Provider Brief June 2014
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- Ariel Floyd
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1 Provider Brief June 2014 From the Desk of the Medical Directors Thank you for playing a significant role in delivering great care to our patients during this first half of our inaugural year. We continue to look for programs and initiatives that help you focus on what you do best provide excellent patient care. Keep reading to learn more about how these programs impact our patient s lives. Network Billing Guidelines You ask, we listen. We understand questions come up regarding our claim and billing processes. Read the below network section to check out this month s billing guidelines and tips. Piedmont WellStar HealthPlans in the Community Summertime is a great opportunity for us to educate our community on the services and support Piedmont WellStar HealthPlans offers. Check out the Health Plan Marketing section below to learn about upcoming community events. Extended Care Team - Improving Outcomes for Patients As we highlighted in last month s edition, our pharmacists are working diligently to ensure that your patients receive the best care possible. Be sure to read our featured patient story in the pharmacy services section below. Feedback We are a provider-led health plan. With that, comes our desire to support you and your needs. As we work to improve processes and education materials offered, we are interested to learn about your preferences. If you have suggestions for how we can improve the provider manual, quick reference guide or other supporting materials, please us at providerrelations@pwplans.org. Accessing the Brief Each month, we will post our provider brief to the Piedmont WellStar HealthPlans provider website at pwplans.org/providers. Click on Helpful Resources and Forms and check under Education & Reminders for past editions. Best, Dr. Kristyn Greifer and Dr. James Sams Co-Medical Directors, Piedmont WellStar HealthPlans IN THIS ISSUE Network Operations HIA/HRA Balances Available on Provider OnLine Health Plan Marketing Pharmacy Services Look Who Joined Our Network
2 Network Operations Home Health and Skilled Nursing Changes (HIPPS) for Piedmont WellStar Medicare Choice Effective July 1, 2014, Piedmont WellStar Medicare Choice will require all Home Health Agencies (HHA) and Skilled Nursing Facilities (SNF) to submit appropriate Health Insurance Prospective Payment System (HIPPS) Codes on Medicare claims. In accordance with Centers for Medicare & Medicaid Services (CMS) guidelines, claims submitted on or after July 1, 2014 without appropriate HIPPS codes will be denied (vs. date of service 7/1/14 and after). Please keep in mind, current reimbursement methodology will not change and Piedmont WellStar Medicare Choice HHA providers should submit a claim line with Rev 023 with the appropriate HIPPS code(s). This line will reimburse at zero value and payment will be reflected based on the current reimbursement rate by appropriate Rev Code submitted. For Further Information Please refer to the following CMS links for additional information related to the use and maintenance of the Health Insurance Prospective Payment System (HIPPS) code set. Payment/ProspMedicareFeeSvcPmtGen/HIPPSCodes.html Billing for Assistant Surgeon Piedmont WellStar HealthPlans issues payment for an assistant surgeon when the procedure permits for an assistant and the person performing the service is a physician, physician assistant (PA), nurse practitioner (NP) or a clinical nurse specialist (CNS). When submitting a claim, please pay close attention to the modifier needed. If the assistant surgeon is a physician, include: Modifier 80 (assistant surgeon), Modifier 81 (minimum assistant surgeon), or Modifier 82 (when qualified resident surgeon not available) If the assistant at surgery is a PA, NP or CNS, include: Modifier AS and Modifier 80, 81 or 82 Claims submitted with modifier AS and without modifier 80, 81 or 82 are returned to the provider Clearinghouse & EFT Reminder Piedmont WellStar HealthPlans is now receiving claims with the following clearinghouses: Emdeon, Relay Health, Gateway EDI, Navicure, Capario, GE Centricity, Care Cloud, Availity, NuSoft, Office Ally, and Practice Insight. Our payer ID is 251PD. If you use Payer Path (Allscripts) or Zirmed as a clearinghouse or revenue cycle management service, they may require a separate payer ID for Piedmont WellStar HealthPlans transactions. Please consult the technical support team at Payer Path (Allscripts) or Zirmed for help in determining what payer ID should be used for your transactions. Piedmont WellStar HealthPlans is processing electronic claims (837) and remittances (835). As a reminder, to submit claims to, or receive electronic remittances from, Piedmont WellStar HealthPlans, you MUST request a connection through your clearinghouse of choice. Until this interface is set up, you will receive paper remittances approximately five
3 business days after funds are disbursed (if funds are being disbursed by EFT). Paper checks and paper remittances advices are released at the same time. The Piedmont WellStar HealthPlans Electronic Fund Transfer (EFT) form is available on our website at pwplans.org/providers. Search under the forms tab to download and complete. Remember, by utilizing this complimentary EFT process, you will receive payments faster and avoid waiting for paper checks. As always, if you have any questions about the updates in this section, please contact Provider Services at Contact Numbers Please reference the table below for contact information. Department Purpose Contact Number Provider Services Eligibility & claims inquiries Medical Management Prior authorization Provider OnLine Technical concerns HIA/HRA Balances Available on Provider OnLine HIA/HRA Balance Available on Provider OnLine Piedmont WellStar HealthPlans is happy to announce that the Healthy Incentive Account (HIA) balance for Piedmont s MyHealth360 employee plan members and the Health Reimbursement Account (HRA) for WellStar Employee Medical Plan members is available on the provider portal, Provider OnLine. The member s co-insurance and deductible balance remain visible on Provider OnLine as well. Please remember, to calculate potential member responsibility, providers can visit Provider OnLine to check the member HIA/HRA, co-insurance and deductible balance. Health Plan Marketing Piedmont WellStar HealthPlans in our Community Piedmont WellStar HealthPlans differs from other plans. We are provider-led and dedicated to improving the health of our greater Atlanta community. To help share our story, we are joining several events in the upcoming months. If you are interested in participating or have suggestions for how we can reach a greater audience, please let us know. Piedmont Sixty Plus, My Healthy Self Senior Wellness Series June 18 th at Piedmont Atlanta Hospital Piedmont Hospital s 65+ program, Sixty Plus, features monthly health seminars focused on promoting a natural way to manage health and age gracefully. Piedmont WellStar HealthPlan representatives will be at the event to promote our brand, educate the attendees on Piedmont WellStar Medicare Choice, and provide general support to the attendees. Atlanta Association of Health Underwriters (AAHU) 3rd Annual Golf Tournament Benefiting Atlanta Children s Shelter June 23rd at Alpharetta Athletic Club
4 The AAHU golf tournament benefits the Atlanta Children s Shelter and Piedmont WellStar HealthPlans is honored to be a part of the event this year. As both sponsors and participants, our health plan representatives will be available to promote our unique, provider-led health plan, while showing support for the Atlanta Children s Shelter. Pharmacy Services Guide to Pharmacy Prior Authorization We work hard to respond quickly to your pharmacy prior authorization requests. To assist in our quick response, please include the following information when applicable: Patient diagnosis Previously medications attempts (including the trial period) Supporting lab reports Notes from patients most recent office visit Contact information for attending physician or office manager Supporting evidence for therapy, if the request is for an off-label medication Featured Patient Story Clinical Pharmacy Success The following story takes us on a patient s journey over the course of nearly six months. For purposes of our story, we will name this patient Rose. Several months ago, Rose made an appointment to see her physician after experiencing confusion. After a physical was conducted, the physician noticed other symptoms, diagnosed her with a Urinary Tract Infection (UTI), and ensured Rose was administered the Folsten minimental state examination. She received a perfect score on overall functioning and cognitive status. About a month later, Rose began to experience other symptoms and visited a physician. She was prescribed Aricept, which led to amnesia episodes. Later, Rose s UTI returned and Namenda Titration was ordered. Her dosage of this medication was increased weekly until a steady dose was established. At this time, Aricept was prescribed again. Office visits increased, Rose fell often and began to suffer from anxiety. She was prescribed Ativan. Rose began to withdraw from family, sleep more and had trouble sorting through her many daily medications. Additionally, Roses COPD worsened and after a hospitalization shortly after, the extended care team, a critical support team offered to Piedmont WellStar HealthPlans patients, was brought in. Our clinical pharmacist and registered nurse members of the team- reported that Rose s medication needed to be staggered to identify the related side effects. The pharmacist also commented that these medications are generally recommended for patients with Alzheimer s or Dementia neither of which did Rose suffer from. The pharmacist also noted that there are medications available in other classes that may carry lower risk. Rose had a follow up appointment scheduled with her physician. Prior to the appointment, the nurse reached out to the medical assistant working at the physician s office. She sent over the pharmacists medication suggestions. The physician reviewed the notes and collaborated with the pharmacist and nurse to administer a solution. Namenda, Aricept, and Ativan were all discontinued.
5 Rose is no longer hypotensive, does not frequent the hospital, and has returned to her old self. Certainly, the work is not complete. However, because the Piedmont WellStar HealthPlans care team was able to flag a concern, offer expertise and collaborate with the physician, the patient avoided unnecessary intervention resulting in improved outcomes. As we mentioned in last month s edition, the extended care team may be offered to some of your more complex patients through our Personal Approach To Health (PATH) program. If you would like more information about the services offered, please call provider services at Look Who s Joined Our Network Piedmont WellStar HealthPlans continues to grow. Please note that most recently we welcomed the following group to our network: Walgreens Home Infusion Pharmacy Services 808 Park North Boulevard Suite 100 Clarkston, GA / Remember, for our complete online directory please visit pwplans.org/providers. Be sure to click on Find a Doctor on the left to choose the appropriate plan from the list and search for a provider
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