Bulletin Dolly C. Goel, MD
As the Chief Medical Officer for Valley Health Plan (VHP), I would like to stress the importance promoting an annual physical with your patients. Each year, things can change with your patient’s health status. Helping your patients know what their health is each year can help them avoid more serious health issues or, help them manage any chronic disease they may have. VHP offers many ways to keep members on track by offering low or no cost classes that include fitness, nutrition and chronic disease management. Please remind your patients to visit the VHP website at www.valleyhealthplan.org under Health and Wellness for classes and a new way to understand their current health status through an online Personal Health Assessment tool where they can earn VHP rewards! Thank you for providing quality care to our Members. VOLUME 19 | SUMMER - FALL 2016
Provider
A Message from
A Message from Dolly C. Goel, MD.......... 1 Pharmacy Corner...................................... 2 Immunization Benefits & Services Update....................................................... 2 New Provider Directory Requirements..... 3 Notice to Healthcare Professionals of Your Rights............................................ 3 Member Rights and Responsibilities........ 3 Affirmative Statement About Financial
Incentives.................................................. 3 Authorization Review Criteria and Decision Making Process......................... 4 Reporting Suspected Fraud...................... 4 Health Education Department Wellness Program..................................... 5 Bariatric Surgery Guidelines..................... 6 Lesbian, Gay, Bisexual and Transgender
(LGBT) Resources.................................... 7 New Plan Option For County of Santa Clara Retirees................................. 8
Table of Contents
Pharmacy Corner
VHP Drug Formulary The VHP Drug Formulary is reviewed quarterly and updated by the VHP Pharmacy and Therapeutics (P&T) Committee. The P&T Committee uses information from many sources to determine the status of each drug. The P&T Committee decisions include adding drugs to the Formulary, requiring prior authorization for some drugs, requiring quantity limits or step therapy, the process for generic substitution, therapeutic interchange, or not adding the drug to the Formulary. These decisions are based on US Food and Drug Administration (FDA) approval, scientific articles, drug safety, and whether there are other like drugs available that accomplish the similar results. Occasionally, VHP will require you to fill out a Prior Authorization for Formulary drugs or an Exception to Coverage form for drugs that are not on our Formulary. These forms will be reviewed by a pharmacist and/or a physician and approval will be based on established criteria and medical necessity. After each P&T Committee meeting or at any time, you can visit www.valleyhealthplan.org to view the drug Formulary and Formulary summary of updates. If you do not have access to the Internet and would like a paper copy of the VHP drug Formulary, please contact Navitus Customer Care at 1.866.333.2757 (toll-free), visit www.valleyhealthplan.org, or call VHP Provider Relations at 1.408.885.2221, option 2. Please refer to the VHP Provider Manual at www.valleyhealthplan.org for information about the VHP P&T Committee. Navitus Health Solutions Navitus Health Solutions is VHP’s Pharmacy Benefit Manager (PBM). Navitus Health Solutions administers the pharmacy benefit on behalf of VHP, including customer service, Formulary maintenance, Prior Authorizations, Exception to Coverage, and drug recall notifications. Navitus Customer Care is available 24/7, except Thanksgiving Day and Christmas Day, at 1.866.333.2757 (toll-free).
Immunization Benefits & Services Update Valley Health Plan (VHP) encourages Members to get required immunizations as recommended by the U.S. Preventive Services Task Force to help keep them healthy. VHP coverage includes immunizations provided by PrimaryCare Practitioners(PCPs) or through VHP Plan Pharmacies where immunization services are available. Travel immunizations are covered only when received at a VHP Plan Pharmacy or through their PCP. (*Please note that travel immunizations received from the Santa Clara County Public Health Travel Clinic at Lenzen are no longer covered by VHP.) Travel immunization consultations are not a covered benefit. For travel immunization information, please visit www.cdc.gov under Travelers’ Health. Please refer your VHP patients to the VHP website at www.valleyhealthplan.org to find a Plan Pharmacy. For additional information, they can call VHP Member Services at 1.888.421.8444 (toll-free). 2 Provider Bulletin | Summer - Fall 2016
New Provider Directory Requirements
Valley Health Plan (VHP) is committed to providing our Members with the most accurate and current Provider Network Information available. In compliance with Health and Safety Code Section 1367.27 as enacted by Senate Bill 137 (2015), VHP will be asking Providers and Medical Groups to annually verify their contact and provider profile information represented in our Provider Directory. To meet this new regulatory requirement, VHP will send out a notification requesting that providers respond to affirm that their profile information is current. Thank you for your assistance in providing our Members with the information needed to access quality care and services within our network.
Notice to Healthcare Professionals
of Your Rights
Healthcare professionals have the right to review information obtained by Valley Health Plan (VHP) to support their credentialing application and obtain the status of their application throughout the credentialing process. If you would like to review the information obtained by VHP, please call Provider Relations to set up a time to meet. You will be given the opportunity to correct any erroneous information obtained during the verification process. VHP will notify you of any information that varies substantially from the information you personally provided on the credentialing application. You will be given 30 days to provide a written response to the person specified on the notification and that information will be included and reviewed by the Credentialing Committee. To receive information about the status of a credentialing or recredentialing application, or if you have any questions about the process or these rights, please contact the VHP Provider Relations Department at ProviderRelations@vhp.sccgov.org or 408.885.2221 Option 2, Monday – Friday, 9am – 4pm.
Member Rights and Responsibilities
For a list visit www.valleyhealthplan.org/sites/providers/fr/Pages/mrr.aspx. You can also contact VHP Provider Relations Department at ProviderRelations@vhp.sccgov.org or call 408.885.2221, Option 2, Monday – Friday, 9am – 4pm for a copy.
Affirmative Statement About Financial Incentives
Valley Health Plan affirms that:
1. Utilization Management decision making is based only on appropriateness of care and service and existence of coverage. 2. The organization does not specifically reward practitioners or other individuals for issuing denials of coverage. 3. There are no financial incentives for Utilization Management decision makers.
www.valleyhealthplan.com 3
Authorization review
Criteria and Decision Making Process
VHP ensures that medical necessity decisions affecting the health care of Members are made in fair, impartial and consistent by using objective measurable and evidence-based medical criteria. Authorization requests are reviewed by the VHP Utilization Management (UM) staff to determine the medical necessity for requested services. The plan uses the following criteria sets to assist in this determination: • Apollo Criteria
• InterQual
• Milliman Care Guidelines
VHP can provide copies or paraphrases the section when copyright restrictions apply, of the criteria applicable to the specific procedure or conditions requested. Visit www.valleyhealthplan.org for the entire VHP Policy and Procedure or contact UM Monday through Friday 9am - 5pm at 1.888.421.8444 (toll-free).
Reporting Suspected Fraud Valley Health Plan (VHP) is committed to providing our Members with quality care. We encourage our Members, providers and community to notify VHP of any suspicion or situations regarding healthcare fraud. This allows us to investigate and take necessary actions to protect our Members from unlawful activities. Fraud and abuse in health care may occur in many different forms, including, but not limited to, the following: • Medical identity theft;
• Unbundling;
• Billing for unnecessary services and items;
• Billing for non-covered services or items;
• Billing for services or items not rendered;
• Kickbacks; and
• Upcoding;
• Beneficiary fraud.
Prevention by Providers In addition to reporting potential fraud and abuse practices, providers may take steps to prevent fraud and abuse, including: • Knowing the regulations and laws governing the services offered by the practice; • Screening potential and existing employees and contractors for current exclusion, or grounds for exclusion, and • Implementing a compliance program How to Report Fraud and Abuse If you believe you’ve experienced or are aware of any fraud (waste or abuse of VHP health care resources), please contact the Valley Health Plan Compliance Department at 408.885.5924. It is against VHP policy and the law to retaliate against anyone who reports, participates, testifies or assists in a potential fraud investigation.
4 Provider Bulletin | Summer - Fall 2016
Health Education Department Wellness Program
We believe that good health is key to everything. The Valley Health Plan (VHP) Health Education Department offers Members onsite classes, personalized health coaching, and online programs designed to help your patient become more active, eat healthier, stress less, and stay healthy at every stage of their life. You can direct your patients to contact the VHP Health Education Department at 408.885.3490 or visit valleyhealthplan.org under Health and Wellness. Fitness Classes Effective April 1, 2016, VHP and our new partner, Reach Fitness, launched a fitness program with classes located throughout Santa Clara County. Classes like ZumbaÂŽ, Bolly X Fitness, High Intensity Interval Training (H.I.I.T.), and sports conditioning are offered for all fitness levels at no cost to VHP Members. To view class information, visit valleyhealthplan.org under Health and Wellness. Camp Superstuff 2016 Asthma Summer Camp Every summer, Breathe California offers a week-long asthma day camp for kids called Camp Superstuff. This camp is designed for children 6 - 12 years old suffering from asthma. Camp Superstuff blends an asthma education program along with traditional summer camp activities like field trips, games, arts & crafts, skits, songs and more! Camp Superstuff has trained staff and volunteers to teach campers important ways they can manage their asthma. DEADLINE FOR REGISTRATION (Space is limited): Friday, June 24, 2016 CAMP DATE: July 18 - July 22, 2016 9:00am - 5:00pm WHERE: Mayfair Community Center - 2039 Kammerer Ave, San Jose, CA 95116 For more information about the 2016 Camp Superstuff, call Breathe California at 408.998.5865 or the VHP Health Education Department at 408.885.3490.
www.valleyhealthplan.com 5
Bariatric Surgery Guidelines
Obesity can impact a patient’s health and quality of life. If your patient is a Valley Health Plan (VHP) member and is interested in weight loss surgery or bariatric surgery, they can register for the VHP Bariatric Surgery Orientation. Participants will learn about the different types of weight loss surgeries, the mandatory bariatric support group, and how to qualify for surgery. Step One: To qualify for weight loss surgery: Interested participants must be between 18 -65 years old, and fall into one of two categories: • BMI (Body Mass Index) of at least 40, or • BMI (Body Mass Index) of at least 35 with co-morbid conditions (e.g. diabetes mellitus, hypertension, arthritis, obstructive sleep apnea, or evidence of cardiopulmonary failure) Patients may not qualify if they have: • Uncontrolled mental illness (e.g. recent hospitalization, requires Electroconvulsive Therapy (ECT), suicide attempt within last year, active binge eating disorder); or • Unstable angina; or
• Pulmonary hypertension; or • Metastatic cancer; or • Active alcohol or substance abuse. Due to postoperative risk of abuse substitution, patient would need to be clean for minimum of three years.
Step Two: Patient must attend the mandatory VHP Bariatric Surgery Orientation before labs are ordered. This class is offered quarterly, usually on the first Tuesday of March, June, September, and December. The patient can contact the VHP Health Education Department at 408.885.3490 for the latest class information and to register. Step Three: Upon successful orientation completion: Order the following Preoperative Evaluation Labs using ICD-10 E66.01: • CBC
• P7
• LFT’s
• B12
• TSH
• FLP
• Fe Level Ferritin
• PT/PTT
• CXR
• EKG
• HgbA1c if diabetic
a) If labs are relatively normal, Schedule for Bariatric Evaluation: 1. Go Healthlink, select General Surgery referral, then choose external location Stanford. 2. In “Provider Information” section, click on next level tab until “Dr. John Morton name is available for selection. Reason – service not available at VMC. 3. In “comment” section, enter “Bariatric Evaluation – patient has completed orientation and initial labs”. 4. Use ICD-10: E66.01 (Morbid Obesity) 5. VHP Case Management will FAX the labs/CXR/EKG to Stanford. NOTE: SCVMC does not have resources to conduct psychiatric and nutritional assessments. These services are done at Stanford. One referral to Stanford will cover the bariatric evaluation, psychiatric assessment, and nutritional counseling. b) If labs are grossly abnormal: 1. Initiate the appropriate medical evaluation if the condition hasn’t been previously identified. 2. If the abnormal labs are identified as their baseline, please refer directly to Dr. John Morton at Stanford as described above. 6 Provider Bulletin | Summer - Fall 2016
Step Four: Once patient has been referred to Stanford: 1. VHP will provide case management services for the patient. 2. A few additional tests maybe requested by Stanford. If the patient presents these requests to you, as their PCP, please order them. Other tests that may be requested include: • Abdominal U/S – only if symptomatic cholelithiasis • Nutritional assessment – see below. • Echocardiogram – hx of phen-fen/OSA/ evaluation of cardiac risks • Lower extremity doppler: only if h/o DVT or venous stasis
• Cardiac catheterization: if h/o CAD • UGI – Please order an UGI instead of a GI referral for endoscopy • Lipoprotein-a, CRP-hs, Homocysteine, Thiamine, Folate, Glucose Tolerance test if nondiabetic
3. Mandatory Support Group Once a patient has started the evaluation process at Stanford, they will be required to attend eight mandatory bariatric surgery support group sessions before having a surgery date scheduled and approved. The VHP support group is held every Wednesday from 6:30pm-8:30pm at the Administrative Office Building, 2325 Enborg Lane, 1st floor Seminar room, San Jose, CA. This is the only support group which will give them credit towards the requirement. There are other bariatric support groups offered throughout Santa Clara County – no credit will be given for these support groups, but patients are encouraged to attend. The patient can contact the VHP Health Education department at 408.885.3490 to request a copy of the flyer that includes the form to be signed by the group instructor confirming their attendance. Step Five: When a patient has completed surgery: After six months of routine post-op follow-ups at Stanford, the patient will be discharged from their post-op care. Patients should be referred back to their bariatric surgeon once a year for gastric bypass or every three to four months for lap band, if they still have the appropriate insurance coverage. Contact Information: • To register for the orientation class, please contact the VHP Health Education Department at healtheducation@vhp.sccgov.org or 408.885.3490. • For questions or to requests tests, your patient or Stanford can contact the VHP Utilization Management Department at 408.885.4647. • Contact Dr. John Morton at morton@stanford.edu or his nurse Michael at mtorno@stanfordmed. org for questions about a patient who is already being evaluated at Stanford or is post-surgery.
Lesbian, Gay, Bisexual and Transgender
(LGBT) Resources
Valley Health Plan encourages all providers to participate in training to improve their capacity to deliver culturally competent care, especially for health care disparities. The health plan is please to inform our providers there is a link to The Fenway Institute, a multi-disciplinary team of clinicians, educators, and public health professionals with expertise in LGBT Health Research and Care on our website. The Fenway Institute provides free trainings, which include on-demand webinars, learning modules, video training and they are certified to offer prescribed credits from the American Academy of Family Physicians. Please visit ww.valleyhealthplan.org/sites/providers/fr/Pages/Training.aspx for more Information. www.valleyhealthplan.com 7
Provider Relations
2480 N. First Street, Suite 200 San José, CA 95131 408.885.2221 ProviderRelations@vhp.sccgov.org www.valleyhealthplan.org
© 2016 Valley Health Plan
New Plan Option For
County of Santa Clara Retirees
County of Santa Clara Retirees now have the option to choose between our Classic Plan or Preferred Plan. There are no changes in the Covered Benefits or Copayments, and the ID Card will identify which Plan has been chosen. VHP Preferred Plan VHP developed the Preferred Plan especially for those interested in receiving primary care services from Santa Clara Valley Medical Center (SCVMC), Community Clinics, Independent providers, and SCCIPA providers. The Preferred Plan offers a lower premium cost with the same benefits and no/low copayments as the current VHP Classic Plan. VHP Classic Plan (Original Plan Offering) The VHP Classic Plan primary care provider network still includes Palo Alto Medical Foundation (PAMF), San Jose Medical Group, Northern Cal Advantage Medical Group, in addition to Santa Clara Valley Medical Center (SCVMC), Community Clinics, Independent Providers, and SCCIPA providers.
VHP CHIEF MEDICAL OFFICER Dolly C. Goel, MD VHP MEDICAL ADVISORS Stephen Harris, MD Michael Meade, MD Gary Steinke, MD
BOARD OF SUPERVISORS Cindy Chavez Dave Cortese S. Joseph Simitian Mike Wasserman Ken Yeager COUNTY EXECUTIVE Jeffrey V. Smith