Stay Healthy. In the Know. Screenings you and your family need. Protect yourself against health care fraud.

Transcription

1 good health FALL 2015 YOUR FAST TRACK TO LIVING WELL Stay Healthy Screenings you and your family need In the Know Protect yourself against health care fraud

2 TELL US HOW WE ARE DOING Whether you are new to AultCare or have been with us for a while, we want your feedback. The New Enrollee Survey allows new members to provide feedback on their enrollment experience and the Member Satisfaction Survey allows all members to provide feedback on their overall satisfaction with AultCare. You can access our surveys by visiting and logging in to your account. If you do not already have an account, click on the create login link and follow the instructions. Once logged in, click on the link at the bottom of your screen titled either Member Satisfaction Survey or New Enrollee Survey. Tell us about your experience. Your responses will provide us with beneficial information to aid in our goal of delivering the best service to all of our members. DEPARTMENT HOURS PHONE NUMBERS AultCare Customer Service Utilization Management Case/Disease Management AULTCARE CONTACT INFORMATION Monday-Friday 7:30 a.m.-5:00 p.m. Monday-Friday 8:00 a.m.-4:30 p.m. Monday-Friday 7:30 a.m.-4:30 p.m TTY: * INQUIRIES AND CONCERNS Claim Status Benefits Eligibility Status of Referrals Pre-certifications Prior Authorizations To Request: Referrals Pre-certifications Prior Authorizations Inquiries and Referrals to Case or Disease Management Programs Too busy to call? You may also us 24 hours a day, seven days a week at by clicking on the Contact Us link at the top of the website homepage. You will receive a response within one business day of your inquiry. *We understand that some of our members have special communication needs. We will provide a translator or hearing impaired services (TTY) to those members who are in need. If you require these services, please contact our service center at the numbers provided and we will gladly assist you (for hearing impaired members, please use the TTY number indicated for Customer Service). 2

3 Information You Can Find on Our Website If you have questions, you may be able to find the answers at We continue to enhance the information available to you on our website. Here s a list of the information, documents and services available on our website: - Member Guide, which includes information on: 1 How to obtain language/interpreter services 1 New Technology Assessment/Evaluation 1 Pharmacy Program Information 1 Information for obtaining a Primary Care Physician or specialist for your care 1 Information for obtaining emergency/ urgent care services whether in or out of the network and during or after normal business hours, including inpatient admittance 1 Information on how and when to submit an appeal or complaint, including the independent appeals process 1 Information on how to submit a claim for covered services 1 Information on services excluded from your coverage 1 Information on our 24-hour Nursing Healthline - Provider Directory: Our searchable provider directory includes information about our network health care professionals. You can search by network, specialty, name, hospital affiliation, languages spoken, gender, ZIP code, county and whether or not they are accepting new patients - Health and Wellness Tools: Access to the Health Talks calendar, interactive selfmanagement tools, and information about the Emmi Education programs - Eligibility, Benefit and Claims Payment Information (requires log-in) - Quality Management Programs, Evaluations and Outcomes: Including HEDIS and CAHPS outcomes, and Quality Management Program Evaluation - Care Coordination Services: Information regarding our Utilization, Case and Disease Management programs - Pharmacy Information: Access to the pharmacy directory, formularies, recall information and prior authorization/step therapy/quantity limit information - Enrollee Rights and Responsibilities - Notice of Privacy Practices - Pre-certification/Utilization Review policy - Health Care Reform You can find all of this useful information by visiting our website at or by contacting our AultCare Customer Service Center. To request a written copy of any of the information mentioned above, please call our Service Center (contact information on page 2). HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). 3

4 KNOW THIS Care Coordination Services 4 UTILIZATION, CASE AND DISEASE MANAGEMENT SERVICES AultCare offers a Care Coordination program that helps you receive the information and community services you need. Our team of registered nurses, licensed practical nurses, licensed social workers and pharmacists are available by phone to help. Services include: - Community resource information to provide assistance with prescriptions, utilities and transportation if you are having financial difficulties - Phone calls with a nurse who specializes in managing care for health conditions - Educational materials to supplement information your physician has provided - Informative mailings and handouts about your condition - Equipment such as the Cardiocom Telescale (CHF monitoring program) and GlucoCom Telemonitoring System (Diabetes Monitoring Program) to help you manage your condition from the convenience of your home - Staff to help you work with your doctors to improve your health - Reliable referrals to service agencies and resources in the community - Assistance with the referral process to out-of-network specialists - Help with transitioning your care to panel providers, if appropriate You may benefit from our Care Coordination services if you: - Have questions about your health status or health care - Are in need of a transplant - Have been newly diagnosed with cancer - Are experiencing complex medical issues - Are receiving specialty care outside of the network UTILIZATION MANAGEMENT DECISIONS ARE BASED ON MEDICAL NECESSITY - Utilization Management decisions are based on the appropriateness of care and services, as well as eligibility and coverage of requested services. - AultCare does not reward practitioners

5 or other individuals for issuing denials of coverage or service of care. There are no financial incentives that result in underutilization. - The specific criteria used in decisions are available at no cost to you by contacting the Care Coordination department. - A physician, nurse or pharmacist reviewer is available to discuss Utilization Management denial decisions by contacting the Care Coordination department. UTILIZATION MANAGEMENT STAFF AVAILABILITY - Utilization Management staff members are available from 8:00 a.m. to 4:30 p.m. Monday through Friday for inbound calls regarding Utilization Management issues and questions regarding the Utilization Management process. - Utilization Management staff members can receive inbound communication regarding Utilization Management issues after normal business hours via voic or fax. - Utilization Management staff can send outbound communication regarding Utilization Management inquiries during normal business hours. - Utilization Management staff members will identify themselves by name, title and organization when initiating or returning calls regarding Utilization Management issues. UTILIZATION MANAGEMENT EVALUATION OF NEW AND EXISTING TECHNOLOGY AultCare investigates all requests for coverage of new technology using a medical technology assessment company as a guideline. If additional information is needed, AultCare utilizes sources including, but not limited to Medicare and Medicaid policies and Food and Drug Administration releases of any current medical peer review literature. This information is reviewed and evaluated by AultCare s Medical Director and other physician advisors in order to determine if a new technology is appropriate for coverage under your AultCare plan. Members may request that a certain new technology be investigated for coverage by contacting the Utilization Management department. Contact information for the Utilization, Case and Disease Management departments can be found on page 2. Appeal Rights Did you know that when AultCare denies coverage or payment, you have appeal rights? AultCare communicates these rights in many ways to ensure that each member understands their appeal rights. Your plan documents, your Explanation of Benefits and a benefit denial letter all describe your appeal rights as an AultCare member. Every member is afforded the same first-level appeal rights or an internal review. If you initiate a first-level appeal and we uphold our original decisions, you will receive a resolution letter outlining additional appeal rights, which may include external review rights. Your rights vary depending on state and federal laws. For more information on your appeal rights, review your plan document, Explanation of Benefits or Member Guide (all available by logging into your account at com), your benefit denial letter or appeal resolution letter, or contact the AultCare Service Center (contact information on page 2). 5

6 GOOD FOR YOU Protect Yourself Against Fraud 6 To protect yourself against fraud, you can do your part by being on the lookout for fraudulent schemes that often include people calling you or asking you for your health plan information. AultCare encourages you to: - Never give out your Social Security, health plan number, date of birth or banking information to someone you don t know - Carefully review your plan statement or explanation of benefits to ensure that all the information is correct - Know that free services DO NOT require you to give your health plan numbers to anyone It has come to AultCare s attention that at health fairs and county fairs, exhibitors or medical companies may be asking individuals to perform high-cost genetic tests. This may include: - Checking for signs of a disease - Determining if you have an increased risk of developing a disease - Providing a general prediction of health These companies are asking for health plan information. AultCare encourages you to not give out your health plan information to these companies. Did you know that identity theft can lead to higher health care costs? Be on the lookout for: - People using your health plan number for services you never received - People calling to ask for your health plan numbers - People trying to bribe you to use a doctor to receive a service you may not need Did you know many legitimate businesses engage in telemarketing, but criminals can also use live or recorded calls to try to steal your identity? AultCare WILL NOT ask you for your banking information or Social Security number. To protect yourself: - Hang up on recorded messages - Do not press any keys or numbers when prompted (even if it is to take your name off of their list) - Write down suspicious numbers and report them Did you know that AultCare DOES NOT sell or mail medical supplies? If you receive medical supplies that you or your doctor did not order, you might be the target of a fraud scheme. Take action to protect your AultCare benefits: - Refuse medical supplies you did not order - Return unordered medical supplies that are shipped to your home - Report companies that send you these items Did you know that you are one of the first lines of defense against fraud? Do your part and report services or items that you have been billed for, but did not receive. Review your plan statement or explanation of benefits and: - Make sure you received the services or items billed - Check the number of services billed - Ensure the same service has not been billed more than once If you suspect that you are the target of a fraudulent scheme, report it to AultCare. - Fraud Hot Line Website

7 TO THE SOURCE PREVENTIVE SCREENINGS I t is recommended that you visit your Primary Care Physician annually. It is important to know that not everyone needs the same tests. Be sure to talk to Screening, test, preventive service Flu Vaccination Cholesterol Screening Blood Pressure Check Blood Glucose Test Colorectal Cancer Screening Breast Cancer Screening Who should receive the services? All individuals 6 months All individuals 20 years All individuals 18 years All individuals 18 years All individuals 50 years Women 40 years and older should have a mammogram How often? Annually Every 5 years or more often as recommended by your physician Every 1-2 years, more often if high risk Every 3 years, more often if high risk One of the following tests: Colonoscopy every 10 years Fecal Occult Blood Test once a year Flexible Sigmoidoscopy every 5 years Double Contrast Barium Enema every 5 years Annually Cervical Cancer Screening Women years Every 3-5 years Osteoporosis Screening Postmenopausal women years with a high-risk factor profile. Men years with a high-risk factor profile. All individuals 50 years who have had an adult age fracture. your doctor about your individual needs for testing. Below is a list of recommended tests and preventive screenings/services that we encourage our members to have. Evaluated for testing every 1-2 years or more often as recommended by your physician This information is intended for educational purposes only. It is not meant to take the place of your doctor's medical advice. Please be advised that we cannot guarantee that your plan provides total coverage for these services. If you have questions about coverage, please contact Customer Service at the phone numbers on page 2. 7

8 BETTER EVERY DAY Pediatric to Adult Care T he goal of a planned health care transition is to maximize lifelong functioning and well-being for all youth, including those who have special health care needs and those who do not. This process includes ensuring that high-quality, developmentally appropriate health care services are available in an uninterrupted manner as the person moves from adolescence to adulthood. 1 Changing doctors is never easy. When you re a teenager new to advocating for your own health care, or one who has a chronic illness like diabetes or cystic fibrosis, it can be even more challenging to make the transition. Ideally, children should transition to adult-oriented health care between the ages of 18 and 21. For adolescents seeing a pediatrician, the transition will involve choosing a new physician, transferring medical records, and communicating treatment histories and insurance information. Although adolescents seeing a family physician may stay in the same practice, they may still need to transfer specialty care to adult subspecialists. 2 Your pediatrician is a good resource and can help you with this transition. It is important to discuss your specific needs with your physician. We understand this process can be overwhelming for some and that s why we are here to help. If you would like additional information about transitioning adolescents to adult health care, contact your pediatrician or AultCare for more information. 1 Pediatrics, Vol. 128 No. 1, July 1, 2011; p American Academy of Pediatrics, "Helping Adolescents Transition to Adult Health Care," June 27, Sixth Street SW Canton, OH PRSRT STD U.S. POSTAGE PAID AvMed Health Plans Published by Manifest LLC All rights reserved. No material may be reproduced in whole or in part from this publication without the express written permission of the publisher. The information in this publication is intended to complement not take the place of the recommendations of your health care provider. Consult your physician before making major changes in your lifestyle or health care regimen. Manifest makes no endorsements or warranties regarding any of the products and services included in this publication or its articles. GHR 403/15