Hospital April EHR Interoperability in Conjunction with Inovalon Pilot
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1 Hospital April 2016 IN THIS EDITION: EHR Interoperability in Conjunction with Inovalon Pilot Lifestyle Management Programs Model of Care Overview Reminder on Prior Authorization EHR Interoperability in Conjunction with Inovalon Pilot Gateway Health is pleased to begin offering EHR interoperability in conjunction with Inovalon! EHR interoperability allows Inovalon to extract medical records on behalf of Gateway Health for health plan operations. Please review the bullets to better understand the process and benefits to your practice. Benefits: Reduce costs o EHR Interoperability transforms quality improvement, risk score accuracy and financial performance while minimizing disruption. o This process reduces the need for onsite medical reviewers, greater staff productivity, seamless record retrieval, greater security associated with the collection of PHI and no cost to the provider practice or hospital. Increases Productivity o The need for risk score accuracy and quality measurement analysis initiatives is on the rise leading to more medical record reviews and request for diagnosis documentation. EHR interoperability automates medical record data capture for HEDIS and risk adjustment eliminating the need for onsite coordination. o Inovalon s EHR interoperability platform facilitates a two-way exchange of clinical data from both cloud and non-cloud based EHR systems, 1
2 connecting thousands of providers in an effective, efficient, secure and scalable fashion while minimizing hospital time and resources. Gateway would like to extend to a few hospitals a pilot prior to roll-out to the network. This allows an opportunity to solicit feedback and refine the process. Please contact your Provider Relations or Provider Engagement Representative if you are interested. Lara Brooks, Clinical Transformation Consultant lbrooks2@gatewayhealthplan.com Cell Lynette Deaver, Clinical Transformation Consultant ldeaver@gatewayhealthplan.com Cell Sharon Marks, Clinical Quality Analyst smarks@gatewayhealthplan.com Cell Shallegra Moye, Clinical Quality Analyst smoye@gatewayhealthplan.com Cell Dan Ruffa, Clinical Transformation Consultant druffa@gatewayhealthplan.com Cell Carol Wanck, Clinical Transformation Consultant cwanck@gatewayhealthplan.com Cell Kathleen Claire, Manager, Provider Engagement Team kclaire@gatewayhealthplan.com Cell
3 Lifestyle Management Programs Gateway s is committed to helping our members who may be living with a chronic medical condition through the Gateway to Lifestyle Management Programs. Gateway to Lifestyle Management includes programs to assist members in managing their asthma, cardiac conditions, COPD, and/or diabetes. Gateway to Lifestyle Management programs aim to: Provide patient education and self-empowerment for medication, diet and lab adherence as well as tools to make sure care is received in the appropriate setting. Delay or diminish the onset of disease specific complications Support the physician s plan of care Encourage adherence to flu and pneumonia authorizations Members enrolled in one of these programs will receive: Reminder tips in the mail and by phone Invitation to take part in a diabetes texting program Calls from a Gateway staff member to help with access to care concerns, including appointment scheduling and transportation, and provide ongoing assessment and condition specific education. Additionally, Gateway members have access to the 24/7 Nurse Line for advice and triage to the appropriate level of care. If you would like to refer a member to a Gateway to Lifestyle Management program please call the Clinical Operations team at the numbers below. Care Coordinators are available Monday through Friday between 8:00 am and 5:00 pm Pennsylvania Medicaid Members Pennsylvania Medicare Assured Ohio Medicare Assured North Carolina Medicare Assured Kentucky Medicare Assured 3
4 Model of Care Overview Gateway currently offers four Special Needs Plans (SNPs): Gateway Health Medicare Assured Diamond - Is a Dual Eligible Special Needs Plan (DSNP) and covers those who have both Medicare Parts A & B and full Medicaid Assistance (Medicaid) or Qualified Medicare beneficiary (QMB/QMB Plus) or Specified Low-Income Medicare Beneficiary (SLMB). Gateway Health Medicare Assured Ruby - Is a Dual Eligible Special Needs Plan (DSNP) and covers those who have both Medicare Parts A & B and receive assistance from the state (benefit categories: Specified Low-income Medicare Beneficiary (SLMB), Qualified Disabled and Working Individual (QDWI) or Qualified Individual (QI). Gateway Health Medicare Assured Gold and Gateway Health Medicare Assured Platinum - Are Chronic Condition Special Needs Plans (S-SNPs), and cover those who have both Medicare Part A & B and at least one of the following chronic conditions: diabetes, cardiovascular disorder or chronic heart failure. There are no income requirements for the chronic conditions Special Needs Plans. As a SNP, Gateway is required by the Centers for Medicare and Medicaid Services (CMS) to administer a Model of Care (MOC) Plan. The SNP MOC Plan is the architecture for care management policies, procedures, and operational systems. Please review the attached document for more detailed information about Gateway s Model of Care. Once reviewed, please go to our website at click on Providers and then Model of Care to complete the attestation to acknowledge you have reviewed and understand Gateway s Model of Care information. 4
5 Reminder on Prior Authorizations Our manual requires you to submit authorizations in advance. In the event of an emergency, you must submit the authorizations within: One (1) business day for Gateway Health Medicare Assured Two (2) business days for Gateway Health Medicaid. To align with our Observation and Extended Assessment and Management in facilities Medical Payment and Prior-Authorization Policy, you should call after twenty four (24) hours of the patient presenting but earlier than two (2) business days of admitting the patient to the inpatient level of care. Failure to authorize will result in an administrative denial of your claim with no review of medical necessity. Retrospective Authorization Request Claims are denied D170 Authorization Not Timely. If you are submitting an exception appeal, please make sure you supply records showing why such as a copy of the incorrect insurance information you were provided along with processing of the incorrect insurance, records that the member was incapacitated, proof that submitted timely, etc. 5
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