Online Provider/Pharmacy Directory: New Guidelines and Requirements

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1 Vol. 3, No. 3 PROVIDER PULSE October In This Issue New Guidelines... page 1 Provider Portal...page 2 Part D...page 2 Medical Services... page 3 Quality...page 4 Claims/New Rep...page 5 Online Provider/Pharmacy Directory: New Guidelines and Requirements The Centers for Medicare & Medicaid Services (CMS) released their 2016 calendar year requirements for the online provider/pharmacy directory and there are significant changes to be aware of as a provider. Provider and pharmacy directories are critical to help enrollees make educated decisions about their Medicare Advantage/Part D choices. The online directories must contain all required information (listed below), such as overall network provider options. In addition, the online provider/pharmacy directory must contain a special notation to highlight providers that are not accepting new patients. Online Directory Formats To assist enrollees, a variety of online provider/pharmacy formats have been identified and described by CMS. Below are the acceptable formats: A searchable master provider directory that represents the complete network for the Plan/Part D Sponsor; Individual provider/pharmacy directories by plan product and/or service area (e.g., mirroring those that will be printed for the Plan/Part D Sponsor membership); A search engine via a website. Monthly Updates CMS guidelines state that plans should contact their network/contracted providers on a monthly basis to update the following information in the online provider/pharmacy directory: Ability to accept new patients; Street address; Phone number; Office hours; and Any other changes that affect availability to patients. Plans/Part D Sponsors are also expected to update directory information any time they become aware of changes. All updates to the online provider/pharmacy directory are expected to be done in real time. Continued, next page please... 1

2 Continued from Page 1 New West Compliance To ensure compliance with CMS guidelines, New West will offer a searchable master provider directory as well as a provider search engine on our website. We will be contacting all providers monthly to update any required information. The contact methods will be a combination of telephone, mailings, and . Should you prefer your monthly contact be via , please notify New West by sending an titled monthly updates to providerinfo@nwhp.com with your business name and contact information. For questions and/or to obtain additional information about New West s online directory, please contact your Provider Relations Specialist or call our Provider Service Department at Monday Friday 8 a.m. to 5 p.m. You may also visit Please reference: Plans/ManagedCareMarketing/MarketngModelsStandardDocumentsandEducationalMaterial.html New West Launches Provider Portal All contracted providers can now access member eligibility, benefit and claims information, or check a prior authorization status, through a new secure web portal called the Constituent Web Solutions (CWS) Provider Portal. Now accessing critical information 24/7 is as simple as a click of a button! Users can self-register using their Federal ID and National Provider Identifier Standard (NPI) numbers through the CWS Provider Portal link located under I m a Provider on our home page, Self-registration is very easy and there is a user friendly self-registration guide on the CWS log-in page. If you would like to set up an in-person or online demo, please contact your New West Provider Relations Specialist. New West s Partners for Prescription Drug Benefit Program CMS expects Medicare Advantage plans to monitor healthcare provided for its Medicare members. New West Health Services, as a Medicare Advantage plan, provides additional health management services for its members as adjunct to services from providers. New West has a strong interest in improving its prescription drug benefit program by offering pharmacy-specific health management programs. Often, New West collaborates with other pharmacy partners such as patient prescription assistance programs, pharmacy benefit managers, specialty pharmacies, and medication therapy management programs. If New West and our partners identify opportunities for counseling based on pharmacy claims data, we will reach out to your patients to counsel them on their medication use. Names of some of New West s pharmacy partners include: MedImpact (pharmacy benefit manager); SinfoniaRx (Medication Management); Big Sky Rx (Montana State Pharmacy Assistance Program); Any of our network specialty and community pharmacies. Continued, see page 3 2

3 Continued from Page 2 These programs are not intended to replace your services as providers; rather, these programs are intended to serve as additional tools. Because New West and its partners receive pharmacy claims data, these programs are intended to notify you of the patient s prescribing patterns and to recommend changes in medication therapy. You as the prescriber have the option of accepting or rejecting our recommendations. Because New West and its partners provide you with valuable information about your patients, we encourage patients to participate in our programs and providers to discuss with patients how New West and its partners can add value to their care. Additional information about specific vendors, partners, and programs will be provided in future newsletter articles. Inpatient vs. Observation The use of observation is frequently misunderstood, especially the difference between observation services and inpatient admission. When a patient, whose condition warrants outpatient observation services, is admitted as an inpatient, the hospital is often required to adjust the hospital bill. Observation services are hospital outpatient services performed to evaluate a patient s condition to determine whether admission is reasonable and medically necessary. To admit a patient for observation services, the order must clearly state the intent for observation services such as outpatient observation. Documentation of the need for observation services is required in all cases. Per CMS, the decision to admit a patient is a complex medical judgment which can be made only after the physician has considered a number of factors, including the patient s medical history and current medical needs, the types of facilities available, the hospital s by-laws and admission policies, and the relative appropriateness of treatment in each setting. This consideration may also include the 2-midnight rule. CMS created the 2-midnight rule for Traditional Medicare Part A and as such applies to only Part A payments. Many providers incorrectly assume that if a patient stays in the hospital 2 midnights, they automatically qualify for inpatient status. However, if the patient does not meet clinical criteria that requires inpatient level of care, but could be treated at a lower level of care, this admission may be denied retroactively months later through a review process by the Quality Improvement Organization (QIO)/Recovery Audit Contractor (RAC). New West Medicare is Part C and, as a Medicare Advantage plan, is allowed to adopt a more liberal approach to inpatient coverage: New West will cover inpatient admissions for any length of stay (LOS), but the clinical criteria for that service needs to be met. Unlike traditional Medicare, New West doesn t insist on a minimum 3-day stay for criteria for Skilled Nursing Facility (SNF) placement payment. New West uses pre-authorization to determine medical necessity and appropriateness of inpatient admission based on nationally recognized guidelines. Continued, see page 4 3

4 Continued from Page 3 New West Medicare s Medical Management Division uses MCG (formerly Milliman Care Guidelines) as a medical necessity screening tool to assist providers in determining a patient s status (inpatient, outpatient, or outpatient with observation services). Admitting physicians should have a general understanding of the criteria for both the severity of illness and the intensity of service for inpatient admissions. Appropriate use of observation status includes: Patients with symptoms suggesting a diagnosis that must be ruled out (e.g., chest pain); Patients requiring medication adjustments or hydration management; Patients requiring pain management; Patients with post-procedure complications which do not require an inpatient level of care but do require on-going monitoring. Inappropriate use of observation status includes: Patients maintained onsite due to social factors; Patients held at physician convenience for later testing or examination; Patients onsite in preparation for, or routine recovery from, ambulatory procedures (including surgery); Patients onsite for routine outpatient procedures (i.e., transfusion or chemotherapy). November is American Diabetes Month Diabetes is one of the leading causes of disability and death in the United States. If it s not controlled, diabetes can cause blindness, nerve damage, kidney disease, and other health problems. To give you a sense of the extent of the disease burden, according to the National Diabetes Statistics Report, 2014, approximately 9.3% of Americans have diabetes that s more than 29 million people. Another 86 million adults in the United States are at high risk of developing type 2 diabetes. The good news? People who are at high risk for type 2 diabetes can lower their risk by more than half when they make healthy changes. These changes include: eating healthy foods, increasing physical activity, and losing weight. You can use this special month to raise awareness among all of your patients about diabetes risk factors and encourage people to make healthy changes. Here are just a few ideas: Encourage people to make small changes, like taking the stairs instead of the elevator; Encourage your patients to come in for regular check-ups. During this time, they can get their blood pressure checked, cholesterol levels screened (if appropriate), and your diabetic patients can have their HbA1c levels checked (The ABC s of diabetes care, as promulgated by the American Diabetes Association). Non-diabetics can be assessed for diabetes risks at this time, as well; Take advantage of programs designed to focus the nation s attention on the issues surrounding diabetes and the many people who are impacted by the disease. The American Diabetes Association has many ideas on how to bring this to fruition. Visit their website at ; Finally, for your patients with diabetes, encourage them to call the New West Medicare Customer Service Department with questions about their coverage for diabetic-related services, such as vision benefits, diabetic education, and diabetic supplies. The toll-free number for New West members is (TTY 711). 4

5 New West strives to pay claims accurately and timely. However, there are some common mistakes with claim submissions that often delay payment: Incorrect member ID number. New West will not accept claims submitted with the Medicare or Social Security number; Wrong date of birth; Inappropriate or missing modifiers; Referencing an incorrect authorization or referral number; As of April 1, 2014, CMS stopped using HCFA form, 1500 (08-05). Please use HCFA 1500 (02-12); We always recommend that you use electronic claims submission. If you are not currently set up with New West, contact your clearinghouse to request access to the New West Payer ID 84141; If you do not have the capability to file electronic claims, please mail your claim form to the following address: New West Medicare PO Box 668 Kalispell, MT Common Claims Submission Issues We would also like to remind you that claims with a date of service on or after October 1, 2015, will only be accepted if they contain a valid ICD-10 code. The Medicare claims processing systems will not have the capability to accept ICD-9 codes for dates of service after September 30, 2015 or accept claims that contain both ICD-9 and ICD-10 codes. New West Welcomes New Provider Relations Representative for Central Montana We are pleased to announce the promotion of Shawn Ratchford to Provider Relations Representative for Central Montana. Shawn joined New West in May of 2014 and previously served as a Clinical Support Specialist in our Medical Services department. Prior to joining New West, Shawn worked in the health insurance industry as a Customer Service Rep, and later a Customer Service Supervisor. Shawn will serve the following counties in central Montana: Beaverhead, Broadwater, Cascade, Deer Lodge, Fergus, Granite, Jefferson, Judith Basin, Lewis & Clark, Madison, Meagher, Powell, and Silver Bow. New West Provider Service Representative Shawn Ratchford To contact Shawn: Cell ; - sratchford@nwhp.com 5

6 New West Medicare 130 Neill Ave Helena, MT 59601