HMSA Provider Bulletin HMS A ’ S P L an fo R Q U E S T M embe R S Bulletin Q08-01 January 15, 2008 A MESSAGE FROM OUR appointments, ensuring the collection and forwarding of MEDICAL DIRECTOR necessary information, obtaining prior authorizations, educating the parents, and following up to ensure appointments are kept is Children with Special Health Care Needs guaranteed to be difficult and time consuming. Children with chronic illnesses are Other examples include children with diabetes, congenital heart challenging for pediatricians and other defects, seizure disorders, asthma, cancer (even if in remission), primary care providers entrusted with and juvenile rheumatoid arthritis. Also included are children their care. This is especially so for with multiple diagnoses, related or otherwise. those children whose management The Hawaii Department of Health has a service dedicated to requires the services of various assisting such children, their families and their caregivers. This medical specialists, allied health care is the Children with Special Health Needs Program, under the providers, organizations, and institutions. A child with Family Health Services Division. Children and youth under 21 a cleft palate, for example, may require the services of years of age residing in Hawaii are eligible if they have chronic an ENT surgeon, oral surgeon, dentist, audiologist, health conditions lasting (or expected to last) at least one year, speech therapist, DME provider (for hearing aids), for which specialized medical care is required. and the Department of Education. Locating these The Children with Special Health Needs Program can assist providers, making the necessary referrals, coordinating QUEST members who are having difficulty in coordinating or obtaining health care services, or who cannot obtain certain Happy New Year 2008 services through QUEST, with the following: IN THIS ISSUE: • Coordination of health care referrals and appointments. This may include follow-up with PCPs, specialists, and other health • A Message from Our Medical Director care providers. • EPSDT Matters • Information about community services and resources, and help — Instructional DVDs Available to obtain these services. — Blood Lead Risk Questionnaire Discontinued • Social work services. — Dental Referrals • Nutrition consultations. — EPSDT Form Reminders For more information, you may contact a program representa- • Hospitalizations During Enrollment Changes tive at the following locations: • Claims Filing Information Oahu (main office) — Documentation for TPL Denials 741 Sunset Ave., Honolulu, HI 96816 • Drug Formulary Updates Phone: 733-9055 • Benefit Policies Fax: 733-9068 — Uterine Artery Embolization From Kauai (toll-free): 274-3141, ext. 39055# • Provider Handbook Updates From Maui (toll-free): 984-2400, ext. 39055# If you have any comments, questions or suggestions for our Bulletin, please call us at 948-6486 on Oahu or From Hawaii (toll-free): 974-4000, ext. 39055# 1 (800) 440-0640 toll-free from the Neighbor Islands. From Molokai/Lanai (toll-free): 1 (800) 468-4644, ext. 39055# P.O. Box 3520, Honolulu, HI 96811 - 3 5 2 0 • O a h u 9 4 8 - 6 3 2 1 • Neighbor Islands 1 (800) 77 1 - 0 6 7 7 Bulletin Q08-01 January 15, 2008 Continued from page 1 Kauai East Hawaii 3040 Umi St., Lihue, HI 96766 46 Keawe St., Hilo, HI 96720 Phone: 241-3376 Phone: 974-4288 Maui West Hawaii 54 High St., Wailuku, HI 96793 81-980 Halekii St. #103, Kealakekua, HI 96750 Phone: 984-2130 Phone: 322-4880 EPSDT MATTERS Program Requirements Reminder for PCPs Under Title XIX of the Social Security Act, the federally Lead risk assessments and blood lead levels are required mandated EPSDT program provides for comprehensive components at the specified ages. health services with emphasis on preventive care with If you have any questions, please call Provider early detection and timely treatment of problems for Services at 948-6486 or toll-free from the Neighbor Medicaid recipients. HMSA’s QUEST plan follows the Islands at 1 (800) 440-0640. You may also contact requirements set by Centers for Medicare and Medicaid Dr. Frank Smith, HMSA QUEST medical director, Services (CMS) and locally by DHS’ Med-QUEST at [email protected]. Division for its EPSDT program. This includes utilizing Limited Number of Instructional DVDs Still Available the EPSDT forms (DHS 8015, 8015A and 8016) that were developed by Med-QUEST and ensuring that all If you missed the informational sessions on the new components of the EPSDT exam are performed and EPSDT forms, we still have a few DVDs of the state’s documented to receive the enhanced global reimburse- Med-QUEST session held last May at The Queen’s ment fee. Medical Center. The DVD can help you understand the forms and how to complete them. We can also send you As a PCP, you are contractually obligated to perform copies of the training materials we used at the HMSA EPSDT exams on members ages newborn through 20 informational sessions conducted last summer. years at intervals specified by the periodicity schedule. If you would like any of these training materials, All of the age-appropriate components listed on the call us at 948-6486 (Oahu) or toll-free at EPSDT form must be completed as part of the EPSDT 1 (800) 440-0640 (Neighbor Islands) Monday exam. Using the EPSDT code(s) on the CMS1500 through Friday between 7:45 a.m. and 4:30 p.m. claim form indicates that the required components were performed and documented on the form and in Blood Lead Risk Questionnaire Discontinued the member’s chart. Included as required components The Childhood Lead Risk Questionnaire, which was are vision and hearing screenings, immunization previously available through the state’s Childhood administration, intradermal placement of tuberculin Blood Lead Surveillance Program, is no longer available. testing material, and developmental and behavioral Therefore, you are no longer required to attach the assessments. These services are included in the global questionnaire to lab requisitions for blood lead testing. fee and cannot be paid separately. Verbal risk assessment, however, must continue to be Other preventive medicine or E/M services may not done for all EPSDT exams from age 6 months to 72 be substituted for EPSDT visits. months. 2 Bulletin Q08-01 January 15, 2008 Dental Referrals plan and transferred to the Medicaid fee-for-service program during the confinement. Dental services for children requiring dental care are provided through the Medicaid fee-for-service When a hospitalized member has an enrollment program. For help in finding a dental provider, change, the plan in which the member was enrolled parents can be referred to the Community Case on the date of admission remains financially Management Corporation at 792-1070, or toll-free responsible for the inpatient services as well as at 1 (888) 792-1070. transportation, lodging and meals for an attendant if required, through discharge as long as the member EPSDT Form Reminders remains in the same acute care facility. In the past, responsibility for inpatient confinements ended Attach only original (red ink) EPSDT forms to claims. when the patient’s level of care dropped. However, The new forms were developed to allow optical this condition no longer applies. Responsibility will scanning for data collection. Photocopies of the form remain with the plan/program until discharge. do not scan properly and will affect measurement of the effectiveness of the program and the type of care Professional services will continue to become intervention that ensures children receive needed care. the responsibility of the new plan/program upon Claims that are submitted with photocopies of the enrollment into the new plan/program, even if the EPSDT forms will be returned. confinement itself is still the responsibility of the plan/ program at time of admission. Only adjustment requests for claims that are being submitted for corrected processing will be accepted with photocopies of the EPSDT forms provided that CLAIMS FILING the original claim was submitted with a valid original EPSDT form. INFORMATION Provide written documentation for Clearly identify the provider conducting the exam. all third party insurance denials. Please legibly print the name of the provider who All other insurance denials must be documented by an conducted the screening exam. This should not be official written denial notice from the other insurance. the name of a clinic or facility. The provider’s This can be a copy of a dated termination letter from signature is also required as the form becomes a the other insurance to the member or the provider, a part of the patient’s medical record. claim denial report from the other insurance company Use your NPI. Be sure to use the NPI number instead to the provider showing the reason for the other of any HMSA legacy provider numbers. insurance denial, or a copy of the patient’s HIPAA Certificate of Coverage from the other insurance showing the termination date. HOSPITALIZATIONS The documentation must include the member DURING ENROLLMENT information and if it is a claim denial, it must indicate CHANGES the reason for no coverage. Notices that do not identify the member or that are not appropriate for Who is responsible? the claims in question are not sufficient and may The new benefit year that began Aug 1, 2007, result in denial of the claim. brought with it a change in the policy regarding who has responsibility for a patient’s confinement when a patient changes plans or is disenrolled from a QUEST 3 Bulletin Q08-01 January 15, 2008 DRUG FORMULARY UPDATES As announced in HMSA’s November 2007 Provider Update for pharmacies, the following changes to the QUEST formulary were effective Jan. 1, 2008, except where noted: Added to the formulary: Generic Name Brand Name Notes albuterol/ipratropium Generic DuoNeb aprepitant Emend trifold pack benzonatate Generic Tessalon carvedilol Generic Coreg darunavir Prezista exenitide Byetta SMBG test strips Freestyle Lite test strips insulin glargine Lantus Solostar Line extension eff.