Executive VP and Chief Medical Officer Joins PacificSource

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1 Winter 2012 Table of Contents Executive VP and CMO Joins PacificSource On the Move Healthy KidsConnect Changes Temporary ID Cards Now Available Low Back Pain Program Credentialing Process Changes New Address for PO Boxes HEDIS Requires Medical Record Collection Clarification of Immunization Admin Codes COB Claims May Now Be Sent Electronically Keeping ed Member Information Secure Provider Manual Updates PacificSource Performance New Large Group Clients Questions? Executive VP and Chief Medical Officer Joins PacificSource We are pleased to welcome Tom Ewing, M.D.to PacificSource Health Plans as Executive Vice President and Chief Medical Officer (CMO). Dr. Ewing will join us in late February as our current CMO, Steve Marks, M.D., prepares to retire in June. In this expanded role, Dr. Ewing will be responsible for all our activities and services that impact the health and healthcare of members, as well as all partnerships and relationships with providers. Dr. Ewing brings a wealth of experience to PacificSource in the areas of clinical management, healthcare delivery system improvement and transformation, quality management, clinical informatics, and patientcentered medical home initiatives. Since 2007, Dr. Ewing served as Chief Medical Officer for PeaceHealth. He has held a variety of clinical leadership roles within PeaceHealth since A boardcertified family physician, Dr. Ewing graduated from Washington University School of Medicine in St. Louis and completed his residency in family medicine at the Medical University of South Carolina. Dr. Ewing is also active in the community. He has served on numerous councils and committees within PeaceHealth and across the state of Oregon, and is currently a board member for the Oregon Health Care Quality Corporation. We re committed to expanding our collaborative partnerships with healthcare providers to reduce costs, improve quality of care, and positively impact health status in our communities, says Ken Provencher, Chief Executive Officer. Dr. Ewing s thoughtful leadership style and experience will be instrumental in helping us move this community health partnership model forward.

2 Please join us in welcoming Dr. Ewing to the PacificSource team and wishing Dr. Marks well in his upcoming retirement. On the Move Michelle Cochran has accepted a promotion to Provider Service Team Leader. Michelle has worked for more than four years as a Service Representative in the Provider Network Department and more than six years for the company. Provider Service Specialists Lizzy Randleman and Shonda Dahl will be working with Michelle s previous provider contacts. Tony Baker and Nicole Hurley, formerly Provider Service Specialists, have both accepted new positions at PacificSource as Provider Contract Specialists. We have filled Tony s and Nicole s positions with two experienced staff members from other areas of our organization. Rhonda Dolbin has replaced Tony s position in our Springfield office. With 19 years of experience in our Claims Department, Rhonda brings to our team her wealth of knowledge about coding, claims adjudication and payment, and provider contracts. She can be reached at (541) or [email protected]. Shonda Dahl took on Nicole s previous role in our Bend office. Shonda has more than six years of experience in health insurance, including positions in billing, enrollment, marketing, sales, and communications. She can be reached at (541) or [email protected]. Healthy KidsConnect Changes Starting January 1, 2012, several changes to our Healthy KidsConnect plans became effective. These changes bring our plans in line with the program s original design. Members are now required to select a PCP, a referral is required to see a specialist, and prior approval is required before a member can see a nonparticipating provider. Also, some services that may have been covered previously may now require preauthorization, or may not be covered as we manage the plan according to Oregon s Prioritized List. Because Healthy KidsConnect plans are a little different than traditional commercial plans, we want to make sure you have resources available to help you navigate the preauthorization requirements and better serve our Healthy Kids members. Our Preauthorization web page now includes links to special Healthy KidsConnect preauthorization lists. You are also welcome to contact Customer Service at (888) or [email protected] for benefit information and other questions. Please note that our process for diagnostic imaging preauthorization has not changed. AIM is still utilized for these preauthorizations. Temporary ID Cards Now Available to Members You may begin seeing PacificSource member ID cards that look a little different from our standard cards. That s because new members who need immediate care, as well as those who have lost their ID card, can now print a temporary ID card from our website. Please see sample above. These temporary paper cards include the member s ID number, group ID number, and whether they have health, dental and/or vision coverage. Note that detailed benefit information, such as copayment amounts, won t be included on the temporary card, but is available

3 online through InTouch. If a patient shows you a temporary PacificSource ID card, please honor it as you normally would a permanent ID card. Low Back Pain Program Seeks to Improve Costs and Outcomes Low back pain is one of the highest contributors to healthcare costs in the non-medicare population. Four out of five people will have an episode of low back pain at some point in their lives. Through a new Oregon Health Leadership Council initiative, providers, employers, and health plans including PacificSource are teaming up to pilot a program to improve outcomes for low back pain sufferers, and ultimately reduce the cost of care and lost work time. Through this two-year pilot that began January 1, eligible Oregon members will have access to a participating physical therapist within 48 hours, without a physician referral. Participation is voluntary, and members must meet specific eligibility requirements. Services are covered as they normally would be under the member s benefit plan. We re pleased to participate in collaborations like this, which not only help improve the overall patient experience but also explore ways to better manage healthcare costs in our communities. For information about this pilot, you are welcome to contact our Customer Service Department at (888) or [email protected]. Credentialing Process Changes and Reminders Members who seek care in our network expect their healthcare providers have met high standards for competent medical practice, and that s the primary reason for our credentialing and recredentialing process. If you have recently added providers to your practice, please remember that they will need to complete our credentialing process before they can be added to the contract. Please also note that to comply with Medicare and NCQA (National Committee for Quality Assurance) standards, we recently changed our process for adding providers to contracts. Providers are now added to the individual or group contract and considered participating effective the first of the month following the credentialing approval date. For example, if the committee approves the practitioner s application on March 3, they will be added to the contract as of April 1. Until the credentialing process is complete and the Credentialing Committee approves the practitioner, he or she will be considered nonparticipating, and claims will be paid at the nonparticipating rate. The first step in the credentialing process is to submit the appropriate state practitioner credentialing application. (For Idaho providers, IPN and BrightPath credentialing criteria apply accordingly.) In addition, providers directly contracted with us are required to complete the recredentialing process at least every 36 months. The following documents are required when submitting a credentialing or recredentialing application: Current copies of DEA certificates (if applicable) Professional Liability Insurance face sheet including coverage effective dates and amounts Physician Assistant Practice Plan Description approval letter or form approved by the state licensing board (applies to Physician Assistants only) Additional supplemental documents as applicable The credentialing process begins when a complete application and documentation are received by credentialing staff and can take 30 to 90 days to complete. Initial applicants approved by the Credentialing Committee will be mailed an approval letter within 60 calendar days of the committee s approval date.

4 The policies of the PacificSource Credentialing Committee are guided by national standards established by NCQA, state and federal laws, and other standards for credentialing activities. If you have any questions about credentialing, you re welcome to contact any member of our Credentialing team at (800) , ext or New Address for PO Boxes The U.S. Postal Service has changed the city and Zip code for several of our PO boxes, as shown in the chart below. (Note that the PO Box numbers themselves and the four-digit Zip code extensions have not changed.) While the old addresses will continue to work for several months, we encourage you to begin using the new address now. We are in the process of revising our materials to reflect these changes. Should you experience any issues with mail delivery, please contact the Gateway post office directly. Old Address PACIFICSOURCE HEALTH PLANS PO BOX 7068 EUGENE OR PACIFICSOURCE ADMINISTRATORS PO BOX EUGENE OR PACIFICSOURCE HEALTH PLANS EMPLOYEE CLAIMS PO BOX EUGENE OR New Address PACIFICSOURCE HEALTH PLANS PO BOX 7068 SPRINGFIELD OR PACIFICSOURCE ADMINISTRATORS PO BOX SPRINGFIELD OR PACIFICSOURCE HEALTH PLANS EMPLOYEE CLAIMS PO BOX SPRINGFIELD OR Administrative News and Reminders HEDIS Reporting Requires Medical Record Collection As part of our ongoing effort to improve healthcare outcomes in the communities we serve, we are again participating in Healthcare Effectiveness Data and Information Set (HEDIS) reporting. HEDIS reporting requires collection of medical records for specific patients, and we have contracted with a vendor, Outcomes Health, to help with that process. If medical records for your patient are required, our vendor will contact you by mail to arrange for convenient collection of that information. You ll be able to fax or the records or arrange for them to be reviewed in your office whichever option you prefer. We appreciate your support with this important quality improvement initiative. Clarification of Immunization Administration Codes Since codes and went into effect in 2011, we have noticed many providers billing these codes incorrectly. To help you avoid the hassle, additional work, and cost of rebilling, we d like to clarify these codes and the guidelines for their use. PacificSource follows the current CPT book guidelines for codes and 90461, which state that counseling must be given and documented by an MD or other qualified healthcare professional. If the counseling is not given or documented, or if the service is not performed by an MD or other qualified healthcare professional (as defined by CPT guidelines), your claim may be denied or paid incorrectly.

5 Please also note that we will perform random claims audits in the coming months to assure compliance with these guidelines. Chapter 11 of our Physician and Provider Manual will be updated to include further details by the end of February. In the meantime, you are welcome to contact your Provider Service Representative with any questions. COB Claims May Now Be Sent Electronically Good news! We are now able accept coordination of benefits (COB) claims electronically via your claims clearinghouse. These claims require: Claim line detail All information as given on the primary claim Amount paid by the primary carrier and their write-off Member responsibility If you re interested in submitting COB claims to PacificSource electronically, simply contact your clearinghouse for set-up information. Keeping ed Member Information Secure Working together, we can ensure personal information is well protected. We use a secure system, Tumbleweed, when sending that includes protected health information or PHI. You can also help by using a secure system when sending patient information to us. Recently, we ve noticed an increase in unsecured s. Some may have private or secure typed in the subject field, but are actually not encrypted. If your practice doesn t have a secure system, we invite you to use our Tumbleweed system. Using PacificSource s Secure System: 1. To get started, you will need to receive a secure message from someone at PacificSource. any of our representatives and ask them to send you a secure When you receive the secure , click the View Message button in the body of the message. You will be directed to our secure mail portal (the Tumbleweed Communications website) where you can follow the on-screen instructions to complete your account registration. Once you re registered, use your browser to access After you log in, you can compose messages, attach files, and check your inbox as you typically would with any software. (Please note that our secure mail portal can only be used to send secure messages to PacificSource and our subsidiaries, not to other companies.) Provider Manual Updates The PacificSource Physician and Provider Manual is your online reference for information about our policies and procedures. To be sure you always have the most current information, please visit the Provider Manual page of our website. The following sections of our PacificSource Physician and Provider Manual were updated in December 2011: Payment Rules for Multiple Scope Procedures

6 11.13 Lab Handling Codes Preauthorization Policy Preauthorization Procedure PacificSource Performance at a Glance - December 2011 Enrollment Total Enrollment: 264,464 Medical Members: 244,513 Dental Members: 72,378* Claims Processing Actual Target Turnaround Time (days): Accuracy: 99.98% 99% Customer Service Actual Target Answer speed (seconds): Abandonment rate: 4.50% 2% Customer Satisfaction Actual Target Members: 92.90% 95% Providers: 98.00% 95% * includes members who have medical coverage. New Large Employer Clients To keep you informed of potential new patients, as well as possible coverage changes for existing patients, we publicize employers with 100 or more employees that have recently enrolled with us. (The number shown in parentheses indicates total subscribers, not including dependents.) November 2011 Alvord Taylor Springfield, OR (100) Ridgeline Management Eugene, OR (118) January 2012 OSU Federal Credit Union Corvallis, OR (182) Fire Mtn Gems and Beads Grants Pass, OR (423) City of Medford Medford, OR (225) Chambers Communication Corp. Eugene, OR (131) Guaranty Chevrolet Junction City, OR (191) Western Trailer Co. Boise, ID (263) North Bend Medical Center Coos Bay, OR (351) First Call Resolution Roseburg, OR (188) Dodge Logging, Inc. Maupin, OR (100) Stahlbush Island Farms Corvallis, OR (103) Transform Holdings Boise, ID (241) Questions? Your Provider Service Representative Is Here to Help If you have questions or need additional information regarding this notification, please contact your Provider Service Representative. If you are unsure who your representative is, please visit our Provider Service Staff Directory and click on your county, or feel free to [email protected].