GATEWAY MEDICAL MANAGEMENT COMMITTEE

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1 CLIENT UPDATE 1 FALL 2011 MALPRACTICE INSURANCE / CHANGES 2 HIGHLIGHTS: MULTIPLAN & SENTARA 3 HIGHLIGHTS: COVENTRY 4 HIGHLIGHTS: VA PREMIER 5 Provider focus ADDRESSING THE NEEDS OF OUR AND BUILDING THE FOUNDATION ADDRESSING THE NEEDS OF PROVIDERS INDIVIDUAL INVESTORS AND PLANTING FOR MORE AFFORDABLE AND ACCESSABLE HEALTH CARE OPTIONS THE SEEDS FOR A SECURE FUTURE. Client Update Gateway Health is pleased to welcome our newest clients! Self Funded: Fluvanna County and Schools - Effective October 1, 2011 Duke LifePoint Cardiac Partners - Effective October 1, 2011 Duke LifePoint Maria Parham Hospital - Effective November 1, 2011 Duke LifePoint Person Memorial Hospital Effective October 1, 2011 UPCOMING MEETINGS GATEWAY MEDICAL MANAGEMENT COMMITTEE DRMC, Administration Board Room October 11, 5:30 pm November 8, 2011 GATEWAY BOARD OF DIRECTORS DRMC, Administration Board Room October 26, pm 1

2 Gateway Health credentials Nurse Practitioners and Physician s Assistants Please notify Carol at cjanke@gatewayhealth.com if you have NPs or PAs in your practice. AFFORDABLE MALPRACTICE COVERAGE Physicians continue to experience high premiums and difficulty finding affordable professional liability insurance. As a service to our physicians, Gateway maintains a partnership with Chas. Lunsford and Associates. Chas. Lunsford Sons & Associates has been successful in reducing physician premiums significantly in Virginia. If you would like access to these competitive quotes or more information, please contact Trish Clark, directly at or by toll free at Insurance, Plan, Benefit Changes Please remember that insurance plans and benefits can change from year to year. Please check insurance cards for new co-pays, deductibles and other insurance information. If you have questions regarding the plans that you participate in, please do not hesitate to contact Provider Relations: Carol Janke at cjanke@gatewayhealth.com. CCNV Has Moved! Their new address is: Community Care Network of Virginia 3831 Westerre Parkway Henrico, VA Phone: (804) Fax: (804) Credentialing Fax: (804) (Please note- these numbers have not changed) 2

3 Multiplan and Sentara HIPAA 5010 and ICD-10 Update The Federal Government, through the Centers for Medicare and Medicaid Services (CMS), is driving the healthcare industry to upgrade core HIPAA transactions (5010) by January 1, 2012 as well as diagnosis and procedure coding standards (ICD-10) by October 1, MultiPlan is working with clients to fully support their 5010 transactions and will begin testing in early 2011 in preparation to support 5010 transactions in Q MultiPlan will provide additional details in the next issue of Partnership. Updated Provider Handbooks Now Available The latest MultiPlan and Beech Street provider handbooks are available on the MultiPlan and Beech Street websites, respectively. CPAP and BiPap Rental Policy Optima Health s Clinical Care Services is modifying the rental policy to state CPAP and BiPAP will be rented up to three (3) months prior to purchase. The goal of this change is to allow members and DME suppliers an extended time period form member adjustment and compliance with the devices. Transition from rental to purchase can occur after the first, second or third month after compliance is established by faxing compliance reports to or All members / providers have access to CPAP education on optimahealth.com My Life My Plan Patient Information and Health Education Krames Online. This policy change will be applied to commercial, Optima Family Care and Optima Medicare PPO members. 3

4 Coventry Health Care Notice from Coventry Health Care Sent: July 12, 2011 To: CareNet Participating Providers Due to federal regulations, the Virginia Department of Medical Assistance Services is requiring all Medicaid health plans to report National Drug Code (NDC) numbers on all drug-related outpatient claims. Beginning with dates of service on or after May 16, 2011, CareNet participating providers are required to submit NDC numbers in addition to the J-coders or CPT codes billed on all drug-related outpatient services. Units of measure must also be included in the claim. This will be a requirement for both paper and electronic claims. Claims that do not contain an NDC number are being rejected with a rejection code on the remittance advice indicated as: Please submit drug name, dose, and NDC # for review. If you receive this rejection code, you will need to resubmit your corrected claim to include the NDC number within 365 days of rejection. Please indicate resubmission on the claim. The following link provides a list of all codes currently requiring NDC: 4

5 : Primary Care Physicians Incentive Plan Effective January 12, 2012 Program Summary: Overview: $2 PMPM base amount $1 PMPM (50% of practice must have open panel status) $2 PMPM HEDIS incentive (based on tier structure below) $5 PMPM available in total HEDIS Measures: Childhood Immunization Status (2) Breast Cancer Screening Comprehensive Diabetes Care o Eye Exam o HbA1c Testing o LDL-C Screening o Monitor Nephropathy Use of Appropriate Medications for People With Asthma o Years o Years Well-Child Visits in the first 15 Months of Life Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life Adolescent Well-Care Visit (12-21) Cholesterol Management Lead Screening in Children Adult BMI Assessment Cervical Cancer Screening Chlamydia Screening in Women Avoidance AB Tx for Bronchitis Pharmacotherapy COPD Tier Structure: Tier One Platinum Practices: $2.00 PMPM Compliancy rate: 90% or greater Tier Two Gold Practices: $1.50 PMPM Compliancy rate: % Tier Three Silver Practices: $1.00 PMPM Compliancy rate: % 5

6 continued September 12, 2011 Letter from VP of Network Development Dear Provider: In keeping with our commitment to promoting continuous quality improvement with diagnostic imaging procedures, Health Plan has entered into an agreement with National Imaging Associates, Inc. (NIA) for outpatient imaging management services. Effective November 1, 2011, we will implement a precertification program for outpatient diagnostic imaging procedures. Under terms of the agreement, Health Plan will retain responsibility and control over claims adjudication and all medical policies and procedures while NIA will manage the precertification process using nationally revered clinical guidelines for imaging/radiology services. NIA will manage the outpatient imaging radiology services listed below through Health Plan's existing contractual relationships. Claims for imaging services will continue to be paid in accordance with the terms of your Virginia Premier Health Plan Participating Provider Agreement. Effective November 1, 2011, Health Plan is implementing a prior authorization program for diagnostic imaging procedures. This communication serves as notice, under your Health Plan Participating Provider Agreement, of changes to the program. Prior authorization will be required for the following outpatient radiology procedures: CT/CTA/CCTA MRI/MRA PET Scan Nuclear Cardiology Please note the following: The ordering physician is responsible for obtaining authorization prior to rendering the above listed services. To obtain authorization, the provider should go to the NIA web-site Or through the NIA dedicated toll free phone number, Providers rendering the services listed above should verify that the necessary authorization has been obtained by visiting or by calling NIA at Failure to do so may result in nonpayment of your claim. Emergency room, observation and inpatient imaging procedures do not require authorization. We appreciate your support and look forward to working with you to assure that Health Plan members receive quality, clinically-appropriate diagnostic imaging services. We will provide additional information as we get closer to the implementation date. If you have questions, you may call Health Plan's Provider Services Department at Sincerely, Patrick McMahon VP, Network Development Health Plan 6

7 continued Effective November 1, 2011 Health Plan has selected National Imaging Associates, Inc. (NIA) to provide radiology network management services. NIA will provide utilization management services for outpatient CT, CT A, CCTA,MRI, MRA, PET Scan, and Nuclear Cardiology imaging procedures. Procedures Requiring Prior Authorization Under Many Health Plan Plans * CT / CTA / CCTA MRI / MRA PET Scan Nuclear Cardiology, *A separate authorization number is required for each procedure ordered. The following services will not be impacted by this relationship: Inpatient advanced radiology services Emergency room advanced radiology services Observation setting radiology procedures Outpatient radiology services other than CT, CTA, CCTA, MRI, MRA, PET Scan, and Nuclear Cardiology imaging studies Health Plan will continue to perform prior authorization of coverage for interventional radiology procedures (even those that utilize MR/CT technology) If an emergency clinical situation exists outside of a hospital emergency room, you should proceed with the examination and call NIA at the next business day to initiate the normal review process. Please refer to NIA's \website to obtain the Premier Health Plan/ NIA Billable CPT Codes Claim Resolution Matrix for all of the CPT -4 codes that NIA authorizes on behalf of Health Plan. Prior Authorization Process You may obtain prior authorization through the NIA website at or through the NIA CaIl Center at (toll-free). To expedite the process, please have the following information ready (*denotes required information): Name and office phone number of ordering physician* Member name and ID number* Requested examination* Name of provider office or facility where the service will be performed* Anticipated date of service (if known) Details justifying the examination:* o Symptoms and their duration o Physician exam findings NIA's Diagnostic Clinical Guidelines can be found on NIA's website, NIA's clinical guidelines for the use of imaging examinations have been developed from practice experience, literature review, specialty criteria sets and empirical data. 7