or 75 minutes of vigorous exercise (or a combination of both) per week, and it doesn’t make exceptions for winter.

Staying active in the winter can be difficult for many. Talk to your patients about ways they can stay active in the winter, including:

  • Going to an exercise class
  • Working out at home with a DVD or free online tutorial
  • Walking around the local mall
  • Joining a gym

Pharmacy Updates

All Plans

Formulary Additions

  • Jynarque (tolvaptan)
    • Vasopressin antagonist indicated to slow the progression of autosomal dominant polycystic kidney disease (ADPKD)
    • Formulary placement recommendations:
      • Commercial—Tier 5 with preauthorization (PA)
      • Medicare—Tier 5 with PA
  • Luxturna (voretigene neparvovec)
    • One-time treatment approved for children and adults with retinal dystrophy due to a mutation of the retinal pigment epithelial 65 kDa protein (RPE65) gene, which causes severe visual impairment beginning in infancy
    • Formulary placement recommendations:
      • Commercial—Tier 6 with PA; change to criteria point #5 noted above
      • Medicare—Part B only
  • Mepsevii (vestronidase alfa-vjbk)
    • The first and only enzyme replacement therapy available to treat mucopolysaccharidosis VII (MPS VII, Sly syndrome)
    • Formulary placement recommendations:
      • Commercial—Tier 6 with PA
      • Medicare—Part B only
  • Palynziq (pegvaliase-pqpz)
    • Phenylalanine-metabolizing enzyme indicated to reduce blood phenylalanine concentrations in adult patients with phenylketonuria who have uncontrolled blood phenylalanine concentrations greater than 600 micromol/L on existing management
    • Formulary placement recommendations:
      • Commercial—Tier 6 with PA; update Continued Approval section as noted above
      • Medicare—Non-Formulary

Criteria Changes

  • Kuvan
    • Exclusion section states that we will not cover concurrent use of Kuvan and Palynziq
  • Spinraza
    • Updated baseline motor milestone scores criteria

WA Individual

Tier Changes

  • Asacol HD—moved from Tier 2 to Tier 3, effective 12/1/18 (notified members)
    • Generic mesalamine 800mg available at Tier 1
  • Mephyton—moved from Tier 2 to Tier 3, effective 11/1/18
    • Not a preferred product
  • Migranal—moved from Tier 2 to Tier 3, effective 11/1/18
    • Generic dihydroergotamine available at Tier 1
  • Nalfon—moved from Tier 2 to Tier 3, effective 11/1/18
    • Generic fenoprofen available at Tier 1
  • Welchol—moved from Tier 2 to Tier 3, effective 12/1/18 (notified members)
    • Generic colesevelam is covered at Tier 1
  • Prenatal vitamins—moving from Preventive to Tier 1 (generics) or Tier 3 (branded products), effective 1/1/19 (notified members)
    • Folic acid 400mcg and 800mcg will remain covered under Preventive

Medicare

Tier Changes

  • Desvenlafaxine ER (Pristiq)—moved from Tier 4 to Tier 2
    • This places it on the same copay tier as desvenlafaxine ER (Khedezla)

 

View as PDF

Midwest December Newsletter

December 11, 2018

As It Relates to You

Reminder: Use New Provider Forms

Please remember to use our new forms to update provider information or add a provider to your practice. You’ll find the forms in the Forms & Resources section of Your Health Alliance for providers.

If adding providers to a currently contracted practice, please use the Provider Addition Form, not the Prospective Provider Form. If you have any questions, contact your provider relations specialist.

Use Internet Explorer to Access EviCore

When using eviCore, please use Internet Explorer as your web browser for best results.

We’ve heard that several providers have received error messages when using eviCore in other web browsers, like Google Chrome. According to eviCore, their system is intended to be used in Internet Explorer only. Please keep this is mind when using eviCore.

New Provider Relations Specialist for Southern Territory

Provider Services would like to welcome a new provider relations specialist, Andrea Barr. Andrea joined the Health Alliance team in October and is ready to service the southern network of providers. This includes but is not limited to SIH/QHP, Southern Illinois Obstetrics & Gynecology, Southern Illinois Orthopedic, Barnes Jewish Hospital, Washington University Physicians and our Reid Health provider network.

Please join us in welcoming Andrea to Health Alliance. She can be reached at 217-902-8254 or Andrea.Barr@healthalliance.org.

Focus on High Blood Pressure

A message from Dr. Good, our chief medical officer:

To all providers: Treat high blood pressure. We continue to find that at least 30 percent of all people with a diagnosis of hypertension continue to have blood pressures over 140 systolic. We know that high blood pressure is the No. 1 treatable cause of coronary artery disease, kidney and heart failure, and stroke. Our non-treatment is adding to the CV statistics.

Prehypertension starts at 120 mm and usually many years before a diagnosis is made. Damage to the vascular system is already occurring at the prehypertension stage. Diet and lifestyle changes should start at this time

Hypertension is generally straightforward in treatment. Although white coat hypertension exists, it can be easily ruled out with verifiable home blood pressure readings. However, published studies suggest that people with white coat hypertension also have increased risk of vascular disease.

Thank you for your cooperation in addressing this serious health issue.

Updates to HEDIS Measures for 2019

  • Controlling High Blood Pressure. NCQA has revised this measure to reflect a new blood pressure target of < 140/90 mm Hg for all adults ages 18–85 with hypertension in accordance with updated clinical recommendations. NCQA has also updated the approach to allow for more administrative methods to collect the measure and added telehealth encounters to satisfy certain components of the measure.
  • Excluding Members With Advanced Illness. Quality measures that were designed and intended for a general adult population may not always be appropriate for those with limited life expectancy or advanced illness and frailty. As such, NCQA is implementing cross-cutting exclusions across selected HEDIS measures to help focus on the population that is most likely to benefit from the measured services.

For HEDIS 2019, the following nine measures exclude individuals 65+ who have an advanced illness and frailty or who live long-term in nursing home settings.*

  • Breast Cancer Screening
  • Colorectal Cancer Screening
  • Comprehensive Diabetes Care
  • Controlling High Blood Pressure
  • Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
  • Osteoporosis Management in Women Who Had a Fracture
  • Persistence of Beta-Blocker Treatment After a Heart Attack
  • Statin Therapy for Patients with Cardiovascular Disease
  • Statin Therapy for Patients with Diabetes

* Members with these conditions may not be excluded during HEDIS chart review.

HEDIS® Chart Reviews Coming Soon

Each spring, 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. Our representatives may visit your office in the spring 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 2019. If you have any questions about HEDIS, contact the Quality Management Department at 1-800-851-3379, ext. 28947.

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

New Locations, New Offerings for Health Alliance Members

Health Alliance Connections is a new retail location where members can drop by and ask a question, sign up for a plan, pay a premium, or attend a class to learn more about health and wellness.

This office is at 3301 Fields South Drive, #105, and replaces our previous Anthony Drive location. Office hours are weekdays 8:30 a.m.–4:30 p.m. and by appointment after hours.

As the name implies, we’re making more connections with our members and connecting them with even more resources. In addition to customer service for Medicare and individual plans, our new site will have:

  • Sales staff to talk to prospective members
  • Nurses performing onsite health risk evaluations
  • A community room where we’ll offer wellness activities, like healthy cooking classes, fitness classes and more (starting in mid-January 2019)

Coding Reminders

Both the Medicare Advantage and commercial Marketplace condition category models are dependent on us receiving accurate diagnosis codes through claims submission. All claims submitted to us must have associated diagnosis codes. There are two areas of opportunity we need your assistance in addressing:

  • Code truncation, or systems limits on the number of diagnosis codes per claim submission
  • Claims that are not submitted at all (e.g., claims for capitated, custodial care, etc.)

These scenarios leave gaps in accurate reflections of the overall risk of the population and may inadvertently omit members from being included in care management programs directed at assisting with health outcomes for their chronic conditions. Please assess your billing practices at an organizational and provider level to ensure these situations don’t apply to you.

If you identify these issues or have concerns that the above applies to your system, contact us at CodingCounts@healthalliance.org, and we’ll reach out to help with a solution.

For useful information on documentation and code reporting,subscribe to our coding e-newsletter.

Statins for Patients with Diabetes

Studies show that statin use in people with diabetes can reduce major cardiovascular events by 35 percent and strokes by 48 percent.

“Statin use in Patients With Diabetes” is a Star measure that follows the American Diabetes Association recommendation that people with diabetes ages 40–75 take a statin medication. This specific measure reflects the percentage of members who have filled at least two prescriptions for diabetes medication and have filled a prescription for a statin.

This Star measure is an administrative HEDIS measure, which means data is collected from claims submitted to Health Alliance. To get accurate results, claims information must be complete, reflecting accurate diagnosis and any conditions that may exclude a member from the denominator. Members with end-stage renal disease and members enrolled in hospice are excluded from the data.

Please discuss the importance of statin use with your patients who have diabetes.

Encourage Chlamydia Screening

Please discuss chlamydia screenings with patients and the parents of teen/young adult patients. 2017 marked the fourth year in a row in which the number of infections nationwide increased.

Eligible population for screening: Women 16–24 years as of December 31 of the measurement year.

One way to reduce the stigma associated with this screening is to encourage getting it as a preventive measure rather than framing it as a sexual-related issue.

Chlamydia is treatable with antibiotics, but it can have long-term consequences when undetected or untreated. Chlamydia can also cause infertility in women.

The national screening average is 50.2 percent. Our 2017 final screening rates are as follows.

  • Commercial HMO/POS: 34.4%
  • Marketplace HMO: 34.5%
  • Marketplace POS: 31.3%

Procedure codes for chlamydia screening:

  • 87270
  • 87320
  • 87490–87492
  • 87810

End-of-Year Screening Reminders

As we wrap up 2018, ensure patients are getting appropriate preventative services to identify any issues or gaps in care.

All Patients

  • Colorectal cancer screening
  • Controlled blood pressure reading
  • Medication review

Women

  • Breast cancer screening
  • Osteoporosis screening in women with a fracture

Patients with Diabetes

  • Controlled A1c readings
  • Nephropathy testing
  • Diabetic eye exams

Children/Adolescents

  • Document counseling for nutrition
  • Document counseling for physical activity

As a reminder, we have health coaching and care coordination services that can help our members better manage their conditions at no extra cost. These services can help improve their health outcomes between visits to your office.

Sarah Bush Lincoln Still In-Network for Medicare

As a reminder, Sarah Bush Lincoln remains an in-network provider for our Medicare Advantage members, including our group Medicare Advantage plans. It is only out-of-network for our commercial group and individual members.

Encourage Physical Activity in Winter

Physical activity is important for all ages and in all seasons. The American Heart Association recommends at least 150 minutes of moderate exercise or 75 minutes of vigorous exercise (or a combination of both) per week, and it doesn’t make exceptions for winter.

Staying active in the winter can be difficult for many. Talk to your patients about ways they can stay active in the winter, including:

  • Going to an exercise class
  • Working out at home with a DVD or free online tutorial
  • Walking around the local mall
  • Joining a gym

Pharmacy Updates

All Plans

Formulary Additions

  • Jynarque (tolvaptan)
    • Vasopressin antagonist indicated to slow the progression of autosomal dominant polycystic kidney disease (ADPKD)
    • Formulary placement recommendations:
      • Commercial—Tier 5 with preauthorization (PA)
      • Medicare—Tier 5 with PA
  • Luxturna (voretigene neparvovec)
    • One-time treatment approved for children and adults with retinal dystrophy due to a mutation of the retinal pigment epithelial 65 kDa protein (RPE65) gene, which causes severe visual impairment beginning in infancy
    • Formulary placement recommendations:
      • Commercial—Tier 6 with PA; change to criteria point #5 noted above
      • Medicare—Part B only
  • Mepsevii (vestronidase alfa-vjbk)
    • The first and only enzyme replacement therapy available to treat mucopolysaccharidosis VII (MPS VII, Sly syndrome)
    • Formulary placement recommendations:
      • Commercial—Tier 6 with PA
      • Medicare—Part B only
  • Palynziq (pegvaliase-pqpz)
    • Phenylalanine-metabolizing enzyme indicated to reduce blood phenylalanine concentrations in adult patients with phenylketonuria who have uncontrolled blood phenylalanine concentrations greater than 600 micromol/L on existing management
    • Formulary placement recommendations:
      • Commercial—Tier 6 with PA; update Continued Approval section as noted above
      • Medicare—Non-Formulary

Criteria Changes

  • Kuvan
    • Exclusion section states that we will not cover concurrent use of Kuvan and Palynziq
  • Spinraza
    • Updated baseline motor milestone scores criteria

Commercial

Tier Changes

  • Asacol HD—moved from Tier 2 to Tier 3, effective 12/1/18 (notified members)
    • Generic mesalamine 800mg available at Tier 1
  • Mephyton—moved from Tier 2 to Tier 3, effective 11/1/18
    • Not a preferred product
  • Migranal—moved from Tier 2 to Tier 3, effective 11/1/18
    • Generic dihydroergotamine available at Tier 1
  • Nalfon—moved from Tier 2 to Tier 3, effective 11/1/18
    • Generic fenoprofen available at Tier 1
  • Welchol—moved from Tier 2 to Tier 3, effective 12/1/18 (notified members)
    • Generic colesevelam is covered at Tier 1
  • Prenatal vitamins—moving from Preventive to Tier 1 (generics) or Tier 3 (branded products), effective 1/1/19 (notified members)
    • Folic acid 400mcg and 800mcg will remain covered under Preventive

Medicare

Tier Changes

  • Desvenlafaxine ER (Pristiq)—moved from Tier 4 to Tier 2
    • This places it on the same copay tier as desvenlafaxine ER (Khedezla)

 

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