NETWORK MATTERS December 2013

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1 Update: GIC Tier Notification Letters HPHCURRENT EVENTS Harvard Pilgrim provides coverage to Massachusetts employees (state and municipal employees and retirees as well as their beneficiaries and survivors) through two tiered products for the Group Insurance Commission (GIC): the Independence Plan PPO and Primary Choice HMO (a limited network tiered plan). The plan year for these products begins on July 1 each year and any updates to provider tier assignments for these products take effect on that date. In the past, physicians received their tier assignments, along with quality and efficiency reports, from Harvard Pilgrim each January. Other health plans serving GIC employees sent GIC tier notices to physicians, as well, resulting in each provider receiving numerous letters and reports. However, beginning in January 2014, the GIC will mail a single tier notice letter, and quality and efficiency reports, directly to individual physicians. This letter will contain the provider s tier assignment for each participating health plan, as well as contact information for each health plan. Tier assignments noted in the January letter will be in effect from July 1, 2014 June 30, The Independence Plan PPO and Primary Choice HMO also feature tier assignments for hospitals. Harvard Pilgrim will mail these tier notifications directly to hospitals in early January. Tier assignments will continue to be based on quality and cost efficiency claims data. If, after reviewing your letter, you would like to receive additional information about how Harvard Pilgrim arrived at your tier designation, or if you believe that your tier designation was not correctly determined, tier_review@harvardpilgrim.org. The deadline for inquiries and appeals is three weeks from the date of the letter, and appeal requests should be accompanied by a completed Tier Review Request Form. For more information, please visit Harvard Pilgrim s GIC plan page on our provider website. Information on the plan year including Fast Facts for Physicians, Frequently Asked Questions, and information on the Physician Review Process (including a link to the Tier Review Request Form) will be posted in January. Harvard Pilgrim Health Care 1 Network Matters December 2013

2 Reminder: Resources Available for Stride SM (HMO) Plans Next month, Harvard Pilgrim s new Medicare Advantage Stride SM (HMO) and Stride SM of New Hampshire (HMO) plans take effect, and Harvard Pilgrim has a variety of resources to help providers who are participating in the Stride network become more familiar with these products and accompanying procedures. Our Medicare Advantage Stride (HMO) website features: An overview of the Stride (HMO) plans A quick reference guide for Stride (HMO) providers This handy 2-page flyer can help you navigate common processes. It explains how to recognize members and verify eligibility, request authorizations, submit claims, and request a claims adjustment or appeal claims. It also includes key contact information. A video presentation for providers This training presentation walks providers through plan design and benefits, and includes an overview of policies and procedures (member eligibility, claims, appeals, credentialing, etc) and using the Medicare Advantage Provider Portal. The Medicare Advantage Provider Manual This reference for providers participating in the Stride (HMO) plans includes detailed information on coverage, provider roles and responsibilities, credentialing and recredentialing, claims and billing, reimbursement methodology, and member rights and responsibilities. Information about the Medicare Advantage Provider Portal This portal supports a variety of online transactions, such as verifying member eligibility and cost sharing, making referrals, and submitting and tracking claims. Visit the Stride (HMO) page to learn about registering for this tool. If you have any other questions about these plans, please contact the Medicare Advantage Provider Service Center at Update: New Preferred Network Plans for Self Insured Employers Effective January 1, 2014, two of Harvard Pilgrim and Health Plans, Inc. self-insured employer customers will begin offering preferred network plans to their employees. Boston Medical Center Boston Medical Center is offering two products to their employees in 2014: BMC Select and BMC Tiered HMO. BMC Select is a limited network HMO; members have access to Harvard Pilgrim Health Care 2 Network Matters December 2013

3 network benefits only from the providers in the product s participating network. BMC Tiered is a full network, tiered HMO, where member cost sharing varies by tier. You can recognize members of these plans by their ID cards, which display BMC plan name in the top right corner, along with the Harvard Pilgrim Health Care logo on the top left. For information on participating providers and tiering (where applicable), please consult the product-specific provider directories on Harvard Pilgrim s member web page. Lawrence General Hospital Employee Medical Plan Health Plans, Inc., Harvard Pilgrim s wholly owned subsidiary, is partnering with Lawrence General Hospital to offer a new preferred network plan for its employees. The Lawrence General Hospital Medical Plan has nearly 2,200 members and features a three-tier design. There is no coverage for out-of-network providers, except in emergencies. You can recognize members by their ID cards, which include logos for Lawrence General Hospital, Harvard Pilgrim, and Health Plans. Visit after January 1st to view tier assignments for Harvard Pilgrim network providers. Please call Health Plans at (877) with any additional questions. Plans currently administered by Health Plans, Inc As a reminder, Health Plans, Inc. administers several other preferred network plans. Below is a list of these plans and the contact information for how you can learn more. Southcoast Health Plan Southcoast Health System offers this three-tier preferred network to 10,000 members in Southeastern Massachusetts. For more information, visit or call Signature Healthcare Medical Plan Signature Healthcare offers a three-tier preferred network. The plan currently has 3,000 members. For more information, visit or call (877) Dartmouth-Hitchcock Medical Plan The Dartmouth-Hitchcock Hospital preferred network plan (PPO), which currently has close to 17,000 members, also features a Harvard Pilgrim Health Care 3 Network Matters December 2013

4 three-tier design. For more information, visit or call CLINICIAN CORNER Screening and Counseling for Domestic Violence While health care providers play an essential role in identifying and responding to domestic violence, many clinicians aren t sure how to handle a disclosure of abuse, the Office on Women s Health reports. Domestic or intimate partner violence includes physical, sexual, or psychological harm caused by a current or former partner or spouse. Domestic violence is about power and control, and doesn t discriminate, affecting people of all cultures, religions, genders, sexual orientations, educational backgrounds, and income levels. The majority of domestic violence victims, however, are women. The following signs are worth noting, because they may indicate possible domestic abuse, according to a report published by the Family Violence Prevention Fund on identifying and responding to domestic violence victimization in health care settings. The patient: Has unexplained injuries or injuries inconsistent with the reported history Delays medical treatment after an injury has occurred Is secretive or obviously uncomfortable when interviewed about the relationship Is accompanied into the examining room with a partner who is overly solicitous and won t leave the patient alone with the provider Returns often with vague complaints Has an unusually high number of visits with health care providers Doesn t keep medical appointments or comply with treatment Has had a physical injury during pregnancy A fact sheet published by the Office on Women s Health (part of the U.S. Department of Health and Human Services) in October, 2013, points out that to conduct a screening, the clinician does not need to be an expert on this type of violence. It recommends that, as part of the screening, the clinician can provide brief counseling to 1) encourage the patient s safety; 2) discuss any possible links between current or previous violence and the person s health concerns; and 3) connect the patient to support services and domestic violence resources. Harvard Pilgrim Health Care 4 Network Matters December 2013

5 Some resources that you and your patients may find helpful include: National Domestic Violence Hotline: SAFE (7233) National Online Resource Center on Violence Against Women: National Dating Abuse Helpline: ; text loveis to Harvard Pilgrim s behavioral health provider, Optum/United Behavioral Health (Optum/UBH), is available to support you and your patients, as well. How Optum/UBH can help your patients For complex clinical situations, Optum/UBH is available to provide consultative assistance. Practitioners can call the Optum/UBH Physicians Consultation Service at (800) To refer a patient for behavioral health services and to facilitate the coordination of care, call Optum/UBH at (888) OFFICE ASSISTANT E-tool Enhancements Aid Providers with Member Eligibility and Authorizations Beginning December 20, 2013, Harvard Pilgrim will introduce enhancements to our e- channels HPHConnect, NEHEN, NEHENNet, HTS and CORE SOAP and MIME that will make it easier for providers to verify member eligibility and request appropriate authorizations for members in limited network products, as well as verify their status in the limited network. Our limited network products include: Focus Network MA (HMO), GIC Primary Choice HMO, ElevateHealth, BIDMC Select Tiered Copayment HMO Plan, and BMC Select. These plans offer access to a provider network that is smaller than Harvard Pilgrim s full provider network. Members have access to network benefits only from the providers in the product s participating network. If a member of a limited network product seeks care outside the network other than for emergency room care Harvard Pilgrim will not provide reimbursement. Harvard Pilgrim Health Care 5 Network Matters December 2013

6 The new information available on our e-channels can help ensure that providers are delivering care that is reimbursable and that members aren t incurring unexpected costs. New eligibility information When checking eligibility for members in a limited network product through our e- channels, providers will receive: A reminder of their participation status in the limited network and tier level (if participating). This reminder is now available in NEHEN, NEHENNet, HTS and CORE SOAP and MIME, and will come to HPHConnect in A message informing them that the member participates in a limited network plan and reminding them to verify their own participation status, as well as the participation status of any providers to whom they are referring the member, before rendering services. This reminder becomes available on December 20, Authorization notices Harvard Pilgrim s e-channels will also provide improved, more detailed messaging to non-participating clinicians seeking authorizations to provide services for members of Harvard Pilgrim s limited network products. For non-emergency services, the provider will receive a message denying the authorization request*, along with an explanation that the provider is excluded from the network in which the member participates. In these cases, please advise the member to consult Harvard Pilgrim s product-specific provider directories or call the Member Services number on their ID card to find a network participating provider. In addition, when a denial is issued, Harvard Pilgrim will send members and providers a letter detailing their appeal rights. * Denials are issued in most cases. However, if the member is between years old, the provider will receive notice that the request is pending while it s determined whether the member is a student and if there is a participating provider who can render the same service. New Urine Drug Testing Payment Policy Harvard Pilgrim Health Care 6 Network Matters December 2013

7 Effective March 1, 2014, Harvard Pilgrim will implement new reporting and reimbursement rules for urine drug testing in addition to those noted in the current Laboratory and Pathology Payment Policy. The new Urine Drug Testing Payment Policy is aimed at ensuring that drug and alcohol testing is appropriate and medically necessary to detect alcohol, drugs, or drug metabolites as part of medical treatment for alcohol or substance abuse. While existing medical literature supports qualitative testing (CPT 80102; which reveals the presence or absence of a substance) as part of a medical treatment plan for alcohol or substance abuse, it does not support routine quantitative testing (which provides the level of a given substance in the sample). The new payment policy is consistent with current medical literature. Under the new payment policy, Harvard Pilgrim will no longer reimburse: Quantitative urine drug testing when no underlying qualitative test has been performed or when the qualitative test is negative Quantitative urine drug testing reported with the same date of service as qualitative testing Qualitative urine testing reported under CPT codes 80100, 80101, or Services for custom profile requisitions without individual orders specific to the member s individual treatment plan More than 20 dates of service per calendar year for all urine drug screening tests In addition, Harvard Pilgrim does not reimburse testing for residential monitoring purposes. Please refer to the new Urine Drug Testing Payment Policy in our Provider Manual for complete policy and coding information. Harvard Pilgrim Health Care 7 Network Matters December 2013

8 Network Matters is a monthly newsletter for the Harvard Pilgrim provider network Eric H. Schultz, President and Chief Executive Officer Richard Weisblatt, Ph.D., Senior Vice President, Provider Network Annmarie Dadoly, Editor Kristin Edmonston, Production Coordinator Read Network Matters online at For questions or comments about Network Matters, contact Annmarie Dadoly at annmarie_dadoly@harvardpilgrim.org or (617) Harvard Pilgrim Health Care 8 Network Matters December 2013