Third Quarter 2013

Provider Newsletter

EPSDT Screening and Lab ReminderThe Maryland Healthy Kids/EPSDT program requires that specific screenings and required labs are completed for children enrolled in their program. These screenings and labs must be documented in the patient’s chart and include:

• Anemia Screening: Screen at 12 and 24 months of age by performing a hematocrit (Hct) or hemoglobin (Hgb). No further screenings are required unless clinically indicated or there are no previous test results available for the child.

• Lead Risk Assessment and Blood Lead Testing: Use the Preventive Screen Questionnaire at each preventive healthcare visit from ages six months to six-years-old. Regardless of the results of the lead questionnaire, every child must have a blood lead level (BLL) test at 12 months and 24 months of age. Initiate BLL testing at any age and when documentation of a previous baseline BLL cannot be confirmed for children up to six years of age. DHMH, consistent with the new CDC guidelines, recommends that children with a lead level greater than the new reference level of 5 mg/dL should be retested within three months.

• Measurements and Graphing: Height and weight is required through 20 years of age and graphed on growth charts. Calculation and graphing of body mass index (BMI) is required on ages two to 20. Measurement and graphing of head circumference to age two is required. Blood pressure must be documented on ages three and older.

• Developmental Screening Tools, i.e Ages and Stages Questionnaire (ASQ) or Parents Evaluation of Development Status (PEDS): These are purchased forms and cannot be photocopied. Implementation of the tools became effective Jan.1, 2012 and must be used at pediatric visits nine,18, and 24 to 30 months. To obtain training on the tools, contact the Maryland Healthy Kids program at 410-767-4804. Since there is an up-front cost to obtain these forms, the provider will

Maryland HealthChoice Program

receive reimbursement for utilizing the screening tools by billing CPT code 96110 on the HCFA 1500 form as each individual form is used.

• M-CHAT (Modified Checklist for Autism in Toddlers): This form is free of charge. It can be printed from the M-CHAT website at MCHATScreen.com and can be photocopied. The form should be used at pediatric visits at ages 18 months and then 24 to 30 months. Providers are reimbursed for completing the M-CHAT by using CPT 96110 on the HCFA 1500 form. If the M-CHAT is performed on the same day as a billable developmental tool using CPT 96110, be sure to attach Modifier 59 to report the services as separate and distinct screenings performed on the same day.

• Substance Abuse Assessment: This assessment should begin at 12 years of age or younger, if indicated, with re-assessment yearly thereafter.

• Hearing and Vision Assessment: This assessment should occur during preventive care visits. Follow up with a qualified specialist for these elements may be indicated when a problem is identified. Newborn hearing screen follow up is required for abnormal results.

• STI/HIV Risk Assessment: Complete the risk assessment at each Healthy Kids visit beginning at age 12 or earlier according to the child’s history. Follow up with appropriate assessments and testing when there is a “yes” answer to any of the questions on the Preventive Screen Questionnaire.

Please contact the Division of Healthy Kids program at 410-767-1903 with any questions. Visit DHMH.State.MD.US/EPSDT/HealthyKids for more information.

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Participate in yearly Provider SurveysEach year, the HealthChoice program sends out a provider satisfaction survey. This survey is separate and distinct from the MedStar Family Choice satisfaction survey that is faxed to each office in November of every year by our Provider Relations department. MedStar Family Choice encourages all offices to participate in yearly satisfaction surveys. Your responses are imperative to improve the services providers receive.

Although MedStar Family Choice scored above the HealthChoice aggregate and above all other HealthChoice MCOs on “Overall experience in obtaining authorization for medications,” this attribute was identified in the survey as being of high importance to our providers. For this reason, MedStar Family Choice is asking for your input to identify opportunities for improvement that will further increase satisfaction with this process.

Please contact your Provider Relations Representative at 800-905-1722, option 6 or send an email to msfcproviderrelations2@medstar.net with your comments and suggestions.

Council for Affordable Quality HealthcareMedStar Family Choice is pleased to announce that we are now a member of the Council for Affordable Quality Healthcare (CAQH). Effective July 1, 2013, providers wishing to participate in the MedStar Family Choice provider networks are required to complete and submit a MedStar Family Choice CAQH Medical Data Sheet that will be used to add you to our CAQH provider roster. This will allow MedStar Family Choice to access your CAQH application and supporting documents for credentialing. Please be sure to update your CAQH record by authorizing MedStar Family Choice to access your credentialing information. Also, please note that a current and signed Standard Authorization, Attestation and Release form is required every 120 days as part of your CAQH application.

Providers in the recredentialing process can now allow MedStar Family Choice to obtain their application through CAQH as well. CAQH will notify a provider when we obtain their application from the site. Therefore, providers will need to continue to keep all of their information and documents updated in order to avoid a delay in their recredentialing process.

Providers who are not a member of CAQH can complete the Maryland Uniform Credentialing Form (MUCF) with a current and signed Standard Authorization, Attestation and Release form, as well as supporting documents.

Please contact Provider Relations with questions at 800-905-1722, option 6.

Member Complaint/Grievance and Appeal ProcessThe MedStar Family Choice complaint/grievance and appeal procedure that members follow can be found on our website at MedStarFamilyChoice.com and in your provider manual. If you do not have access to our website or a provider manual, you may call our Provider Relations department at 800-905-1722, option 6 for a copy of the manual. The process will tell you the following:

• How members can file a complaint, grievance or appeal, and the differences between them

• How quickly we will respond to the member and the provider

• What to do if the member does not agree with our decision

Please note that providers may not appeal a decision on the member’s behalf without written permission from the member. Members have the right to contact the HealthChoice Enrollee Help Line at 800-284-4510, Monday through Friday, 7:30 a.m. to 5:30 p.m., when they have a concern about a decision made by MedStar Family Choice.

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Eye ExamsEffective July 12, 2013, CPT codes 92002, 92004, 92012, and 92014, General Ophthalmological Service, are noncovered services for screening vision eye exams

On Dec. 16, 2012, CPT code 92015, Eye Exam, Determination of Refractive State, became a non covered service for screening vision eye exams.

Under the Early Periodic Screening and Development program, children up to five years of age are assessed for vision impairments through health history, physical examination and gross subjective assessment. Objective vision tests are recommended at four through six, 12 years, 15 years, and 18 years of age.

CPT codes 92002, 92004, 92012, and 92014, classified as General Ophthalmological Services, and 92015—Determination of Refractive State, are not recommended objective vision screening test(s) in the EPSDT recommendations or federal mandates and are not intended as screening test(s). Claims submitted with these codes by providers other than optometrists or ophthalmologists will be denied by MedStar Family Choice. Appropriate claims for the CPT codes listed in this communication, rendered by optometrists or ophthalmologists, are processed by Advantica. Please contact Advantica at 888-998-5005 regarding participation and claims processing questions.

Coordination of Care Between Members, the PCP, and the Emergency RoomAll too often, our members visit the Emergency Room and you, the providers, are not aware. The member does not follow up and call for an appointment or the ER does not send you the ER report. MedStar Family Choice now receives ER reports for all our members who visit the ER. In an effort to coordinate care between the member and their PCP, MedStar Family Choice wellness coordinators will notify your office and, whenever possible, obtain the ER report and send it to your office. They will also call the member to assist them in getting a follow-up appointment with you. We will be targeting members ages three through six and members 12 through 21. If the wellness coordinator finds that the member did not have their annual physical examination, they will be assisting the member to schedule that appointment as well. We are asking that providers complete the annual physical examination and follow up from the ER in one visit when applicable. If you have any questions or would like further information, please call Janelle at 410-933-2213.

MedStar Family Choice E/M AuditsThroughout each year, MedStar Family Choice conducts random chart audits. Once a provider’s office is selected, a MedStar Family Choice provider relations representative will contact the physician’s office and request a copy of specific dates of services for MedStar Family Choice members. The records are reviewed by our internal claims auditor and each code that was billed and paid is analyzed. For E/M visits, many providers complete the work associated with the level of service that was billed, but they fail to document the visit in detail in the medical record. As a result, it appears as though the level of service provided was lower than what was actually billed and these payments may be retracted at a later date.

To avoid retractions, providers should ensure that all levels, especially higher levels, of E/M codes are documented appropriately. It is extremely important for providers to document each component of the office visit clearly. The documentation in the medical records must be legible, dated, signed by the provider, and support the CPT code that was billed on the claim. If you have any questions regarding MedStar Family Choice chart audits, please contact Provider Relations at 800-905-1722, option 6.

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ICD-9 Codes Used on Laboratory Request FormsPlease be advised that the ICD-9 250 range of diabetes codes are used for patients that have diabetes. When you wish to screen for diabetes, be careful to select an ICD-9 screening code, such as V77.1 (Special screening for diabetes mellitus). Labcorp data feeds into MedStar Health databases and will assign your patient with a diagnosis of diabetes if you enter an ICD-9 code of 250. If the laboratory results are negative, our mutual member will be incorrectly identified as having diabetes. Subsequently, coding of ICD-9 250 causes an automatic process where these patients will receive mailings from MedStar Family Choice indicating that they have the diagnosis of diabetes. Using the screening code will prevent any inappropriate mailings. We appreciate your attention in our effort to maintain data integrity.

Health Education ScheduleWe offer health education classes free of charge to MedStar Family Choice members. Classes are designed to appeal to our members on many health levels. For example, prenatal classes are available for moms-to-be, along with education for infant safety and sibling classes. These are just a few classes offered through the birth and family education listings. In addition to these classes, MedStar Health hospitals offer blood pressure screenings, and cancer, diabetes and heart disease education, as well as smoking cessation support. Providers are encouraged to refer members to these classes and document the referrals, as well as the member’s feedback, in the member’s chart. Visit MedStarFamilyChoice.com for a complete listing of classes. If you do not have access to the Internet, you may call MedStar Family Choice Provider Relations at 800-905-1722, option 6, for a listing of classes.

PCP Auto AssignmentMembers who fail to designate a primary care provider (PCP) after enrolling in MedStar Family Choice will be called by our Member Services team and assisted in selecting a PCP. If we are unable to contact the member, we will automatically assign a PCP that is geographically close to the member’s residence. Members under the age of 21 are automatically assigned to EPSDT providers as appropriate. Members may change PCPs at any time by calling Member Services. If your name is not listed on the member’s card on the date of service, you are permitted to see the member as long as you are participating with MedStar Family Choice and the member is eligible with MedStar Family Choice on the date of service. When possible, we ask that your office assist the member in having his/her member card changed to reflect the correct primary care provider by calling Member Services at 888-404-3549. We continue to mail member rosters to PCPs on a monthly basis, but this information changes daily and should not be used to determine member eligibility. Therefore, provider offices should be utilizing the state’s EVS line to verify benefits on the date of service. If you have more questions regarding eligibility, our Outreach department is available to answer questions by calling 800-905-1722.

Organ Transplants—Complex Case Management ServicesMedStar Family Choice offers complex case management services to all MedStar Family Choice members who are being considered for an organ transplant. Complex case managers are available to assist MedStar Family Choice providers and potential transplant members with the coordination of care. Physicians who are evaluating a member for an organ transplant should contact the MedStar Family Choice Care Management department Monday through Friday from 8:30 a.m. to 5 p.m. by calling 800-905-1722 or sending a fax to 410-933-2274. Please note: Faxes or voicemail messages received after hours will be addressed the next business day.

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Completing Back to School FormsPrior to the start of a new school year, parents of MedStar Family Choice members may request that their child’s PCP complete applicable school forms. Please remember that the completion of forms cannot be billed to patients participating in the Maryland Medical Assistance program. All other services that are not covered or not reimbursed under the Maryland Medical Assistance program can be found at EMDHealthChoice.org/ProviderInfo/pdf/2010/Nov10/Phys-svcs-prov-fee-man_Nov-2010.pdf in the Maryland Medical Assistance Program Physicians’ Services Provider Fee Manual.

Find a Provider OnlineFinding a participating MedStar Family Choice provider couldn’t be easier! Visit MedStarFamilyChoice.com to look up participating PCPs and specialists by logging on to our online provider directory. Providers can be found by:

• Specialty

• Last name/facility name

• First name

• Group name

• Languages

• Hospital affiliations

• New patients

• Gender

• City

• Radius/ZIP

Just complete one or more of the search fields and you will get updated information instantly. If your office does not have access to the web, please contact Provider Relations at 800-905-1722, option 6.

Patient Safety Information Regarding PharmaceuticalsMedStar Family Choice receives safety information, including black box warnings or recalls, from our pharmacy benefit manager. Visit MedStarFamilyChoice.com to view these safety updates, as well as current MedStar Family Choice pharmacy protocols and clinical practice guidelines.

EPSDT Materials and CertificationWe continue to urge primary care providers who treat members under the age of 21 to use the standard EPSDT forms during well-child visits. The forms are age appropriate and help offices to meet all the program elements required by the state of Maryland when used accurately. Visit the Maryland Healthy Kids website at DHMH.State.MD.US/EPSDT/HealthyKids for up-to-date forms, schedules and clinical guidelines, as well as a copy of the provider manual. If your office does not have Internet access, hard copies of current EPSDT forms and related materials can be requested from MedStar Family Choice Provider Relations by calling 800-905-1722, option 6.

If you are a primary care provider and you are treating patients under the age of 21 but you are not EPSDT certified, MedStar Family Choice encourages you to become certified by completing EPSDT training through the Healthy Kids program. The first step to becoming EPSDT certified is to contact a Healthy Kids program nurse consultant by calling 410-767-1683. If you have questions or require additional assistance, please do not hesitate to contact our Provider Relations department at 800-905-1722, option 6.

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Provider Participation and Demographic ChangesMedStar Family Choice requires participating providers and/or groups to submit written notification of all changes regarding their practice prior to the change(s) effective date. Changes that require written notification prior to the change(s) effective date are:

• Participation status (90 days notification is required for terminations)

• Group/Doing Business As (DBA) names

• Tax ID numbers (45 days notification is required for changes)

• NPI

• Service location addresses (additions and closings)

• W-9 name

• W-9 addresses

• Billing addresses

• Telephone/fax numbers

Providers and/or group written notifications must include the provider’s name, tax ID number, authorizing signature, contact information for inquiries and a description of the change along with the effective date. Once the appropriate documentation has been received, MedStar Family Choice will update the information to reflect the change in our systems. Failure or delay in submitting provider and/or group change information may result in a delay of claims payment or claims denial.

It is important to note:

• All changes to billing addresses and tax ID numbers must be accompanied by an updated W-9 form or the change cannot be processed.

• Provider, group and/or tax ID changes may require the completion of new contracts to retain participation status.

Visit MedStarFamilyChoice.com for a provider demographic change of status form. You may also submit written notification of changes by fax, postal mail and/or email to:

MedStar Family Choice 8094 Sandpiper Circle, Suite O Baltimore, MD 21236 ATTN: Provider Relations Department msfcproviderrelations2@medstar.net 855-600-3077 FAX

Obtaining Prior AuthorizationsA limited number of services require authorization from the MedStar Family Choice Care Management department before the patient receives care. To obtain prior authorization, the rendering/ordering provider must complete the MedStar Family Choice Care Management Authorization Request form or the Maryland Uniform Referral form that includes the following:

• Requesting Provider’s Name

• Rendering Provider Name and Location

• Exact diagnosis code(s)

• Exact procedure (CPT) code(s)

– Please note: The diagnosis and CPT code provided for the authorization request must match the diagnosis and CPT code that will be billed to ensure proper claims processing.

In addition to completing the MedStar Family Choice Care Management Authorization Request form or the Maryland Uniform Referral form, the rendering/ordering provider must attach all pertinent clinical information supporting the request for medical review. Failure to provide clinical information within seven days of your original request will result in denial of services. Also, to avoid unnecessary cancellations, please send elective authorization requests at least seven days in advance of the procedure.

Please fax your authorization request to the MedStar Family Choice Care Management department at 410-933-2274 or 888-243-1790.

A copy of the MedStar Family Choice Care Management Authorization Request form can be found at MedStarFamilyChoice.com or call Provider Relations at 800-905-1722, option 6 for a copy.

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Services Not Requiring AuthorizationServices must be performed by a participating MedStar Family Choice provider in a participating MedStar Family Choice facility using the appropriate CPT code listed for the service being provided. Failure to meet all elements could result in claim denials.

Most commonly billed services that do not require prior authorization when performed by a participating MedStar Family Choice provider in a participating facility include:

CPT Code Description Who can perform/ order this service

Where can this be performed?

Radiology Codes

MRI/CT/X-Rays Any participating provider

Any participating facility

43235 43251 43255 43260

EGD Any participating provider

Any participating facility

45378 45387 45391 45292

Colonoscopy Any participating provider

Any participating facility

45330 45342 45345 (45336 is not valid)

Sigmoidoscopy Any participating provider

Any participating facility

19100 Breast biopsy Any participating provider

Any participating facility

54150 54160 54161

Circumcision Any participating provider

Any participating facility

76801 through 76828 with 93325

High-risk OB Radiology

Any participating provider

Any participating facility

Note: This is not an all inclusive list

For questions regarding prior authorization, please contact our Care Management department at 800-905-1722, option 1.

Update to the MedStar Family Choice Formulary Maryland HealthChoiceUpdates continue to be available quarterly on MedStarFamilyChoice.com and more frequently on ePocrates. Paper copies of the 2013 formulary booklet can be requested from the MedStar Family Choice Provider Relations department. Details of the prior authorization criteria are available on the MedStar Family Choice website with the other pharmacy protocols. Contact Provider Relations at 800-905-1722, option 6 if your office does not have access to the Internet and you would like copies of this information.

At the July 2013 Pharmacy and Therapeutics Committee meeting, the following changes were made:

Additions that have or will go into effect in the next few weeks:

• OTC doxylamine

• OTC pyridoxine

• OTC Plan B – age restriction removed

Additions with prior authorization effective on or around Aug. 1, 2013:

• Tecfidera (dimethyl fumarate DR) for relapsing multiple sclerosis.

Removals

• None

Removal of Prior Authorization

• None

Managed Drug Limitations and Step Therapy

• None

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8094 Sandpiper Circle, Suite O Baltimore, MD 21236 888-404-3549 PHONE

The MedStar Family Choice Newsletter is a publication of MedStar Family Choice.

Submit new items for the next issue to Melanie Bodencak, MedStar Family Choice, melanie.bodencak@medstar.net

Kenneth A. Samet, FACHE President and CEO, MedStar Health

Eric Wagner President, MedStar Family Choice

Melanie Bodencak Editor

MedStarFamilyChoice.com

13-MFC-0887.092013

Tips for Ensuring Patient PrivacyThe HIPAA Privacy Rule and HIPAA Security Rule are federal laws that regulate what can and cannot be done with patient information. Protected health information (PHI) is “anything you see or hear that lets you know about the health of a specific patient.” Electronic protected health information (ePHI) is “any electronic form of PHI, including data stored on computer hard drives, file servers, data storage tapes, and CDs, as well as data transmitted electronically.” A few simple steps can help protect PHI and ePHI daily. These tips include:

• Do not leave patient information in areas where it can be viewed by unauthorized personnel.

• Sign-in sheets should not state the reason for the patient’s medical appointment.

• Face sheets should be turned toward the wall if patient charts are outside of an examination room.

• Keep confidential conversations at a low level.

• Leave minimum information regarding appointments on patients’ voicemails.

• Computers/work stations should be in an area that minimizes accidental/nonauthorized viewing of patient information.

• Assign strong passwords to computer systems.

• Do not share user IDs or passwords with anyone.

• Do not post passwords in or around workstations or leave them where they can be easily viewed by others.

• Always log off of computers/work stations when leaving work for a long period of time or lock computers when away from the work station.

• Add password-protected screensavers to personal work stations.

• Protect electronically transmitted PHI through encryption and password protect electronic patient information.

• Save PHI data to the appropriate locations and in the appropriate manner so the data is backed up regularly.

• Properly dispose of any documents or papers containing PHI in shredders or special destruction boxes.

Visit the U.S. Department of Health and Human Services website at HHS.gov for more information regarding HIPAA rules.

Provider Training on State-Mandated Developmental Screening ToolsDevelopmental training or retraining on pediatric screening tools for children under six years old is recommended. The training covers the recommended ASQ or Peds screening tools that Maryland pediatric primary care providers are required to use in their office, as well as how to interpret and document screening results and how to refer and track referrals. Please contact Marti Grant, RN, MA, consultant, at 443-621-8361 or by email at garymarti1@verizon.net to schedule a training.