Provider Insider January 2017

Transcription

1 Provider Insider January 2017 Happy New Year from Kaiser Permanente! Our new claims system is now live. The Epic product replaced our current claims system, allowing us to create end-to-end seamless access and integration between the electronic health record system and the claims system. Of particular improvement for our network providers is the easy-to-understand Explanation of Payment statements, as well as a more reliable timeframe of reimbursement for services. In time, you also will have visibility to claims status via Affiliate Link. A number of capabilities are included in this implementation: Improved data quality from reduced manual entry Members will be able to access their claims status online at KP.org Accurate and up-to-date accumulation of benefits including tiered-products Integration with authorization and referral processing supporting easier access to care We are committed to delivering a technology solution that will result in an improved claims processing. Resources for You Provider Representative Line: Lunch N Learns Receive important information on being a Kaiser Permanente network provider at our Lunch N Learns. Find out more information and dates of upcoming events on our website. Changes to Your Practice? We Need to Know Please inform your provider representative of any adds, changes, or terms. If you have any questions us at: CO-Roster@kp.org. Kaiser Permanente Provider Manual Whether you just joined us as a network provider, or you have contracted with us for years, here are the most recent provider manuals, right at your fingertips. Have a Question about your EOP? If you disagree with the payment you receive, please know Pharmacy formulary Welcome to our quick guide to formularies for different Colorado regions and plan types. No more

2 you can ask for reconsideration before filing an appeal. The reconsideration process should be followed before filing a level 1 appeal. Refer to our provider manual for more information. calling to be sure just bookmark this page for a copy of the Kaiser Permanente drug formulary used to verify most prescriptions. Member Service Numbers Concerns with New Authorization Form We regret any confusion the new authorization letter is creating. You may have noticed the changes within the letters pertaining to the codes no longer include individual numbers. The authorization letter reflects the codes that could be performed with the total number of services approved noted in the authorization paragraph, beginning with "Kaiser Permanente has authorized XX visits for the following service(s) or supplies that you requested for the individual named above:" Please reference affiliate link or order entry for additional authorization information. Service area phone numbers for member services to help you direct member questions Denver / Boulder: Mountain Northern Southern Mountain Colorado Helping Patients Understand the New Medical Aid-In-Dying Law As you are aware, Ballot Proposition 106, the Colorado End-of-Life Options Act, passed on November 8, The law permits terminally ill adults, who meet specific qualifications, to request and receive a prescription for lifeending medication from their physician. Kaiser Permanente is working to understand how best to implement this new law. This includes ensuring participating physicians know how to comply with the law s requirements. We recognize that our members may turn to you, their care provider, with questions about Medical Aid in Dying. If you have questions for Kaiser Permanente, please contact your provider representatives at and they can seek out specific answers for you. Care for Ski Injuries We re now partnering with Centura s Summit County Urgent Care clinics at the base of area ski resorts to better manage the care of our members. Northern Colorado Second Medical Offices Location for Fort Collins Our new medical offices in Fort Collins are now open. The Kaiser Permanente Spring Creek Medical Offices are located at 1136 E. Stuart Street, Suite 200 and offer primary care, laboratory, and pharmacy services to our northern Colorado Kaiser Permanente members. Southern Colorado Important Information on Opioid Prescriptions Background: Updated Formularies The Kaiser Permanente Commercial Drug Formulary is now in place with the formularies for Southern Colorado large group HMO, Self-Funded (EPO),

3 Effective January 1, 2017, the Centers for Medicare and Medicaid Services (CMS) requires Medicare Part D plan sponsors (Kaiser Permanente) to implement Point-of-Sale (POS) edits to monitor for opioid overutilization. Kaiser Permanente has implemented a soft reject edit that triggers whenever a patients prescription exceeds 100mg daily morphine equivalent dose (MED) within a 90-day time frame. The prescription adjudication system will calculate a daily MED dose for each prescription when the pharmacy processes it. The calculation considers the quantity, day supply, medication dosage and MME (Morphine Milligram Equivalence) for historical and current claims. Federal Group. Additionally, the KPCO PPO Preferred Drug List is now consolidated to match the drug formulary listing currently in place for Denver/Boulder, Mountain Colorado, Northern Colorado, and the Colorado Marketplace. As a reminder, this change resulted in the creation of the Kaiser Permanente Commercial Drug Formulary. Processes have been put in place to avoid rejections for members in hospice, with a cancer diagnosis or undergoing palliative care. Necessary Actions: If claims reject for exceeding the 100mg daily morphine equivalent dose (MED): The pharmacy should verify that they entered the correct day supply. The dispensing pharmacist should evaluate if the dose is reasonable and appropriate. If the pharmacist determines the dose to be reasonable and they wish to proceed with dispensing the drug, they may contact the Pharmacy Benefits Manager (PBM) at for an override code. If the pharmacist has concerns regarding the dose they may contact the prescriber for verification. Once verified and the pharmacist wishes to continue to dispense the medication they may contact the Pharmacy Benefits Manager (PBM) for an override code. Claim rejections due to exceeding the 100mg daily morphine equivalent dose (MED) do not require prior authorization from the Medicare Part D plan sponsors (Kaiser Permanente). Overriding these rejections is a dispensing pharmacist responsibility. New Services and Specialties in 2017 Kaiser Permanente members who live in the Estes Park area now have access to many services and specialties at

4 Estes Park Medical Center and Estes Park Medical Group. This includes: Full service Emergency Family Medicine Physicians Internal Medicine Orthopedics Orthopedic Surgery OB/GYN Radiology Ophthalmology Podiatry New laboratory locations have also been added to better serve our members living in the Estes Park. New Benefit for First Responders Beginning in July, firefighters and other first responders in all Kaiser Permanente Service Areas can now take advantage of a first responder benefit. Coverage is limited to specific groups who have purchased the First Responder benefit. Members will need to identify as having this benefit when booking an appointment and bring three completed questionnaires to the appointment: PHQ-9, CAGE-AID & Epworth Sleepiness Scale. Additional talking points are available on the community provider portal and your provider representative will have more information at the February Lunch N Learn meetings. Medical Financial Assistance Available to Kaiser Permanente Members Kaiser Permanente, a nonprofit healthcare provider, strives to support our patients, and in some cases, that means locating assistance programs for medical services and pharmacy expenses for eligible patients in need. Kaiser Permanente members may be eligible for a government medical assistance program or a Kaiser Permanente sponsored financial assistance program. If you have Kaiser Permanente patients who may benefit from these types of programs, please direct them to call one of our Medical Financial Assistance (MFA) counselors.

5 They can provide information, determine eligibility, and assist with the application process. Counselors can be reached at (TTY: 711), Monday - Friday, 8 a.m. - 5 p.m. Send feedback, questions, comments, and ideas for future newsletters to: CO-ProviderCommunications@kp.org For more information visit: providers.kaiserpermanente.org/cod/ or call: Click to view this in a browser If you no longer wish to receive these s, please reply to this message with "Unsubscribe" in the subject line or simply click on the following link: Unsubscribe Kaiser Permanente Colorado E. Dakota Ave. Denver, Colorado US