Announcing the New Name for Our Maternity Program: Bright Start!

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1 The Newsletter for Keystone Mercy Health Plan Providers Visit us on the web at Issue 2, 2012 In This Issue Announcing the New Name for Our Maternity Program...1 Moving Towards ICD-10 Implementation...2 Medical/Dental Conference...2 Rapid Response and Outreach Team Here to Support you...3 Keystone Mercy s Quality Improvement Program...4 Important Notice Formulary Update...5 Providing Culturally and Linguistically Appropriate Service....6 Keystone Mercy Continues to Add Information to NaviNet Care Gaps...7 Keystone Mercy Adult Pharmacy Benefit Limits....8 Submit Pharmacy Prior authorization Requests Via the Web...9 Criteria Availability Coming Soon - The Annual Practitioner/ Provider Satisfaction Survey Announcing the New Name for Our Maternity Program: Bright Start! Bright Start will have the same quality and excellence goals of its predecessor the WeeCare program: promoting healthy behaviors and controlling risk factors during pregnancy, with the ultimate outcome of our members delivering healthy, full-term infants who will have a bright start in their new life. The program is a complementary extension of Keystone Mercy s existing core obstetrical program. The goals of the Bright Start program are: Early identification of pregnant members Early and continual intervention throughout pregnancy Provision of programs designed to encourage members to seek care and follow prenatal protocol For more information or to refer your Keystone Mercy members to the Bright Start program call: or or us at at [email protected] 1

2 Moving towards ICD-10 Implementation All HIPAA-covered entities were required to upgrade to Version 5010 by January 1, However, the Centers for Medicare & Medicaid Services (CMS) initiated an enforcement discretion period which ended on June 30, 2012 to give the industry additional time to complete testing and for vendors to complete software installation. At this point, your upgrade to Version 5010 should be complete with time and resources turning to the transition to ICD-10 for medical diagnosis and inpatient procedure coding. The implementation of ICD-10 will result in more accurate coding which will improve the ability to measure health care services, improve data reporting by providing more detailed clinical information about conditions, diseases and injuries. Keystone Mercy is committed to making all necessary changes to be in compliance and has a dedicated team working on the ICD-10 transition requirements. We continue to align our ICD-10 program milestones with the Centers for Medicare & Medicaid Services (CMS) recommended timelines for ICD-10 readiness. On April 9, 2012, the Department of Health and Human Services (DHHS) announced a proposed rule that would delay the compliance date for ICD-10 from October 1, 2013 to October 1, 2014; however, due to the complexity and enormity of the transition to address business and clinical issues it is critical not to delay planning and preparation. Medical/Dental Conference AmeriHealth Mercy Foundation, in concert with Drexel University College of Medicine and Kornberg School of Dentistry hosted its first conference at Drexel University on June 8, The topic, Promoting Wellness through Collaboration: The Integration of Dental and Medical, was chosen to assist all clinicians in understanding the benefits of a comprehensive approach to healthcare. What should you be doing now? Develop a budget and project timeline for your organization. Identify your organization s current systems and processes that use ICD-9 codes. Contact your current vendor about accommodations and readiness for ICD-10. Identify potential impact to staff, billing services, work flow, and business processes. Identify personnel training needs. Contact your billing or software vendor to understand their plans for conversion and testing. Keystone Mercy s ICD-10 Resource Center The Provider Center at has a dedicated ICD-10 Resource Center that provides you with answers to frequently asked questions, timelines and links to additional sources of information. You can submit any questions you might have about Keystone Mercy s transition to ICD-10 via a secure contact form. As our entire industry works towards becoming ICD-10 compliant, Keystone Mercy will continue to communicate and provide you with timely and useful information regarding ICD-10 via fax blasts and E-Lerts. For the most up-to-date information please visit the ICD-10 Resource Center frequently. The keynote speaker, Dr. David Nash, Professor of Health Policy at the Jefferson School of Public Health, delivered a spirited presentation to the 134 guests that included physicians, dentists, nurse practitioners, case managers, dental hygienists and office personnel. A panel of experts, referred to as the dream team provided a perspective from each of their disciplines. We d like to thank all attendees for their time, participation and positive feedback on this informative and educational opportunity. Panelists from the Integration of Dental and Medical Conference held at Drexel University s College of Medicine. Featured above from left to right (top) Maria Pajil Battle, Lawrence Paul, DDS, Eric Berman, DO, MS, Brian J. Bastecki, DMD, Michael Glick, DMD, (bottom) Marla J. Gold, MD, David B. Nash, MD, D. Walter Cohen, DDS, and Amid Ismail, BDS, MPH, DrPH, MBA. 2 Questions? Call Provider Services at hours a day/7 days a week

3 Innovations in Care Keystone Mercy s Rapid Response and Outreach Team Here to support you! The Rapid Response and Outreach Team (RROT) was developed to address the urgent needs of our members and support Keystone Mercy providers and their staff. The RROT team consists of Registered Nurses, Social Workers, and Case Management Technicians who are trained to assist members in investigating and overcoming the barriers to achieving their health care goals. There are three key service functions performed in the RROT unit: 1. Inbound Call Service. Members and Keystone Mercy providers may request RROT support via a direct, toll-free Care Coordination line. Referrals to RROT are also received through many sources, such as the Special Needs Call Line, Member Services, Pharmacy, Utilization Review, Retention Unit and Provider Relations. The RROT toll-free number is provided as a contact point for all member mailings and automated messaging encouraging members who need additional support or information to call. 2. Outreach Service. Outreach activities include telephonic survey or assessment completion and support of special projects or quality initiatives. RROT associates also place outreach follow-up calls to those members who have called the 24 hour Nurse Line and require further assistance from Case Management staff. 3. Clinical and Non-Clinical Case Management Support. Case Management Technicians (CMTs) support Case Managers in Care Coordination by providing administrative support to members. These include appointment scheduling and reminders, transportation support, member educational mailings, and other administrative tasks assigned by Case Managers. Case Managers provide Care Management Services for members with urgent health concerns that are clinical in nature. Calls are transferred by CMT associates to Case Managers when indicated by an Urgent Needs Assessment or when case management services are requested. The Rapid Response and Outreach Team can be reached at , 8:00 a.m. 6:30 p.m. or us at [email protected] 3

4 Keystone Mercy s Quality Improvement Program Keystone Mercy has a Quality Improvement (QI) Program to monitor and evaluate the health care services used by our members. Services are monitored to see that they: Meet quality guidelines Are appropriate Are efficient Are effective Significant improvement of the Healthcare Effectiveness Data and Information Set (HEDIS) measures: Breast cancer screening Chlamydia screening Children s access to Primary Care Practitioners (ages 7 to 11 and 12 to 19) Annual dental care for 2 to 21 year olds The Quality Improvement Committee (QIC) oversees the QI Program. The QIC is made up of Keystone Mercy s health care professionals, associates and local health care providers. Every year, the QI Program sets goals to improve member health outcomes and services and conducts activities to meet the goals. Goals The overall goal of the QI Program is to provide high quality and safe clinical care and services to all members. To meet this goal, the QI Program manages and analyzes data and takes action to manage risks. Evaluation Every year, Keystone Mercy evaluates the QI Program to see how well it meets its goals. We look at all parts of the QI Program, including clinical and service activities. The evaluation includes suggestions to improve the QI Program and goals for the next year. It also identifies the resources needed to meet the goals and objectives. Accomplishments for 2011 QI Program: Improved our national ranking from 27th to 25th (U.S. News & World Report s rankings of Best National Medicaid Plans) Maintained NCQA Excellent accreditation Awarded the NCQA s Multicultural Health Care Distinction Hosted a member focus group to gather members feedback on collecting race/ethnicity and language data Started additional interventions for reducing childhood obesity Continued participation in two DPW initiatives: Reduced disparities at the practice site Health Choices/Health Connections Improved in four member satisfaction survey areas Successfully in-sourced the dental program Program Goals for 2012 Maintain NCQA Excellent accreditation status Strengthen childhood obesity interventions Continue to improve HEDIS measures by identifying gaps in care Continue to improve member satisfaction survey results Continue collaborative efforts with behavioral health organizations If you would like additional information about the QI Program, please call Provider Services at The Quality Improvement Program sets goals to improve member health outcomes and services and conducts activities to meet its goals. The overall goal is to provide high quality and safe clinical care and services to all members. 4 Questions? Call Provider Services at hours a day/7 days a week

5 Important Notice Formulary Update The following drugs have been added to the Keystone Mercy formulary: Drug Xarelto (rivaroxaban) Tablets: 10mg Pradaxa (dabigatran etexilate mesylate) Capsules: 75mg,150mg Juvisync (sitagliptin/metformin) Tablets (sitagliptin/ simvastatin): 100mg/10mg, 100mg/20mg, 100mg/40mg Uroxatral (alfuzosin HCl) Tablets : ER 10 mg Janumet XR (sitagliptin/metformin extended-release) Tablets : 100 mg of sitagliptin/1000 mg of metformin HCl extended-release, 50 mg of sitagliptin/500 mg of metformin HCl extended-release, 50 mg sitagliptin/1000 mg of metformin HCl extended-release Indication Reduction of stroke and systemic embolism in patients with nonvalvular atrial fibrillation. Reduction of stroke and systemic embolism in patients with nonvalvular atrial fibrillation. Indicated for treatment in patients for whom treatment of both simvastatin and sitagliptin are appropriate: Simvastatin: Treatment of dyslipidemias (to reduce elevated total cholesterol, LDL-C, apolipoprotein B, and triglycerides), increase HDL-C in patients with primary hyperlipidemia or mixed dyslipidemia. Sitagliptin: Adjunct to diet and exercise to improve glycemic control in patients with type 2 diabetes. Indicated for the treatment of signs and symptoms of benign prostatic hyperplasia. Indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus when treatment with both sitagliptin and metformin extended-release is appropriate. Seroquel is indicated for the treatment of schizophrenia, acute treatment of manic episodes associated with bipolar I disorder, both as monotherapy and as an adjunct to lithium or divalproex, acute treatment of depressive episodes associated with bipolar disorder, and maintenance treatment of bipolar I disorder as an adjunct to lithium or divalproex. Formulary Update: Effective 4/1/2012, medications used to treat Attention Deficit Hyperactivity Disorder (ADHD) are no longer a covered benefit for members of age 21 years and older. Additional information on Keystone Mercy s Formulary is available in the Pharmacy Services section of the Provider Center or us at [email protected] 5

6 Providing Culturally and Linguistically Appropriate Service Last in a series devoted to providing tips and strategies for communicating with member of diverse backgrounds. Two years ago, Keystone Mercy made the commitment to improving multicultural health care and in April, 2011 that commitment was rewarded with the prestigious NCQA Multicultural Health Care (MHC) Distinction accreditation. This award, developed as a way for health plans to monitor and improve culturally and linguistically appropriate services and reduce health care disparities, reflects the passion that Keystone Mercy has for this initiative. With so many of our members coming from diverse backgrounds, it is important for Keystone Mercy to continue this pattern of excellence in developing new standards in providing care for members of these communities. By addressing the issues of low health literacy and cultural competency, we aim to bridge communication gaps and help members get care they need. Now more than ever, communication with your patient plays a key role in making informed shared medical decisions and eliminating disparities in healthcare. Your continued partnership in the multicultural health initiative gives us confidence that your patients are becoming engaged and involved in their health care outcomes. We hope that this series of articles has been both informative and practical for you as you diagnose and give care to members of diverse backgrounds. We would like to leave you with some universal tips and culture clues, courtesy of the University Of Washington Medical Center, that can be used with members of all backgrounds. Helping Your Patients Feel Comfortable If English is your patient s second language or the patient is deaf/hard of hearing or has vision impairment, make sure to involve an interpreter in all of your care discussion. Do NOT rely on family members to translate health information. *Language Service Associates (LSA) is available for both you and your patient. When appropriate, use the terms partner or spouse rather than husband or wife to avoid making assumptions about sexual orientation. Establishing a Relationship with Your Patients Pay attention to patient cues and follow their lead. If they do not establish eye contact or refuse to shake your hand, a cultural custom or spiritual belief may be guiding their behavior. Ask your patients how they would like to be addressed, and remember to continue calling them by their preferred name. Ask your patients what they think their goals are for their visit. Remind them they are an active partner in their care plan. Maintain Good Communication with Your Patients Acknowledge and respect you patients perceptions of their illnesses. Listen carefully. When you talk with your patients, let them know you are listening by nodding your head and maintaining eye contact if that is their norm, or avoiding eye contact if that is their norm. Use open-ended questions to make sure you and your patients share a common understanding. Tell your patients what you are doing and what they will feel if you are doing an exam, procedure, or other care that involves physically touching them. To be in compliance with federal law and state contractual requirements, you have the responsibility to make arrangements to procure translation services when a Keystone Mercy member requires or requests translation services because he/she is either non-english speaking, is of limited or low English proficiency, or if the member has some other sensory impairment. * To assist with this requirement Language Service Associates (LSA) provides discounted interpretation services for both you and your patient. Take advantage of the AmeriHealth Mercy Family of Companies corporate rates! For more information, call ext or visit the Provider Center at 6 Questions? Call Provider Services at hours a day/7 days a week

7 Keystone Mercy Continues to Add Information to NaviNet Care Gaps Keystone Mercy appreciates the attention that is paid to the Care Gap alerts you receive regarding critical services that our members need to maintain good health. We continue to add alerts with information that assist you in determining your patients who might be at risk. To make this identification easier we have added a new status of risk that will pop-up on your screen (if applicable) when checking a member s eligibility and benefits. This status provides you with information that puts your patient at risk such as a missing medication therapy. The chart below lists the currently available pharmacy gaps in care that will help identify your patients that might be in the risk status. Condition Service Status Status Indication Acute Coronary Syndrome ACE/ARB Therapy Risk Indicates status post-acs that may benefit from ACE Inhibitor/ ARB therapy Acute Coronary Syndrome Acute Coronary Syndrome Aspirin Therapy Risk Indicates status post-acs that may benefit from aspirin therapy Beta-blocker Therapy Risk Indicates status post-acs that may benefit from beta blocker therapy Acute Coronary Syndrome Clopidogrel (Plavix ) Therapy Risk Indicates status post-acs that may benefit from clopidogrel (Plavix ) therapy Acute Coronary Syndrome Statin Therapy Risk Indicates status post-acs that may benefit from statin therapy Asthma Controller: All Inhaler Ratio Risk Indicates under-utilization/absence of controller medication Diabetes ACE/ARB Therapy At Risk Indicates Hypertension or Proteinuria that may benefit from ACE/ARB therapy Diabetes Blood Glucose Monitoring At Risk Indicates diabetic patient not monitoring blood glucose Dyslipidemia Lipid Lowering Therapy At Risk Indicates Dyslipidemia that may benefit from lipid lowering therapy or us at [email protected] 7

8 Keystone Mercy Adult Pharmacy Benefit Limits Keystone Mercy members age 21 and over are eligible for six (6) prescriptions per month. Automatic exceptions to the benefit limit: This change does not apply if the member is under the age of 21. Members who are pregnant (including throughout a 60-day postpartum period) and members over 21 years of age residing in long term or intermediate care facilities are also exempt from these benefits limitations. Drugs dispensed as an emergency supply will not count towards the member s six prescription per month limit. The medications in the list below will be approved automatically at the pharmacy point-of-sale even if the member has filled more than six total prescriptions that month. Occasionally, a new medication may be added to these therapeutic classes, and may be rejected at the point of sale. A temporary supply will be issued to the member while we update our system with the new medication. Keystone Mercy will grant a benefit limit exception (BLE) when one of the following criteria is met: Member has a serious chronic systemic illness or other serious health condition and denial of the exception will jeopardize the life of the member; or Member has a serious chronic systemic illness or other serious health condition and denial of the exception will result in the rapid, serious deterioration of the health of the member; or Granting a specific exception is a cost effective alternative for Keystone Mercy; or Granting an exception is necessary in order to comply with federal law. (continued on page 9) Alpha Blockers Alzheimer s Therapy Antianginal Drugs Antiarrhythmic Drugs Anticoagulant Drugs Anticonvulsant Drugs Antidepressant Drugs Antihepatitis Drugs Antihyperlipidemic Drugs Antihypertensive Drugs Antiinfective Drugs Antineoplastic Drugs Antiparkinsons Drugs Antipsychotic Drugs Asthma and COPD Drugs Bone Resorption Inhibitors CNS Stimulants Diabetes Agents Enzyme Deficiency Agents Family Planning Drugs Folic Acid Preparations Glaucoma Drugs Glucocorticoids Growth Hormone H2 Receptor Antagonists Hemophilia Agents HIV/AIDS Drugs Immune Deficiency Agents Immunosuppressant Drugs Mood Stabilizers Mucolytics Multiple Sclerosis Drugs Narcotics NSAIDs Opiate Dependency Agents Prenatal Vitamins Proton Pump Inhibitors Psychostimulants Pulmonary Hypertension Drugs Respiratory Tract Agents Selective Estrogen Receptor Modulators (SERM) Thyroid Drugs Triptans 8 Questions? Call Provider Services at hours a day/7 days a week

9 Keystone Mercy Adult Pharmacy Benefit Limits (continued) Benefit Limit Exceptions and Prior Authorization If a drug does not require prior authorization, the BLE is valid for six (6) months. If a drug also requires prior authorization, the start and end dates of both the BLE and the prior authorization will be the same. All prior authorization requirements continue to apply and documentation of medical necessity for the drug will be reviewed concurrent to consideration of the benefit limit exception. The prescribing provider should submit the documentation of medical necessity (to support the prior authorization decision) along with the clinical information to support the BLE request. To request a benefit limit exception: > By Fax: Fax a completed BLE request form. The form is available at the Provider Center: Benefit Limit Exception Form. > By Phone: Have the following information available: Member s name, address, date of birth, and Keystone Mercy ID number Provider name, address, telephone and fax number, medical license number and NPI number Information about the drug being prescribed, the diagnosis and why the exception is being requested Keystone Mercy will respond to a prescriber s request for a pharmacy BLE within 24 to 72 hours after all of the necessary information is received. Please contact Pharmacy Provider Services at if you have any questions regarding this benefit change. Submit Pharmacy Prior Authorization Requests Via the Web No more deciding which form to use! No more fax numbers to remember! Keystone Mercy and PerformRx are pleased to announce an easier, more efficient way for providers to submit pharmacy prior authorization requests. All information can be entered on the web and submitted to PerformRx instantly. Using our online web submission form providers can: Electronically submit all relevant member information Attach member specific documents such as labs, chart notes, consults etc. Save unique provider information in order to expedite future web submissions Print summary page for easy referencing To start using this user-friendly interactive web form, simply go to: providers pharmacy services PerformPA Web Submission Form For any assistance, please call or us at [email protected] 9

10 Criteria Availability Keystone Mercy has adopted clinical practice guidelines for use in guiding the treatment of members, with the goal of reducing unnecessary variations in care. The clinical practice guidelines represent current professional standards, supported by scientific evidence and research. These guidelines are intended to inform, not replace, the physician s clinical judgment. The physician remains responsible for ultimately determining the applicable treatment for each individual. All clinical practice guidelines are available on the Provider Center of our website at or upon request by calling the Provider Services Department at Keystone Mercy will provide its Utilization Management (UM) criteria to Network Providers upon request. To obtain a copy of a UM criteria: Call the UM Department at Identify the specific criteria you are requesting Provide a fax number or mailing address You will receive a faxed copy of the requested criteria within 24 hours or written copy by mail within five (5) business days of your request. Please remember that Keystone Mercy has Medical Directors and Physician Advisors who are available to address UM issues or answer your questions regarding decisions relating to Prior Authorization, DME, Home Health Care and Concurrent Review. Call the Medical Director Hotline at: Additionally, Keystone Mercy would like to remind Providers of our affirmation statement regarding incentives: UM decision-making is based only on appropriateness of care and the service being provided Keystone Mercy does not reward Providers or other individuals for issuing denials of coverage or service Financial incentives for UM decision makers do not encourage decisions that result in underutilization Coming Soon The Annual Practitioner/ Provider Satisfaction Survey Watch your mail for the survey sometime in September If your practice is one of the randomly selected participants, please take a few minutes to complete the survey. Your feedback is critical and extremely important to us in identifying what we do well and areas that are opportunities for improvement. Keystone Mercy Health Plan 200 Stevens Drive, Philadelphia, PA Messenger Editorial Board Eric J. Berman, DO, MS Chief Medical Officer Northeast Region, Keystone Mercy Health Plan Paul L. Staudenmeier Associate Vice President Provider Network Management Linda Travaglione Director, Provider Communications Marianne Gravina Editor, Provider Communications Matt Reilly Contributor, Provider Communications 10 Questions? Call Provider Services at hours a day/7 days a week