1. health and fitness
2. drugs

NMHC Provider Connection
A Newsletter for Contracted Providers of
New Mexico Health Connections
Volume 2, Issue 1 • Spring 2015
Please share this newsletter with all healthcare providers
and administrative billing staff in your office.
Check eligibility and claims status and submit prior authorizations – all online!
NMHC has created a Secure Provider Portal that will
allow you to access Explanations of Payment (EOPs),
check claims status and eligibility, and submit prior
authorizations.
site: mynmhc.org/prior-authorization-requests.aspx.
After you’ve filled out the form, email it to provider.
[email protected]. Soon afterward you’ll receive
access to the portal so you can start using this
time-saving tool.
Getting started is easy! Just download and complete
the Portal Access Request form located on our web-
NMHC receives NCQA Accreditation for its health plans
We are pleased to announce that the National Committee for Quality Assurance (NCQA),
a private, non-profit
organization dedicated
to improving healthcare
quality, has awarded
NMHC Accreditation
status for its HMO and
PPO plans sold on and off the Exchange. NCQA
Accreditation is considered the gold standard in
the industry and offers many benefits to employers,
consumers, and health plans:
• Employers look for NCQA-Accredited plans to
ensure they are receiving the best value for their
healthcare spending.
• Consumers can use NCQA Accreditation as an
indication of a health insurer’s quality when
comparison-shopping for health plans.
• NCQA Accreditation contains all the key elements that federal law and regulations require
for health plans sold on the Exchange (Marketplace), thus helping health plans compete in the
Exchange.
NCQA is dedicated to assessing and reporting on the
quality of managed care plans, managed behavioral
healthcare organizations, preferred provider organizations, new health plans, physician organizations,
credentials verification organizations, disease management programs, and other health-related programs. To learn more about NCQA, visit ncqa.org.
Can a single question make a profound impact on women's care?
In 2014, the Oregon Foundation for Reproductive
Health launched an initiative to improve reproductive healthcare for women and to help ensure that
more pregnancies are wanted, planned, and healthy.
One Key Question® asks women, “Would you like to
become pregnant in the next year?” We at NMHC
believe that this simple question can foster better
communication between women and their providers,
help bring other potential health issues to light, and
ID0222-0315
help empower women to take charge of their own
reproductive health.
Learn more at onekeyquestion.org and read an indepth article about the initiative at Public Health
Newswire: publichealthnewswire.org/?p=10989. (The
article is in Public Health Newswire’s top 10 list of
most-viewed public health news stories of 2014.)
Remember: Refer your patients to in-network providers and preferred lab providers
Please use our online provider directory at mynmhc.
org/find_a_doctor.aspx to refer your patient to in-network practitioners, laboratories, and other facilities.
Doing so ensures that your patients are not billed by
out-of-network providers. If you need help using our
online directory, please call your provider services
representative.
in member dissatisfaction because your patient will
receive a bill from the out-of-network lab, and he or
she will be responsible for payment. You can find
a list of lab draw station locations by reviewing our
online provider directory at mynmhc.org/find_a_doctor.
aspx.
NMHC preferred laboratory providers
Please remember to send your NMHC patients to
TriCore Reference Laboratories or Quest Diagnostic
Laboratories. Both laboratories can provide you with
requisitions if you draw blood in your office. Having
lab work done via an out-of-network provider results
Compound pharmacy credentialing coming in April 2015
We are establishing a program to credential compounding pharmacies. Our new credentialing program
is called the Safe & Effective Compound Use Reassurance Effort (SECURE). As part of the SECURE
program, all network compounding pharmacies will
be required to go through a credentialing process to
verify that certain quality and safety standards are in
place for the compounded drugs.
Starting in April, if you write a prescription for a
compounded drug, your patient must fill it at a
NMHC credentialed compounding pharmacy. Once
our credentialing process is complete, we will post a
list of credentialed compounding pharmacies on our
website. Any compounding pharmacy not on the list
will be considered out of network.
Behavioral health screening tool now available
We are now offering a behavioral
health screening
tool to our members through our secure online member portal. The
M3 Clinician™ is a 27–question, validated behavioral
health screening tool that helps the member learn
the risk of having or developing a behavioral health
issue, such as depression, anxiety, post-traumatic
stress disorder, bipolar disorder, substance abuse,
and functional disabilities. Members can complete
the screening as often as they wish.
• Members may share their results with you, which
could be an included in treatment plan.
• You can accelerate your members’ intake and assessment process by directing members to the M3
Clinician and asking for the members’ results.
• Primary care and specialty medical providers may
detect co-morbid conditions more quickly by encouraging and obtaining individual member
results. In addition, if members are willing to
complete a release of protected health information, NMHC may share M3 Clinician reports with
providers.
We encourage all our contracted providers to direct
NMHC members to our website, mynmhc.org/
health-risk-assessment-hra-.aspx. From there, members can access the tool and learn how their health
information will be used. M3 Clinician results are
available immediately and can be printed or emailed.
The screening tool offers several benefits to providers:
Providers can contact Mat McFadden, Senior Director
of Behavioral Health Management, at (505) 200-0414
or [email protected] with questions.
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Pharmaceutical utilization management
Health plan pharmacy utilization management (UM) programs use a variety of tools to manage drug benefits
in order to hold down cost of care. Examples of commonly used UM tools are exclusions from coverage, prior
authorization (PA), step therapy, and quantity limits. Coverage rules for drugs and therapy classes that are
commonly subject to UM are: Experimental and investigation drugs, weight loss, infertility, erectile dysfunction, non-sedating antihistamines, growth hormones, and injectables.
Because our formulary is new to many providers in our network, we’ve listed the eight most common drugs
that are denied for a pharmacy UM edit routinely for your reference. The formulary clinical alternatives are
noted to the right of each drug.
Drugs Impacted by
NMHC Formulary Drugs
NMHC UM Edits
Adderall XR
amphetamine/dextroamphetamine, Dexmethylphenidate, dextroamphetamine,
methylphenidate
Advair
Dulera, Symbicort
Brintellix
sertraline, fluoxetine, buproprion, citalopram, escitalopram, mirtazapine,
paroxetine, venlafaxine
Butrans
buprenorphine, buprenorphine/naloxone
Flovent
Asmanex, Pulmicort, Qvar
Levemir
Lantus
Suboxone
buprenorphine, buprenorphine/naloxone
Synthroid
levothyroxine
It is also good to know that specialty drugs are subject to specific criteria in order for members to obtain
them. Two examples of drugs that fall in this category are Enbrel and Humira. Our denial data indicates these
two drugs often receive denials because criteria is not met. A full list of pharmacy criteria are listed on our
website, mynmhc.org/medical-management.aspx. Here are the specific criteria for the use of Humira and Enbrel.
Rheumatoid Arthritis and Polyarticular Juvenile Idiopathic Arthritis
Patient has had an inadequate response to, intolerance to, or contraindication to one or more non-biologic
disease modifying anti-rheumatic drugs (DMARDs; see table below) for at least three consecutive months.
Non-Biologic Disease-Modifying Anti-Rheumatic Drugs (DMARDs)
Drug
Treatment Period
Usual Maintenance Dose
Hydroxychloroquine 2 to 6 months
200 mg twice daily
Sulfasalazine
1 to 3 months
1000 mg 2 to 3 times daily
Methotrexate
1 to 2 months
7.5-20 mg weekly
Leflunomide
4 to 12 weeks
10-20 mg daily
Azathioprine
2 to 3 months
50-150 mg daily
Cyclosporine
2 to 4 months
2.5-4 mg/kg/day
Plaque Psoriasis
Patient has had an inadequate response to, is intolerant to, or is contraindicated to conventional therapy with
at least one of the following:
• Phototherapy (including, but not limited to, Ultraviolet A with a psoralen [PUVA] and/or retinoids [RePUVA]) for at least one continuous month; OR
• One or more oral systemic treatments (e.g., methotrexate, cyclosporine, acitretin, sulfasalazine) for at
least three consecutive months.
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we know you do too. If you would like to receive future
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[email protected]. We will not share your
information with anyone outside of our office.
• The email address of the office manager, billing
manager, and/or other specific staff who should
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• The name of your practice.
90-day prescription supply from a retail pharmacy
Many members on routine medications prefer to get
a 90-day supply of them. In 2014 members could do
this only by going through our mail-order pharmacy,
but now members can receive a 90-day supply of
drugs from their retail pharmacies. Receiving a 90-
day supply from a retail pharmacy does not change
the member's copay or coinsurance responsibilities.
They still will need to pay three copays for a threemonth supply. However, this option offers members
greater convenience.
NMHC Provider Relations staff directory
Note: The general Provider Relations fax number is 1-888-282-3483.
Name
Title
Phone
Fax
Email
Jeane Fowkes
Provider Relations
Specialist
(505) 200-0416
1-866-311-7044
[email protected]
Norma Ray
Provider Relations
Specialist
(505) 847-4943
1-866-796-2312
[email protected]
Jessica Griego
Provider Relations
Specialist
(505) 492-2073
1-800-504-6545
[email protected]
David Flores
Senior Credentialing
Specialist
(505) 633-8042
1-888-821-7596
[email protected]
Amy Riddle
Credentialing
Specialist
(505) 404-1208
1-800-947-8701
[email protected]
Donna Martinez
Manager, Provider
Services
(505) 404-1230
1-888-282-3483
[email protected]
Paula Hoskins
Senior Director,
Provider Services
(505) 633-8065
1-888-282-3483
[email protected]