Newsletter. Provider. MedStar PromptCare Centers. Utilization Management Authorization Review Process

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1 Second Quarter 2014 Provider Newsletter D.C. Healthy Families/D.C. Healthcare Alliance MedStar PromptCare Centers Urge your members to visit the MedStar PromptCare centers when they aren t able to see you, their PCP. Remind them that they should only go to the Emergency room at their local hospital when they, or a loved one, is experiencing a lifethreatening illness or injury. The MedStar Family Choice website (MedStarFamilyChoice.com) has a search function that members can use to locate a MedStar PromptCare center that is closest to their home or job. MedStar PromptCare, an urgent care center, is open days, evenings and weekends; offering high quality medical care for most illnesses and injuries for people of all ages, and no appointment is ever needed. MedStar PromptCare (Capitol Hill) 228 7th St, SE Washington, DC PHONE MedStar PromptCare (Adams Morgan) 1805 Columbia Road, NW Washington, DC PHONE Utilization Management Authorization Review Process Our experienced clinical staff reviews all requests. Pre-authorization decisions are based on nationally recognized criteria, such as Inter-Qual and Medicare guidelines. Additional authorization criteria utilized by MedStar Family Choice can be found at MedStarFamilyChoice.com under our utilization management (UM) process policy. Decision making is based only on appropriateness of care and service and existence of coverage. We do not specifically reward practitioners or other individuals for issuing denials of coverage of care. In addition, there are no financial incentives for UM decision makers that would encourage decisions which result in underutilization. Providers may request a written copy of the criteria used during the decision-making process by contacting the Utilization Management department at , Monday through Friday from 8 a.m. to 5:30 p.m. Authorization requests should be made no less than five to seven business days in advance of the service. MedStar Family Choice has up to 14 days following the receipt of the request to process a complete authorization request. Requests are considered complete when all necessary clinical information is received from the provider. (continued on page 7)

2 Update to the MedStar Family Choice Formulary District of Columbia Healthy Families Updates will continue to be available quarterly on the website, and more frequently on epocrates. Paper booklets of the 2014 Formulary have been mailed. If you have not received a copy or would like additional copies, please contact your Provider Relations representative. The first quarter updates are available on the MedStar Family Choice website. Second quarter updates will be posted on the website before or after July 1, Additions that have gone (or will go into) effect in the next few weeks: Cholecalciferol (additional strengths and preparations) Lamisil (terbinafine) OTC Nasacort (triamcinolone acetonide) OTC epinephrine injection 0.15 ml and 0.3 ml EpiPen generic carbidopa (generic) fluorscein/benoxinate ophthalmic sol (0.25 percent/0.4 percent) Additions with Prior Authorization effective on or around April 1, 2014 Opsumit (macitentan) is an endothelin receptor antagonist (ERA) that is administered orally once daily for the treatment of pulmonary arterial hypertension (PAH). Adempas (riociguat) is indicated for treatment of adults with persistent/recurrent CTEPH World Health Organization (WHO) class IV after surgical treatment or inoperable CTEPH, to improve exercise capacity and WHO functional class. Adempas (riociguat) is also indicated for treatment of pulmonary arterial hypertension (PAH) (WHO class I) to improve exercise capacity and WHO functional class, and to delay clinical worsening. Pimtrea (desogestrel/ethinyl estradiol) monophasic OCP new brand OCP Norditropin has been added to the formulary due to a shortage of Tev-Tropin in the marketplace Additions with Prior Authorization effective on or around July 1, 2014 Hep C drugs will follow American Association for the Study of Liver Diseases/Infectious Disease Society of America guidelines until final guidance is provided by the DHCF. Removals: None Removal of Prior Authorization: None (continued on page 7) 2

3 Pharmacy MedStar Family Choice has approved a wide variety of prescription medications available for our physicians to prescribe. MedStar Family Choice also pays for many over-the-counter (OTC) medications. These approved drugs are listed on MedStar Family Choice Provider website under the pharmacy tab. If a physician feels it is medically necessary to prescribe a medication not on the formulary, the physician may submit a request to MedStar Family Choice. These requests must include clinical documentation which supports the medical need for that specific medication. Physicians may call MedStar Family Choice at or fax requests to With a prescription from a physician, a MedStar Family Choice member may also use the pharmacy benefit to cover the cost of many OTC medications, such as cough syrups, cold medicines, laxatives, and vaginal creams. Please note that requests for Synagis (palivizumab) require a completed Statement of Medical Necessity form. It may be faxed to Staying Healthy for Mothers-to-Be MedStar Family Choice members who are fewer than 28 weeks pregnant are eligible to participate in the Momma & Me Program. Once enrolled in the program, the member can receive a $25.00 gift card for just going to all of her OB appointments and one dental check-up. All appointments are verified with the member s obstetrician and dental provider. Educational materials are also provided to the member when she enrolls in the program. Attending educational prenatal classes is also encouraged for the expectant mom to increase awareness of prenatal and postnatal health strategies. For information Call or Health Education Available at MedStar Georgetown University Hospital and MedStar Washington Hospital Center We offer health education classes free of charge to MedStar Family Choice members. Classes are designed to appeal to our members on many health levels. For example, prenatal classes are available for moms-to-be, along with education for infant safety and sibling classes. These are just a few of the classes offered through the birth and family education listings. In addition to these classes, MedStar Health hospitals offer blood pressure screenings, cancer, diabetes, and heart disease education, as well as smoking cessation support. Visit MedStarFamilyChoice.com for a complete listing of classes. If you do not have access to the internet, you may call MedStar Family Choice Provider Relations at , option 5 for a listing of classes. 3

4 MedStar Family Choice Complex Case Management and Disease Management Programs MedStar Family Choice has a highly qualified staff of nurses and social workers who are available for MedStar Family Choice members with serious medical conditions or have complex and/or special needs. Our nurses and social workers are responsible for specific programs, based on their areas of expertise. They provide support and guidance to those members who need or would like extra assistance with their health care. Our Case Managers can also assist with care coordination. Below are some examples of medical conditions or circumstances where Case Management or Complex Case Management may be helpful: Disease Management Pediatric Asthma Hypertension Adult Respiratory Adult Diabetes High-risk Pregnancy HIV Pain Management Substance Abuse Wound Care Pediatric Diabetes Complex Case Management Transplants Multiple chronic illnesses with high utilization Catastrophic conditions/special needs requiring coordination of care Special needs populations, who require assistance with coordination of care and are not covered in a MedStar Family Choice Disease Management program. COPD If you would like to refer a member to our Complex Case Management program, please fax a referral to , or call our Case Management department at We are available Monday through Friday, 8 a.m. to 5:30 p.m. Any faxes or voice messages received after hours will be handled the next business day. MedStar DC Healthy Choice District of Columbia Provider Relations Each participating MedStar Family Choice provider is assigned a provider representative to assist offices with questions regarding the MedStar Family Choice health plan. Your representative is assigned to you according to the ZIP code of your office. If you are not certain who your provider representative is, please call or MedStar Family Choice Provider Relations and we can assist you. Provider relations main telephone number: , option 5 Provider relations main fax number: medstarfamilychoiceproviderrelations2@medstar.net 4

5 Clinical Practice Guidelines Clinical Practice Guidelines (CPG) are available through MedStarFamilyChoice.com. Click on the appropriate MedStar Family Choice Plan, there will be a link to the currently approved CPGs. These guidelines include: Recommended screening guidelines Outpatient management of patients with community acquired pneumonia The assessment and prevention of falls in older people Management of adult diabetes mellitus Guidelines for the diagnosis and management of asthma Management of hypercholesterolemia Identification and management of clinical depression in adults Management of hyperbilirubinemia in the healthy term newborn Management of hypertension in adults age 18 years and older Identification, evaluation, and treatment of overweight and obese adults EPSDT (HealthCheck) Providers HealthCheck/primary care providers seeing patients under the age of 21 are required to complete the District s HealthCheck Provider Training prior to joining the plan network and every two years after the initial training. Providers who are not up to date on their training may not be recredentialed with the health plan. This program is accessible online at DCHealthCheck.net and requires a provider s NPI to log-in. The training program is free for participating plan providers who are due to receive the training. Upon completion of the online training module, providers receive five free continuing medical education (CME) credits. Yearly Exams Please be aware that MedStar Family Choice DC Healthy members may schedule yearly exams, including well-child and well-woman appointments, before the anniversary date of their last annual check-up. Claims are not denied if the exams fall short of the member s anniversary date or are within the same calendar year. Please contact MedStar Family Choice Provider Relations with any comments or questions at Management of osteoporosis Managing otitis media in children ages one to three years Management of abnormal Pap smear Management of acute group a streptococcal pharyngitis infection Management of venous thromboembolism Sleep apnea guideline 5

6 DC Healthy Families and DC HealthCare Alliance Updated Provider Manual MedStar Family Choice has updated the provider manual for the DC Healthy Families and DC Healthcare Alliance products. The new manual becomes effective July 3, A brief summary of changes is listed below. Please take the time to review the latest version of the Provider Manual to make sure you are familiar with all of the changes and new content. Chapter 1 Clarification of program differences Member rights and responsibilities changes Primary Care Selection process update ER-Auto pay list Clarification payments Balance billing of members Chapter 4 Clarification of covered and non-covered services Chapter 5 Provider role in quality management A copy of the updated manual may be reviewed and downloaded from the DC Healthy Families and DC Healthcare Alliance portion of our website at MedStarFamilyChoice.com. Initial Credentialing changes related to CAQH, DC HealthCheck requirements, non discrimination language, recredentialing changes related to CAQH, use of provider performance data. Chapter 2 Updates to PCP and specialist responsibilities Chapter 3 Complex Case Management and Disease Management program listings Health Education classes related to smoking cessation Primary dental care program Nurse Advice line Utilization Management Financial incentives For those without internet access, a copy of the changes to the Provider Manual can be mailed to you. If you are in need of additional copies, please contact Provider Relations at HIV/AIDS medications Pre-authorization grid updates 6

7 (Utilization Management continued from page 1) Vaccines For Children Program The Vaccines for Children (VFC) program is part of the DC Department of Health Immunization program. It is a federally funded entitlement program that provides vaccines free of charge to providers with eligible patients. Requirements for Participation By participating in the VFC program, you agree to: Screen all children for eligibility Submit documentation to the VFC program for each vaccine dose administered Follow the recommended immunization schedule established by the ACIP, the American Academy of Pediatrics, the American Academy of Family Practitioners and state law except where medically contraindicated Not to charge for VFC-supplied vaccine Provide vaccine information materials as prescribed by law An additional 14 days can be given to make a decision if it is requested by the member or the provider, or if MedStar Family Choice believes it is in the best interest of the member. For members with urgent authorization needs, the physician or a physician s staff member should contact MedStar Family Choice Care Management at If MedStar Family Choice denies the pre-authorization request, the provider and member will receive a copy of the denial. In addition, the denial letter will indicate that the treating provider may contact the MedStar Family Choice physician advisor to discuss the case by calling (Formulary continued from page 2) Managed Drug Limitations and Step Therapy Chantix limited to 24 week of therapy per 12 month period butalbital/acetaminophen added MDL 30 tabs/23 days to align with other butatalbital containing medications Removed step therapy for montelukast Details of the Prior Authorization Criteria are listed on the MedStar Family Choice website. (MedStarFamilyChoice.com) Complete the Provider Profile and Enrollment form Allow VFC staff access to your practice for technical assistance and program review. To become a VFC provider you may request a provider enrollment packet through the VFC program at , ext. 11 or by visiting CDC.gov/Vaccines/Programs/VFC/ Contacts-state.html. 7

8 Contact Us Please call : option 1 for Outreach for Eligibility Verification and Transportation Assistance or fax to option 2 for Pharmacy, Preauthorizations, Inpatient Reviews, Case Management, and Special Needs, or fax to option 3 for Member Services or Denials and Appeals option 4 for Claims option 5 for Provider Relations or fax to option 6 for Dental, Vision, Substance Abuse, or Mental Health option 7 for Compliance You may contact MedStar Family Choice Monday through Friday between 8 a.m. and 5:30 p.m. Providers have the option to leave a message or send a fax after normal business hours. However, any calls and faxes received after hours will be addressed the next business day. Provider Resources The MedStar Family Choice Provider Manual and Quick Reference Guide are available on MedStar Family Choice web site (MedStarFamilyChoice.com) under the Provider Resources tab. 901 D St., SW Suite 1050 Washington, D.C PHONE The MedStar Family Choice Newsletter is a publication of MedStar Family Choice. Submit new items for the next issue to Ricardo L. Jones, MedStar Family Choice, at ricardo.l.jones@medstar.net. Kenneth A. Samet, FACHE President and CEO, MedStar Health Eric Wagner President, MedStar Family Choice Ricardo L. Jones Editor MedStarFamilyChoice.com 14-MFC