HealthPro News A monthly publication for participating HMSA health care providers, facilities, and their staff. October 2016 ADMINISTRATION & NEWS C Q M Open Enrollment Season Open enrollment is here! HMSA has resources to help your patients learn more about the open enrollment What’s season. These resources include posters to display in your office and rack cards to Inside give your patients or have available at your reception counter. The open enrollment periods for our members include: Coding & Claims • QUEST Integration: October 1–31. 4 • EUTF retirees: October 10–31. Pharmacy • HMSA Akamai Advantage®: October 15–December 7. 4 • Affordable Care Act (ACA), individuals and small groups: November 1–January 31. Plans 11 • Federal Plan 87: November 14–December 12. To get these open enrollment resources, email Provider Services at Policy News [email protected] or call 948-6820 on Oahu or 1 (877) 304-4672 11 toll-free on the Neighbor Islands. Calendar 13 C Q M Bone Density Scans HMSA is offering a new service for HMSA Akamai Advantage members who need evaluation for osteoporosis. Members who have had a recent fracture and have difficulty going to an imaging center for a DXA scan can have a heel scan provided by our Health Management staff at an HMSA Center or in their home. HMSA will contact physicians to offer this service as we identify members who are eligible. Heel scans are free for eligible members; HMSA will handle scheduling and testing and will send the results to your office. C Q M Commercial QUEST Medicare C Q M Integration 2016 High Performer Program HMSA is pleased to offer a special bonus program to our primary care providers again this year. This program identifies members who may be less likely to receive certain preventive services and rewards providers for their extra effort to encourage these patients to take an active role in their health care. Hawai‘i Medical 818 Keeaumoku St. P.O. Box 860 hmsa.com Provider Resource Center Service Association (808) 948-6330 Honolulu, HI 96808-0860 hhin.hmsa.com hmsa.com/portal/provider An Independent Licensee of the Blue Cross and Blue Shield Association 1100-6351 2 w HealthPro News - Health Care Providers, Facilities, and Staff October 2016 ADMINISTRATION & NEWS (CONTINUED) This is an invitation-only program for PCPs who meet performance and volume criteria. Providers will receive bonus payments for each gap they close for their targeted patients. We’re also pleased to once again offer incentives for your entire team. We know that your staff plays an essential role in the success of this program, so they’re eligible for gift cards when they achieve certain goals. Invitation letters and detailed program guides were mailed to providers on September 1. The program runs through December 31, 2016. To find out how to participate or if you have any questions, please call us at 952-7822 on Oahu. C Q M Telephone Survey to Assess Appointment Availability SPH Analytics will call you this month about the availability of the following types of appointments for HMSA QUEST Integration members: • Urgent care visits (high fever, ear pain, or infections): within 24 hours. • PCP pediatric sick visits: within 24 hours. • PCP adult sick visits: within 72 hours. • Behavioral health visits (routine visits for adults and children): within 21 days. • PCP visits (routine visits for adults and children): within 21 days. • Specialist visits: within four weeks. • Non-emergency hospital stays: within four weeks. Our goal is 90 percent or better for appointment availability. The survey takes less than 10 minutes to complete. If another time would be more convenient than when we call, let us know and we’ll call you back at a time that works for you. Thank you in advance for taking the time from your busy schedule to respond to this telephone survey. The information you provide to SPH Analytics helps us maintain our successful relationship with the state of Hawaii for our QUEST Integration plan. Here are the results from the previous survey. SHHMSA QUEST Integration Appointment Availability Report Second quarter 2016 % of requests that meet Average wait (days) Provider Type/Class Wait standard waiting time for those over standard standard Urgent care 24 hours 97.4% 6 days PCP pediatric sick visits 24 hours 97.6% 20 days PCP adult sick visits 72 hours 99.1% 21.5 days Behavioral health (routine visits for adults and children) 21 days 92.9% 35 days PCP visits (routine visits for adults and children) 21 days 99.4% 54 days Specialist 4 weeks 97.1% 59 days Non-emergent hospital stays 4 weeks 99.4% 24 days C Q M Commercial QUEST Medicare Integration 3 w HealthPro News - Health Care Providers, Facilities, and Staff October 2016 ADMINISTRATION & NEWS (CONTINUED) C Q M Behavioral Health: Telephone Survey on Appointment Availability We’d like to ensure that our members have good access to behavioral health providers when they need care. As part of our quality improvement efforts, we’ve contracted with SPH Analytics to conduct a behavioral health-specific survey this month. If SPH Analytics calls your office, we kindly ask that you participate in the short telephone survey. Your ability to confirm that our members have good access to behavioral health services is greatly appreciated. Good access to behavioral health providers is generally defined as a patient receiving care for: • Non-life-threatening emergencies within six hours. • Urgent care appointments within 48 hours. • Initial routine care appointments within 10 business days. • Follow-up routine care appointments within 10 business days. • Follow-up appointment within seven calendar days after a hospital discharge. HMSA is fortunate to have an excellent provider network and anticipate great survey results. We’ll report the results in future issues of HealthPro News. Thank you in advance for taking the time to participate in this important survey. C Q M Payment Transformation 835 Electronic Remittance We’re modifying the way check, claim, and service line level adjustments appear on our Report-to-Provider statements and Electronic Remittance Advice (HIPAA 835 transaction). These changes will more accurately reflect reimbursement under the HMSA payment transformation model. They’ll provide a greater amount of detail and should help providers in the payment transformation program reconcile payment for claims. We’re hoping to make the changes in the first quarter of next year. We’ll provide more details soon. If you have questions, please contact your Provider Services field representative or call 948-6820 on Oahu or 1 (877) 304-4672 toll-free on the Neighbor Islands. C Q M Clinical Labs of Hawaii Clinical Labs of Hawaii offers physicians the ability to view their patients’ results online anytime with its Physician Portal at md.clinicallabs.com. This mobile-friendly application provides lab and pathology results to physicians and their staff in real time. Key features of CLH’s online Physician Portal include: • Alternate medical record number search capability. For lab reports, search for the test name, report type, collection date, patient name, date of birth, CLH medical record number (MRN), or client-generated IDs. • Viewable PDF reports. Physicians may download the lab reports, file them as attachments in their local electronic medical records (EMR) systems, or print the reports and file a hard copy with the patient’s medical record. • Cumulative lab reports. Cumulative lab reports enable users to view comparative test results over a specified period of time and create and save multiple cumulative report templates. The Physician Portal ensures the confidentiality of patient data in accordance with standards outlined in HIPAA regulations. For information about the Physician Portal, please email a service representative at [email protected] or call 677-7998 on Oahu. C Q M Commercial QUEST Medicare Integration 4 w HealthPro News - Health Care Providers, Facilities, and Staff October 2016 CODING & CLAIMS C Q M Claims Processing Change for Bundled Codes For claims processed on or after January 1, 2017, HMSA will no longer separately pay for 92133 and 92134 when these two codes are billed together for the same date of service and rendered by the same provider. Procedures 92133 and 92134 aren’t considered distinct procedures. CPT manual guidelines say, “Do not report 92133 and 92134 at the same patient encounter.” Therefore, the following modifiers aren’t appropriate to bill with these codes: 58, 59, 78, 79, XE, XS, XP, or XU. This is consistent with CMS NCCI bundling editing. Affected codes: • 92133 — Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve. • 92134 — Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina. PHARMACY C Q M Insulin Changes Thank you for taking the time to provide feedback on our preferred insulin changes. We’ve taken your feedback into consideration and will be working with our prior authorization center to streamline the process for your patients who must remain on their current regimen. Effective December 1, 2016, Novolin® (with the exception of ReliOn® Novolin), NovoLog®, and Lantus® will be the preferred brands of insulin on the Select, Choice, Essential, and Metallic formularies. Current therapies will have a transition period until February 28, 2017, to switch to a preferred product. We encourage you to help your patients switch as soon as possible. If you believe that your patient should continue taking their current medication, you can request a non-formulary exception on the Essential Prescription formulary or submit a medical necessity prior authorization (MN-PA) on the Select, Choice, or Metallic formularies. These requests can be submitted after December 1. Call HMSA’s pharmacy benefits manager, CVS Caremark®, at 1 (855) 240-0543 toll-free to initiate a coverage review, which can be completed by phone or fax.