For Participating Medical Practitioners October 2010

Transcription

1 HMSA s For Participating Medical Practitioners October 2010 What s Inside Connect to HMSA on the go 1 Oxygen Equipment Rental Policy Changes 1 Correction 1 Evaluation and Management Documentation of Chief Complaint 2 Codes for diabetes mellitus with manifestations 2 Beating the flu with HMSA s Online Care 2 HMSA Flu Shot Clinics Annual review of medical policies 4-5 BCBSA router tool available 5 TriWest Enhances Secure Online Functions 6 Connect to HMSA on the go Improved access and member satisfaction are the motivating factors behind the development of the new Mobile hmsa.com, which instantly connects your patients with HMSA services, partners and participating providers. Mobile hmsa.com features the following convenient and easy-to-use functions: Find a physician or dentist (search by name, address, city, ZIP code, specialty, or near your current GPS location). Find a pharmacy or facility (search for medical centers, clinics, laboratories or pharmacies by name, address, plan benefits, or near your current GPS location). For services rendered on or after Jan. 1, 2011, HMSA s policy regarding billing requirements and claims for oxygen equipment will be consistent with CMS policy, which includes a 36-month limit on equipment rental. Correction Find health and wellness vendors that offer HMSA365 member discounts (on all islands). Find HMSA contact information and locations (phone numbers and addresses on all islands). Follow or view HMSA on social media sites (blogs, Twitter, YouTube videos). The new HMSA Web tool supports iphone, ipod Touch, Android and PalmPre. HMSA will be supporting more devices, including Blackberry smart phones, and adding more features in the near future. Mobile hmsa.com is free, and can be accessed via hmsa.com. Oxygen Equipment Rental Policy Changes For more information on CMS reimbursement policy for oxygen equipment and supplies, please visit CMS website: news/manual/chapter5.html. Federal Plan members (coverage code 87) receiving the intranasal flu vaccine (90660) or any of the three preservative-free vaccines (codes 90655, or 90662), will be reimbursed the full New Average Wholesale Price (AWP) amount by HMSA and are not subject to the balance billing method. Contrary to an article in the September 2010 Provider Update, providers may not collect the difference between the AWP and their charge Hawaii Medical Service Association 818 Keeaumoku St. P.O. Box 860 Honolulu, HI Phone: (808) Branch offices located on Hawaii, Kauai and Maui Internet address: Provider Resource Center: hhin.hmsa.com

2 2 Provider Update - Medical Practitioners October 2010 Evaluation and Management Documentation of Chief Complaint Incomplete or unclear documentation can raise questions about the service provided in a CMS audit. Documentation of a patient s history must include the patient s chief complaint. A chief complaint is a concise statement describing the symptoms, problem, condition, diagnosis, or other factors that establishes the medical necessity for the visit. The chief complaint must be readily identifiable. This is the first step in establishing medical necessity. Example of correct documentation of a chief complaint: 25-year-old established patient returning for follow-up of diabetes mellitus. Example of incorrect documentation of a chief complaint: Patient here for follow-up. If there is no chief complaint, the service is preventive and should be coded with a preventive medicine code. Please refer to Coding Reviews of E&M Services in the Provider E-Library for more information on HMSA s coding reviews, coding worksheet, documentation checklist, and CMS guidelines. Codes for diabetes mellitus with manifestations Diabetes mellitus is an ICD-9 diagnosis in which the base code also indicates major manifestations of the disease. When a patient has both diabetes and a linked disease manifestation, ICD coding rules require that the underlying condition be sequenced first, followed by the manifestation code, when completing the billing form CMS 1500 (block 21). Diabetes and renal disease: Many forms of renal disease are caused by diabetes. In these circumstances, the provider must document the relationship between diabetes and the renal manifestation, submitting both diabetes and renal codes. Diabetes and neurological manifestations: For those neurological manifestations caused by diabetes, it is important to document the causal relationship in the medical record. Additional resource: provider/zav_pel.aa.dia.300.htm Beating the flu with HMSA s Online Care Patient questions about influenza vaccinations and treatment of the flu can easily be addressed through HMSA s Online Care. HMSA recommends that physicians encourage their patients to use HMSA s Online Care should they suspect they have the flu. Patients showing signs of flu should be encouraged to talk to an HMSA s Online Care doctor for advice, said Patricia Avila, M.D., HMSA s Online Care medical director. Patients can avoid transmitting the flu virus to others by staying home and using the Online Care option. Consider it a safety net for patients across the state seeking the advice of a credentialed provider when they need one. HMSA has launched its annual community flu shot clinics statewide for HMSA and Medicare Part B members. Clinics are conducted by HMSA s subsidiary, ISI Health Enhancement Services. The flu vaccine will protect against three different flu viruses: an H3N2 virus, an influenza B virus, and the H1N1 virus that caused so much illness last year. See a list of clinics on page 3. Leading medical authorities suggest that everyone over the age of 6 months consider the flu vaccine this season, Avila said. More importantly, it is highly recommended for high-risk groups with serious related complications or those who live with or care for people at high risk of developing flu complications.

3 3 Provider Update - Medical Practitioners October 2010 HMSA Flu Shot Clinics 2010 For HMSA, HMSA s 65C Plus (Cost), HMSA QUEST, BCBS, and BCBS-FEP members, and Medicare Part B beneficiaries: No charge for the flu vaccine. Health plan membership card required. Driver s license or other photo ID required. Must be 18 years of age or older. For all others, $40 for the flu vaccine. Sorry, no checks or credit cards accepted. Flu shots for also help protect against the H1N1 virus. Shots administered by nurses through ISI Health Enhancement Services. Oahu Location Start End Saturday, Oct. 2 Leeward Community College - LA 104 & a.m. 3 p.m. Tuesday, Oct.5 Consolidated Theatres - Kahala 8 8 a.m. 10:30 a.m. Saturday, Oct. 9 HMSA Center - Multi-Purpose Room, Lobby 9 a.m. 3 p.m. Wednesday, Oct. 13 Foodland - Kailua 9 a.m. 3 p.m. Thursday, Oct. 14 Consolidated Theatres - Kapolei 16 8 a.m. 10:30 a.m. Monday, Oct. 18 Consolidated Theatres - Pearlridge 16 8 a.m. 10:30 a.m. Tuesday, Oct. 19 The Ward Warehouse - Kakaako Room, Second Floor 9 a.m 3 p.m. Saturday, Oct. 23 Kapiolani Community College - Kopiko 242 (Parking in Lot A) 9 a.m 3 p.m. Wednesday, Oct. 27 Consolidated Theatres - Koko Marina Stadium 8 8 a.m. 10:30 a.m. Thursday, Nov. 11 Consolidated Theatres - Mililani Stadium 14 8 a.m. 10:30 a.m. Saturday, Nov. 13 Windward Community College - Hale Akoakoa a.m. 3 p.m. Monday, Nov. 15 Walgreens - Kailua 9 a.m. 3 p.m. Friday, Nov. 19 The Ward Warehouse - Kakaako Room, Second Floor 9 a.m. 3 p.m. Saturday, Nov. 20 HMSA Center - Multi-Purpose Room, Lobby 9 a.m. 3 p.m. Monday, Nov. 22 YMCA - Leeward Branch - Large Meeting Room 9 a.m. 3 p.m. Maui Location Start End Monday, Oct. 11 Foodland - Kaahumanu 9 a.m. 3 p.m. Tuesday, Nov. 9 Consolidated Theatres - Kaahumanu 6 8 a.m. 10:30 a.m. Molokai Location Start End Monday, Oct. 25 Molokai General Hospital 10 a.m. 2 p.m. Kauai Location Start End Thursday, Oct. 28 Kauai PrimeTime Wellness Fair - Kauai Beach Resort 8:30 a.m. 12:30 p.m. Friday, Oct. 29 Foodland - Princeville 9 a.m. 3 p.m. Hawaii Location Start End Thursday, Oct. 7 East Hawaii PrimeTime Wellness Fair - Edith Kanakaole Stadium 9 a.m. 1 p.m. Wednesday, Oct. 20 Kealakekua Ranch Center 9 a.m. 3 p.m. Wednesday, Nov. 3 Sack n Save - Kona 9 a.m. 3 p.m. Thursday, Nov. 4 Foodland - Kamuela 9 a.m. 3 p.m.

4 4 Provider Update - Medical Practitioners October 2010 Annual review of medical policies The following policies have undergone annual review and have been updated. Please refer to the Provider E-Library to view the individual policies; copies are available upon request. Ambulatory Blood Pressure Monitoring. Artificial Disc Replacement Cervical. Biological Agents for the Treatment of Plaque Psoriasis. Bortezomib (Velcade). Cognitive Rehabilitation and Sensory Integration Therapy (effective Jan. 1, 2011). Fentanyl Oral Products. Non-coronary Brachytherapy (effective Jan. 1, 2011). Occupational Therapy. Omalizumab (Xolair). Palivizumab (Synagis). Panitumumab (Vectibix). Physical Therapy (effective Jan. 1, 2011). Speech Therapy. Cognitive Rehabilitation and Sensory Integration Therapy (effective Jan. 1, 2011) The policy has been revised to cover cognitive rehabilitation therapy for patients with traumatic brain injury. Precertification is required. Cognitive rehabilitation for all other diagnoses and sensory integration therapy will continue to not be covered. The policy s references and scientific background were also extensively revised. Non-coronary Brachytherapy (effective Jan. 1, 2011) Clarification was made to the criteria for head and neck and ocular brachytherapy. The criteria for soft tissue sarcoma and gynecological brachytherapy have been expanded and include the NCCN practice guidelines. Brachytherapy for brain tumors was removed as it is not the standard of care. No significant changes were made to all other indications. References were updated. Physical Therapy (effective Jan. 1, 2011) The policy has been revised to require precertification. Precertification requirements are subject to HMSA s variable intensity review program. When required, a treatment authorization request must be completed and sent to Landmark Healthcare. The following policy has been archived and is no longer available on the Provider E-library: Nonmyeloablative Allogeneic Transplants of Hematopoietic Stem Cells for Treatment of Malignancy.

5 5 Provider Update - Medical Practitioners October 2010 New medical policy (effective Jan. 1, 2011) Ninety-day notice is provided here for the following policy effective Jan. 1, This policy is posted in the Provider E-library: Precertification Requirements Akamai Advantage This new policy addresses precertification requirements for the new Medicare Akamai Advantage plans. The policy outlines how determinations will be made, including the order in which various criteria should be applied. Included in the policy is an appendix that lists services requiring precertification. Provider input solicited for annual policy review October HMSA s medical directors welcome comments and suggestions from participating physicians regarding medical policies that are undergoing annual review. The following is a list of policies for which HMSA is currently soliciting input. Comments are due by Oct. 31, Physicians may comment by fax at (Oahu) or [email protected]. Comments will be taken into consideration during the annual review process. However, HMSA does not guarantee any specific proposed change will be included in the final policy. HMSA s policies rely on the use of evidence-based medicine, typically from peer-reviewed literature. Codes that do not meet payment determination criteria Effective Jan. 1, 2011, the following codes have been added to the list: 0239T to 0244T, 0249T, 0254T, 0255T, and Claim documentation requirements Effective Jan. 1, 2011, the following codes that require documentation have been added to the list: 0250T to 0252T, 0253T, 0256T, and 0257T to 0259T. BCBSA router tool available Physicians submitting comments should include supportive citation source material to assist HMSA s medical directors in evaluating the comment or proposed change. DME Durable Medical Equipment. Home Health Care. Negative Pressure Wound Therapy. Oscillatory Device for Bronchial Drainage (The Vest). Sorafenib (Nexavar). Spinal Cord Stimulators. Stereotactic Radiosurgery. Sunitinib (Sutent). Effective Oct. 1, 2010, HMSA, along with Blue Cross and Blue Shield Association (BCBSA) plans across the country, will implement the Medical Policy and Pre-certification/Pre-authorization Router. You will be able to use this tool to check on the medical policies and pre-certification/pre-authorization requirements when your patient is covered by another BCBSA plan. This should make it easier for you to address the administrative needs of your patient s plan. The router tool can be accessed from HMSA s website at hmsa.com. Come check it out! If you have any questions, call 1 (800) toll-free.

6 6 Provider Update - Medical Practitioners October 2010 TriWest Enhances Secure Online Functions TriWest Healthcare Alliance Corp. and its claims processor, Wisconsin Physicians Service (WPS), continue to enhance the online features of the secure provider portal at To register and get instant access to your secure account, go to: Registered users can use the secure website to perform the following functions and streamline their work. In addition, we have created several secure website demonstrations, which can be accessed at: esem/2010tutoriallinks/review_index.html. Registered User Options Verifying Patient Eligibility Research Benefits, Check Referral/Authorization and Medical Review Requirements Online Referral/Authorization Submission and Status Submit Claims and View Claims Status Online Download Remittance Advices Download Claims Status Reports Claims Correspondence/Webmail Electronic Funds Transfer (EFT) Details From the Eligibility & Benefits area, view the patient s TRICARE status, Primary Care Manager history (if applicable), and details on eligibility, other health insurance and out of pocket. In the West Region Benefit Lookup Tool, users enter the CPT or HCPCS code and appropriate information about the patient. The tool will display benefit exceptions, if applicable, based on search criteria. From the Referral and Authorization area, you will get an almost immediate response to your online referral and authorization requests in most cases. You can view the real-time status of your request online. In some cases, you can even give the beneficiary a copy of their approved request before they leave your office. Under the Claims Center area, submit TRICARE West Region claims (including secondary claims) online and receive an immediate processing response. The claim entry screens contain only the data required for claims processing. Realtime adjudication allows for most clean claims to complete processing within 24 hours. Use View Claim status to determine a claim s status, regardless of the submission method. Electronic Remittance Advice (ERA) is an electronic version of the provider s Remittance Advice and gives detailed financial information regarding processed claims. This report provides financial information for all claims processed over a four-week period. It can be printed, downloaded to an Excel spreadsheet or viewed online. Registered users can use online claims correspondence for appeals, claim check and claim reviews. Webmail allows users to submit inquiries regarding their user profile that don t necessarily require an immediate resolution. Coming soon! For questions about TriWest, please contact HMSA s TRICARE unit at on Oahu, providerservice@triwest. com or call 1 (888) TRIWEST ( ).