Bulletin Program
Valley Health Plan Care Management Program works with Members to improve their health and quality of life. Our program consists of complex case management, care coordination and preventive health education, including chronic disease self-management. The Care Management Program encompasses two programs: Disease Management and Complex Case Management. VHP has partnered with McKesson Care Management to co-administrate these programs. McKesson is a leading provider of disease and care management services, offering more than 25 million enrolled patients immediate access to a broad range of health and disease management services. The Care Management Program is delivered by a team of specially trained registered nurses and other professional staff, using state-ofthe-art information systems to provide knowledge, support, and monitoring for patients between practitioner visits. Members are identified for the Complex Case Management and Disease Management programs through historical claims data (medical and pharmacy) along with requests for services requiring prior authorization and use of the health information line for Members with high and/or complex needs. Members and caregivers may also self-refer to the VHP Care Management Program by calling 1.855.624.5223. (Continued on pg. 2)
VOLUME 17, WINTER 2014
Provider
CARE MANAGEMENT
Care Management Program ............1 The Road to ICD-10............................2 Timely Filing of Claims....................3 Avoiding CCS Claims Denials.........3 National Provider Identifier (NPI) Required on All Claims....................3 Network Update for Compounding Pharmacies..............4 Prescription Drug Prior Authorization Request Form............5 Medication Adherence for Members with Depression...............6 Authorization Denial Disputes........8
Provider Network Change for InHome Supportive Services (IHSS) Members..............................................8 Valley Express Access.......................9 Updated VHP Identification (ID) Card.....................................................9 New or Departing Providers.........10 Changes in Your Information........10 Credentialing Process.....................10
Choosing Wisely速............................11
Table of Contents
1
(Continued from pg. 1) The Disease Management Program is a care management program that partners with medical practitioners and is designed to support patients by helping them with chronic medical conditions to improve and better manage their health. This program promotes adherence to the primary care practitioners’ treatment plans for patients who have chronic conditions such as: • Asthma
• Depression
• Bipolar Disorder
• Diabetes
• Chronic Obstructive Pulmonary Disease (COPD)
• Heart Failure
• Coronary Artery Disease
• Schizophrenia
Valley Health Plan has adopted the following clinical guidelines for practitioners’ use for diagnostic and treatment purposes: • Coronary artery disease • Diabetes • Depression • Attention Deficit Hyperactivity Disorder (Children and Adolescents) The Complex Case Management Program has McKesson care managers working with Members along with their caregivers and their physicians to coordinate care, educate members, transition smoothly between care settings, and assist with community resources and other social needs. The goals are to help your patient navigate the health care system along with encouraging adherence to their treatment plan and to decrease hospitalizations and unneeded use of emergency rooms. These programs are a benefit and a FREE service provided to eligible patients. Patients who do not wish to participate in the program can opt out of the program at any time. Eligible patients are identified and stratified by chronic condition risk levels using historical claims data. We appreciate practitioner input on identifying eligible patients, along with validating conditions identified and care plan needs. We can receive this input by phone 1.855.624.5223 or through a secure fax line at 1.800.542.8074. The Care Management Program hours are Monday - Friday, 8am – 8pm and Saturdays from 8am – 12pm. These programs were designed using current, nationally recognized evidence-based clinical guidelines. Please refer to the Valley Health Plan website www.valleyhealthplan.org to review the clinical guidelines. If you would like paper copies of the clinical guideline summaries, please contact the Care Management Program at 1.855.624.5223.
the road to ICD-10
Although the transition to ICD-10 has been delayed until October 1, 2015, all organizations should capitalize on the delay and focus their efforts on preparing systems and staff for this future conversion. Continued validation and testing with the ICD-10 code library will ensure that the next deadline will not become a burden. The Centers for Medicare & Medicaid Services (CMS) have stated that they will provide instructions for all health care entities involved in the ICD-10 transition and have released more information. Visit the CMS website at www.cms.gov/Medicare/Coding/ICD10/ for additional information on the ICD-10 transition. 2
Timely Filing of Claims
Valley Health Plan (VHP) follows Department of Managed Health Care (DMHC) regulations regarding payment of claims. Please submit your claims as soon as possible in order to expedite payments. • Contracted providers must submit claims within 90 calendar days following the dates of service unless otherwise mandated by law or in the provider contract. A claim received after the 90 days billing time limit is subject to denial. Claims are normally paid within the time frames outlined in the provider contract. • Non-contracted providers must submit claims within 180 calendar days following the date(s) of service. • Medi-Cal and Healthy Kids claims have a timely filing of one (1) year following the date(s) of service. If you have any additional questions, please contact the VHP Claims Department at 408.885.4563, Monday – Friday, 9am – 4pm. WHERE TO MAIL CLAIMS: VHP Employer Group Plan P.O. Box 26160 San Jose, CA 95159 VHP Healthy Kids P.O. Box 28410 San Jose, CA 95159
Avoiding ccs
VHP Individual & Family Plan P.O. Box 650864 Dallas, TX 75265
VHP Covered California Plan P.O. Box 650854 Dallas, TX 75265
VHP Medi-Cal P.O. Box 28407 San Jose, CA 95159
Claims Denials
The California Children’s Services (CCS) program provides diagnostic and treatment services, medical case management, and physical and occupational therapy services to children under age 21 years old with CCS eligible medical conditions. Examples of CCS eligible conditions include, but are not limited to, chronic medical conditions such as cystic fibrosis, hemophilia, cerebral palsy, muscular dystrophy, spina bifida, heart disease, cancer, traumatic injuries, and infectious diseases producing major sequelae. The following examples will result in rejection, delays, and possibly wrong payments and/or denials:
• Billing a claim with a CCS eligible condition or with a diagnosis that is CCS eligible. • The member has an open CCS case, but the CCS condition was not the reason for seeing the patient. The CCS diagnosis should not be listed on the claim. • Treating a CCS member for the CCS diagnosis when you have not requested paneling from CCS. If you have any questions, please contact CCS at 408.793.6200. CCS claims should be mailed to: California Children’s Services (CCS) 720 Empey Way San Jose, CA 95128
nATIONAL PROVIDER IDENTIFIER (NPI) Required on All Claims
Valley Health Plan (VHP) requires that all providers submit their registered National Provider Identifier (NPI) for purposes of claims processing. Only valid NPI’s will be accepted by VHP as the primary identification on submitted claims. To submit claims electronically, please send an email to ProviderRelations@vhp.sccgov.org requesting EDI with your name, TIN, and NPI. VHP will process these requests within 14 days and will provide further instructions. 3
network update
for Compounding Pharmacies
Effective March 1, 2015, Valley Health Plan’s (VHP) contract with Leiter’s Pharmacy will terminate. Leiter’s Pharmacy will no longer provide pharmacy/compounding services to VHP Members. Leiter’s Pharmacy was mostly utilized for compounding services. VHP Network Pharmacies that provide compounding services are listed below: Compounding Pharmacies: Walgreens 350 N. Capitol Ave. San Jose, CA 95133 408.259.9200
Walgreens 423 N. Santa Cruz Ave. Los Gatos, CA 95030 408.354.8029
Walgreens 2600 Mowry Ave. Fremont, CA 94538 510.742.9356
Safeway 160 1st Street Los Altos, CA 94022 650.949.1067
Formulary Drugs: Providers must continue to use the VHP Formulary when writing prescriptions, including those to be compounded. Non-Formulary Drugs: If an active ingredient in the compounded product is not on the VHP Formulary, providers are required to fill out a Non-Formulary Prescription Drug Prior Authorization Form. For your VHP Member patients: • Compounding products are expected to be processed at a VHP Network Pharmacy at the time the prescription is filled. When using the above listed VHP Network Compounding Pharmacies, Members will not have any out of pocket costs for Formulary drugs (see above regarding Non-Formulary Drugs). • Members who use VHP Network Pharmacies for compounding services other than the Compounding Pharmacies listed above may be asked to pay the full cost of the prescription up front. Members would then need to request a Member Reimbursement if for a covered Formulary drug, and they would be reimbursed. If you have questions regarding compounding services, please call Navitus Customer Care at 1.866.333.2757 (toll-free) or VHP Provider Relations at 408.885.2221, option 2.
4
Prescription drug
Prior Authorization Request Form
Effective January 1, 2015, all providers must begin utilizing the uniform Prescription Drug Prior Authorization Request Form (Form No. 61-211) required by the Department of Managed Healthcare (DMHC). Valley Health Plan, or Navitus - VHP’s Pharmacy Benefit Manager, will notify the prescribing provider within two (2) business days of receipt of a completed prescription prior authorization request that either: • The prescribing provider’s request is approved; or
• The Member is no longer eligible for coverage; or
• The prescribing provider’s request is denied as not medically necessary or it is not a covered benefit; or
• The Prescription Drug Prior Authorization Request was not submitted on the required form. Please resubmit the request on Form No. 61-211.
• The prescribing provider’s request is denied as missing material information necessary to approve or deny the request; Please note the following:
• Health plans and their delegated groups cannot require the prescribing provider to provide more information than is on Form No. 61-211. The Form cannot be customized (health plan logo). • If the denial notice is not sent to the prescribing provider within two (2) business days, the request shall be deemed approved. Visit www.valleyhealthplan.org under I’m a Provider > Forms & Resources > Forms for a copy of this form. Please fax the Prescription Drug Prior Authorization Request Form to the Navitus Prior Authorization Fax: 1.855.668.8551. For questions, please call Navitus Customer Care at 1.866.333.2757 (toll-free). 5
Medication Adherence for Members with Depression
The Valley Health Plan (VHP) Quality Management Department reviewed Member’s non-adherence with medication pick-up for first prescription with major depressive disorder: single episode for 2013. Our data showed 15.3% of Members prescribed a medication for major depressive disorder did not pick up their medication. VHP worked with the Behavioral Health Committees and determined this was a quality improvement opportunity. We hope by informing you of this finding that you will: • Continue to foster and/or enhance member participation in their planned care; • Ensure your patients have a clear understanding of why picking up and taking the medication you prescribed is important; • Help your patient understand how the medication can benefit them and that it may take time to work; and • Explain the possible side effects they may experience and how to cope with it. VHP Member Newsletter - Perspectives VHP will be providing the information below in the next issue of the VHP Member Newsletter – Perspectives. We ask that you partner with VHP to educate Members to: • Be a part of their treatment plan with their physician; • Give consent to share their information; and • Understand the importance of picking up their prescribed medication and taking it. Continuity and Coordination of Care VHP wants you, our Members to receive the best health care possible. One of the most important steps you can take is to make sure that your doctor knows about all the health care you are receiving from other doctors or health care professionals you are seeing. This includes obstetricians and gynecologists (OB/GYNs), family planning providers, dentists, behavioral health providers such as psychiatrists, psychologists and 6
counselors, chiropractors, and eye doctors. Also, ask any specialist you are seeing to let your doctor know about any care or medications provided to you. They can share this information if you sign an Authorization for Use and/or Disclosure of Protected Health Information Form that permits your doctor or health care professional to share information about your care with each other. You can also talk to your doctor about any information that other health care professionals have given you about your care or any drugs that you have been told to take. It is very important that all of your doctors know about all medications you take, even over-the-counter medications, such as vitamins or herbal supplements. Keep a list (electronic and/or written) of the medications you take and share this information with your doctor. Remember to keep your list updated when changes occur to make sure it includes all current medicines and doses. Treating Depression Everyone feels sad once in a while. Usually these feelings pass in a few days, but if you feel sad or down for days at time, see your doctor. Seek help immediately if you feel hopeless, are thinking about suicide, or turn to alcohol or drugs for relief. If you are experiencing depression, you can get better with the proper medical care. You may need medical treatment with medication and/ or counseling, or you may only need treatment to get past the feelings of depression. If you have questions about the treatment plan, talk to your doctor and/or counselor. Some common thoughts you may have: • “I do not need or want medication and I do not want to pick up my prescription.” It is always important to be a part of the decision on what prescription you may need to take, please speak with your doctor about the medication they are prescribing. When you play a part in this important decision, you will better understand the importance of picking up and taking your medication. • “I am feeling better and do not need any more medication.” Feeling better is great news, and it may be the right time to stop your treatment, however, it is important to ask your doctor how long to continue taking your medication and be sure that you both agree on the treatment
plan. Sudden stopping of your medications could result in a return of your depression or withdrawal symptoms such as dizziness, sleeping problems, and anxiety. It is important for you and your doctor to work together to determine when it is right for you to stop or start reducing your medication. • “I do not like the side effects of the medication.” If the side effects are bothering you, let your doctor know. Explain what you are experiencing so your doctor can adjust or change your medication or treatment. You may also find that some side effects of the medications will get better with time, your doctor can tell you about this for the medication prescribed to you. • “This medication is not working.” Make sure you give the medication enough time to work. Some medications can take several weeks or longer before you start feeling much better. If a medication does not work for you, let your doctor know. You and your doctor can work together and discuss whether to change the medication. You can also talk to your doctor about counseling, “talk therapy”. Along with taking the medication, adding counseling can be very effective.
Once you and your doctor figure out the right treatment plan for you, you will be well on your way to feeling good again. Here are some easy tips to help you manage your medicines: • Be a participant with your doctor on your treatment plan, which includes your medications. • Please pick up your medication. • When picking up your medication, if you have questions – ask the pharmacist. You can also talk to your doctor. • Read all the information about your medication before you take it. • Always keep enough of your medication on hand; get refills before you run out of your medication. • Develop a schedule for taking your medication and stick to it. • Remind yourself by setting an alert on your cellphone or other electronic device, sending yourself an email or text, writing a note, create a checklist, or some other type of self-reminder. • Develop a supportive network of your family and friends.
7
authorization Denial Disputes If an authorization is denied, a provider may request reconsideration of denied services in writing through the Provider Dispute process. Each dispute must contain the following information: • Provider name • Provider identification number (NPI) • Provider contact information • Member name and Plan ID • Original authorization number • Reason for dispute • Any documentation supporting the dispute Disputes must be submitted in writing to the following address:
A Provider Dispute will be acknowledged in writing to the provider within 15 business days and a resolution will be sent to the provider within 45 business days. Provider Disputes that do not include all required information may be returned for additional information. VHP will clearly identify in writing to the provider the missing information necessary to resolve the dispute. Providers Providerscan cansubmit submitan an amended dispute including the missing information within 30 business days. Please Pleasecontact contactProvider Provider Relations at 408.885.2221, option Option2,2,Monday Monday–– Friday, 9am – 4pm with any additional questions or concerns. Discussing an Authorization Denial or Potential Authorization Denial If you would like to discuss an authorization denial or potential authorization denial, you can contact the VHP Chief Medical Officer at 408.885.4647.
Valley Health Plan Provider Relations Dispute Resolution P.O. Box 28387 San Jose, CA 95159
provider network
Change for In-Home Supportive Services (IHSS) Members Valley Health Plan (VHP) now has two group plan designs offered to active IHSS employees. There are no changes to benefits for either group plan design, however, the provider networks are different. IHSS Classic Provider Network IHSS Members effective before 9/30/2014 will not experience any changes to their provider network. IHSS Preferred Provider Network IHSS Members effective 10/01/14 and after have a narrowed provider network. Providers at NorCal Advantage Medical Group, San Jose Medical Group, and Palo Alto Medical Foundation will not be paid for services rendered to IHSS Preferred group members. Please see below for contracted IHSS Preferred network providers:
8
Contracted Primary Care Physicians (PCP) Santa Clara Valley Medical Center, Community Clinics, Independent Providers, SCCIPA (PCP services only, no SCCIPA specialists) Contracted Specialists (authorization required) Santa Clara Valley Medical Center, Stanford Hospital and Clinics, and Lucile Packard Children’s Hospital; all contracted Ancillary, Facilities, and Behavioral Health; all contracted Urgent Care locations (Except for San Jose Medical Group) Contracted Hospitals (authorization required except in an emergency) Santa Clara Valley Medical Center, Stanford Hospital and Clinics, Lucile Packard Children’s Hospital, and Saint Louise Regional Hospital.
valley express Access With the growing need for practitioners to have access to electronic services that offer improved control, convenience, and flexibility, VHP maintains a constant focus on technological innovation. VHP’s Valley Express is tailored to meet your needs and provide the tools and information needed to make the business of healthcare easy. Valley Express will allow you to: • Check member eligibility • Create referrals • Create authorizations • Search referrals • Search authorizations • Submit clinical documentation with referrals and authorizations To set up an account, please contact Provider Relations at ProviderRelations@vhp.sccgov.org or 408.885.2221, option 2, Monday – Friday, 9am – 4pm. Accounts are created within 48 hours once the necessary information is obtained. Each individual staff member must have their own account and should not share accounts or passwords. Valley Express Provider Portal Referral and Authorization Submission You can submit referrals and authorizations through the Valley Express Provider Portal. You may submit documentation after you submit your request, however, to ensure timely processing, please remember to electronically attach clinical documentation at the time of submission by scrolling down to the bottom of your request and click “add attachments”. Please confirm that all information is thorough and complete before submitting your request and include the submitter’s contact information. If you have questions, or if your office is in need of access or training, please contact your Provider Relations liaison at ProviderRelations@vhp.sccgov.org or 408.885.2221, option 2, Monday – Friday, 9am – 4pm.
updated VHP identification (id)
Card
Valley Health Plan ID cards issued after November 2014 will have an added “Group” field. This field will identify which employer group the member is associated. Valid employer groups are as follows: County of Santa Clara, IHSS Classic, IHSS Preferred, Santa Clara Valley Transportation Authority (VTA), Santa Clara County Office of Education (SCCOE), Santa Clara County Fairgrounds, Sourcewise, VMC Foundation, and South Bascom Pediatrics. Please see the card sample to the right:
Employer Group Plan
Member Name
DOB
Identification #
Group
Gender
Network Primary Care Physician (PCP)
RxGroup# VHP
RxBIN# 610602
RxPCN# NVT
9
new or departing Providers When providers join or leave their practice, VHP Provider Relations must have a 60 day notice in order to complete timely credentialing and/or properly notify the network of the departure and coordinate the care for our Members. To notify Provider Relations of any changes to your practice, please email ProviderRelations@vhp.sccgov.org or call 408.885.2221, option 2.
t r o p e R anges Ch VHP Provider Relations 2480 N. First Street, Ste. 200 San Jose, CA 95131 Fax: 408.793.6648 Email: ProviderRelations@vhp.sccgov.org
changes
in Your Information
It is critical that VHP has the most up to date address, telephone, and fax number for you and your practice. Medical Group Affiliation If you are affiliated with a contracted Medical Group, please contact them directly and make sure they provide the information to VHP. Other Contracted Providers If you are not associated with a medical group or are an independent provider, please submit a letter on your business letterhead that includes your signature and what the changes are along with the effective date of the change.
credentialing Process Files that meet established credentialing criteria will be presented to the Chief Medical Officer on a monthly basis for review and subsequent approval. All practitioners must be approved and actively credentialed before providing care to VHP Members. All active practitioners are re-credentialed every three years. Please reply promptly to credentialing inquiries to prevent a delay in the process. 10
Choosing Wisely®
A Resource for Better Doctor/Patient Communication Recognizing that patients need better information about what care they truly need in order to have conversations with their providers, Consumer Reports developed patient-friendly materials and is working with consumer groups to disseminate them widely. Choosing Wisely® aims to promote conversations between providers and patients by helping patients choose care that is: • Supported by evidence • Not duplicative of other tests or procedures already received • Free from harm • Truly necessary In response to this challenge, national organizations representing medical specialists have asked its providers to “choose wisely” through the identification of tests or procedures commonly used in their field, whose necessity should be questioned and discussed. The resulting lists of “Things Providers and Patients Should Question” will spark discussion about the need—or lack thereof—for many frequently ordered tests or treatments. This concept was originally conceived and piloted by the National Physicians Alliance, which, through an ABIM Foundation Putting the Charter into Practice grant, created a set of three lists of specific steps physicians in internal medicine, family medicine and pediatrics could take in their practices to promote the more effective use of health care resources. These lists were first published in Archives of Internal Medicine. Choosing Wisely® recommendations should not be used to establish coverage decisions or exclusions. Rather, they are meant to spur conversation about what is appropriate and necessary treatment. As each patient situation is unique, providers and patients should use the recommendations as guidelines to determine an appropriate treatment plan together. Providers can visit choosingwisely.org/doctor-patient-lists/ to view evidence-based recommendation resources dedicated to providers and patients. It has been found that patients often ask for tests and treatments that are not necessarily in their best interest. For our members, VHP has also partnered with Consumer Reports Choosing Wisely® to provide tools and resources to help them prepare for health care discussions prior to their visit. VHP members can visit consumerhealthchoices.org/vhp/ to view fact sheets and resources.
11
Provider Relations
2480 N. First Street, Suite 200 San Jose, CA 95131 408.885.2221 ProviderRelations@vhp.sccgov.org www.valleyhealthplan.org
Š 2014 Valley Health Plan
VHP CHIEF MEDICAL OFFICER Dolly Goel, MD VHP MEDICAL ADVISORS Stephen Harris, MD Michael Meade, MD Gary Steinke, MD BOARD OF SUPERVISORS Mike Wasserman Cindy Chavez Dave Cortese S. Joseph Simitian Ken Yeager COUNTY EXECUTIVE Jeffery V. Smith
12