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Topics Covered in this Issue:
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HEDIS Data Collection Began in February
How To Request Reviews or
Reconsiderations For Claims Processed
Best Practices in Pain Medicine
Pre Authorization Reminder
Valuable Information Available Online
Training Sessions Now Available for
www.directprovider.com
NCQA /CMS Required Information
Important Network Information Specialty
Pharmacy Program
HEDIS Data Collection Began in February
The Healthcare Effectiveness Data and Information Set
(HEDIS) is a widely-used set of performance measures in the
managed care industry, developed and maintained by the
National Committee for Quality Assurance (NCQA).
HEDIS was designed to help consumers compare health plan
performance to other plans and to national or regional
benchmarks. HEDIS information is also used to identify trends.
The Centers for Medicare and Medicaid Services (CMS)
require that Managed Care Organizations (MCOs) submit
HEDIS data in order to provide MCO services.
Coventry Health Care of Illinois, Inc. (“Coventry”) / Coventry
Health Care of Missouri, Inc. (“Coventry”) participates in the
annual HEDIS data collection project. Data collected supports
quality improvement projects for our Commercial, Medicare,
and Medicaid populations. Data is collected from primary
care practitioners and specialty providers.
HEDIS will begin in February and end in May. A member of our
Quality Improvement team will contact your office before midFebruary to schedule visits or request that records be faxed or
mailed. Some providers have expressed concern about
whether they may disclose medical record information to
Coventry in light of the Privacy Rule requirements of the Health
Insurance Portability and Protection Act (“HIPAA Privacy
Rule”). In its “Guidance Explaining Significant Aspects of the
Privacy Rule” dated December 4, 2002, the U.S. Department
of Health & Human Services Office of Civil Rights stated a
provider may disclose protected health information to a health
plan for the plan’s Health Plan Employer Data and Information
Set (HEDIS) purposes. Please see 45 CFR 164.506(c) (4) for
more detailed information.
As always, we thank you for your assistance with collecting the
data for HEDIS. We look forward to working with you again this
year. For more information on HEDIS visit the NCQA website
at www.ncqa.org.
How to Request Reviews or Reconsiderations
for Claims Processed
Our claims and correspondence team receive countless
pieces of mail to review. Frequently x-rays or notes are sent
with no explanation. To avoid delays, or unnecessary return
mail, please make sure the member name, member ID and
claim number(s) are included on any request for review or
reconsideration. A brief cover letter with the member ID, the
claim number and the reason for the request will significantly
expedite the review process. Appeals must have an formal
letter attached to be considered and reviewed as an
appeal.
Best Practices in Pain Medicine: Neuroablation:
Part 2: Technique and Coding
The purpose of this article is to give a general overview of
practices accepted by both International Spinal Injection
Society (ISIS) and American Society of Interventional Pain
Physicians (ASIPP). It is not designed to be a technical manual
on how to perform each procedure.
General Considerations:
Prior to all neuroablative procedures, it is imperative to assess
the patient both physically and psychologically.
Comprehensive informed consent is not only required but is an
ideal method of defining what can be expected to the patient
and to answer any questions. This is especially important when
the full onset of the effects of neuroablation can be delayed
from days to weeks, and the pain will probably recur at some
future date. A diagnostic block using local anesthetic prior to
performing the ablation is also required to identify the probable
result of the procedure. Although ISIS and ASIPP both
recommend two diagnostic blocks prior to medial branch
ablation, such a requirement is not always adhered to by
insurance carriers allowing the physician to proceed with
neuroablation after one successful diagnostic block.
The diagnostic procedure and the ablation should be
performed using accepted standards of sterility and monitoring.
Sedation should be kept at a minimum to reduce the risk of
unidentified nerve injury. Almost universally, the definition of
successful diagnostic block is pain reduction of greater than
50% and duration of relief of 80% of the estimated duration of
the local anesthetic used. In general, for spinal medial branch
blocks and ablation, the performance of four diagnostic blocks
per region and two ablation procedures per region per year is
the normal maximum frequency. Please note, the performance
of unilateral or bilateral procedures is not defined in these
restrictions; therefore, the technique of performing two blocks
on one side, followed by lesioning and then doing the same on
the other side will count as the entire year’s limit.
Coventry Health Care of Missouri, Inc./Coventry Health Care of Illinois, Inc. (“Coventry”) Network Connection
March 2014 • 1
Specific Considerations:
• For sacroiliac joint ablation, the performance of diagnostic
SI joint injections is not adequate to confirm the pathology.
Successful blockade of the lateral branches of S1, S2 and
S3 are required prior to ablation. Appropriate CPT codes for
this procedure are 64622 and 64623.
• Neurolysis of the celiac plexus: 64680
• Neurolysis of the superior hypogastric plexus: 64681
• Blockade or neurolysis of the splanchnic nerves: 64999
• Blockade or neurolysis of the ganglion impar: 64999
• Neurolysis of other peripheral nerve: 64640
• Neurolysis of the plantar common digital nerve: 64632
• Neurolysis of intercostal nerve: 64620
• Neurolysis of pudental nerve: 64630
Pre Authorization Reminder
When calling the Pre-Authorization line, please listen carefully
as the prompts have changed.
Valuable Information Available Online
You have access to valuable information online through our
website at www.chcmissouri.com or www.chcillinois.com. Click
“Providers” on the home page. You and your office staff can
access links to the following resources:
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Comprehensive provider search
Drug formulary (prescription coverage)
Prior authorization information, including applicable
CPT codes
Medical injectable list
Authorization form
Network participation details
Credentialing policies, criteria and related provider
rights
Wellness - Highlights on preventive health guidelines, clinical
practice guidelines and disease management programs
Training Sessions Now Available for
www.directprovider.com
If you or your office staff is interested in participating in a
www.directprovider.com training session, please register by
sending an email with “directprovider.com training” in the
subject line to: [email protected]. In the
email, please also identify the date, section and how many
staff members will be attending.
You will receive an email confirmation along with your login
and dial-in instructions prior to the training session.
AUTHORIZATIONS & REFERRALS
April 4, 9 or 23 at 11 a.m.
CLAIMS/REMITTANCE ADVICES
April 8 or 22 at 11 a.m.
WORKERS’ COMPENSATION
April 11 at 11 a.m.
FIRST HEALTH/TPA BILLS
March 28 or April 4 or 11 at 12 p.m.
PCP HEDIS REPORTS
March 28 or April 3 at 11 a.m.
ADMINISTRATOR REGISTRATION
April 1 or 25 at 11 a.m.
MANAGE ACCOUNT & MSG CENTER
April 1st or 25th at 12 p.m.
ELIGIBILITY & ID CARDS
April 10 or 24 at 11 a.m.
Visit the “Provider Document Library” to access:
Provider Manual - Information about claims processing,
member rights and responsibilities, and other helpful resources
Complex Case Management – Information on our complex
case management program and how to refer patients to the
program
Network News - Current and past issues of Network
Connection, our provider newsletter
Quality Improvement Policies and Procedures – Quality
improvement annual evaluations and medical record
documentation standards
Utilization Management Policies - Summaries of our
evaluation of new medical technology, utilization management
criteria and financial incentives policy. You can also obtain
copies of the criteria used in the medical necessity review by
either reviewing the policy on www.directprovider.com or by
contacting the prior authorization department.
RESOURCE LIBRARY & NEWS
April 8 at 12 p.m.
CN PPO FS & CLIENT LISTING
April 22 at 12 p.m.
The following articles in this newsletter are devoted to the
provider notifications required for our accreditation status
with NCQA and to meet CMS requirements.
Peer-to-Peer Process
What do you do if you do not agree with our decision? If a
provider does not agree with a decision a Coventry medical
director has made, he or she has the opportunity to speak with
the medical director who made the decision by calling
314-506-1708. The Health Services staff will arrange a time
suitable for both the provider and medical director to discuss
the case. Peer-to-peer discussions should occur within two
business days of the decision.
Coventry Health Care of Missouri, Inc./Coventry Health Care of Illinois, Inc. (“Coventry”) Network Connection
March 2014 • 2
Evaluation of New Technology
Coventry evaluates benefit coverage for new medical
technologies or new applications of existing technologies on an
ongoing basis. These technologies may include medical
procedures, drugs and devices.
The following factors are considered when evaluating the
proposed technology:
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Input from appropriate regulatory bodies
Scientific evidence that supports the technology’s positive
effect on health outcomes
The technology’s effect on net health outcomes as it
compares to current technology
The evaluation process includes a review of the most current
information obtained from a variety of authoritative sources
including medical and scientific journals, medical databases
and publications from specialty medical societies and the
government. Contact your Provider Relations representative if
you have any questions.
Complex Case Management
Our members have access to unrivaled complex case
management—a collaborative process between Coventry, the
member and the provider. Our complex case management
programs are designed to assess, plan, implement and
evaluate services and resources required to meet the
member’s health care needs. The process aims to efficiently
produce the highest quality outcomes and manage health care
costs.
The program is staffed by registered nurses to advocate for the
member in the case management process. Coventry nurses
are educated in health care management and service delivery
and help our members smoothly navigate their health care by
connecting them with resources and support within their
respective communities. Our health plan nurses embrace
cultural diversity and are well-suited to assist members of any
background. We require that Coventry nurses continue to
expand their expertise through professional development
including certification, seminars and classes for continuing
education and case management credits.
Help Us Better Serve Your Patients
Coventry wants to match our members with the provider bestsuited for their individual needs. Our online provider search
tool can help them choose providers by various criteria like
location, specialty or language. To ensure your office
information is accurate and up-to-date, and to help
accommodate our diverse membership, please fax information
updates to Provider Relations:
Missouri: 866-874-6403, mail to Coventry Health Care
Provider Relations, 550 Maryville Centre Drive, Suite 300, St.
Louis, MO 63141; or email to [email protected].
Illinois: 800-562-5792, mail to Coventry Health Care
Provider Relations, 2110 Fox Drive, Champaign, IL 61820
or e-mail to [email protected].
Clinical Appeals Process
Clinical appeals must be submitted in writing (unless
expedited) within 180 days of the adverse benefit
determination and must contain the following information:
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Member name
Member identification number
Member date of birth
Provider name, address, phone number and fax number
Service being appealed
Expected date(s) of service, or if service has already been
provided, date(s) of service received
Clear indication of the remedy or corrective action being
sought and an explanation why the plan should reverse the
adverse benefit determination
Copy of documentation to support the reversal of decision
(e.g., emergency details, date, time, symptoms, etc.)
A member designated release of information form must be
completed in cases where an authorized representative
appeals on behalf of the member. Appeals department fax:
855-426-6155.
Policy for Financial Incentives
We are committed to ensuring appropriate health services for
our members. We support open communication between our
members and their doctors regarding treatments that may or
may not be medically appropriate or necessary. Utilization
decisions are based solely on the appropriateness of care and
service and the existence of medical coverage. Financial
compensation to our Health Services staff and consultants is
completely independent of the quantity and types of decisions
they make. Our employees do not receive rewards for issuing
denials, nor do they receive financial incentives to make
decisions that otherwise limit medically necessary care.
Notice of Change:
National Coverage Determinations
(Medicare Providers Only)
As an organization with Medicare Advantage plans, Coventry
(MAO – Medicare Advantage Organization) has a responsibility
to notify providers of new Medicare national coverage
determinations (NCDs) that are released on a periodic basis.
For additional information, please visit
http://www.cms.gov/medicare-coverage-database/overviewand-quick-search.aspx.
Advance Directives
Please help our members plan ahead with a living will, durable
power of attorney for health care and/or a DNR order. It is
never too early to create a plan which will allow you and your
Coventry Health Care of Missouri, Inc./Coventry Health Care of Illinois, Inc. (“Coventry”) Network Connection
March 2014 • 3
patient to discuss his or her wishes should a catastrophic
medical event occur.
Here are some talking points for these conversations:
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Scheduled annual physicals and preventive health visits
provide the ideal time to discuss the importance of an
advance directive with Coventry members that are 18 years
of age and older, or to discuss any changes or updates to
an advance directive already in place.
Encourage the member to have a copy of an advance
directive kept in his or her medical record and a copy
available to take with them to the hospital should the need
arise. Whether using a written or electronic medical record
format, please ensure that some type of flagging system is
in place, indicating when an advance directive is either
absent or has been completed.
Take advantage of this valuable opportunity to initiate and
impact this important decision-making process while our
members can clearly communicate their wishes to you and
their family members.
The Centers for Medicare and Medicaid Services
(CMS) Compliance and Fraud, Waste and Abuse
(FWA) Training
CMS requires that we train our first tier, downstream and
related entities (FDRs) on compliance and FWA annually.
A provider that is contracted for our Medicare products
is considered a first tier entity needing training. Providers can
find detailed training materials at
www.coventrymedicarefdrs.com. Additional information can be
found in the provider manual or on our website
at www.chcmissouri.com or www.chcillinois.com.
How to Contact Us
Website: www.chcmissouri.com or www.chcillinois.com
Provider Relations Hotline:
MO 800-755-5242
IL 800-562-5792
Did You Know?
Many people with a limited ability to speak English admit they
only seek emergent medical care because they fear the
communication barriers at the doctor’s office. Language Line
Services offers certified medical interpreters every day, 24
hours a day, year-round. Call 800-752-6096 for more
information.
Utilization Management Criteria
We use the following protocols based on national criteria and
reviewed by the Quality Improvement/Utilization Management
committee:
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Aetna Clinical Policy Bulletins and medical review policies
Nationally recognized medical management criteria
American College of Obstetrics and Gynecology criteria
Specialty society and internally developed guidelines and
policies
Medicare coverage issues
National Comprehensive Cancer Network guidelines
Health Services Pre-Authorization Department:
314-506-1843 or 800-546-4603
Health Services Fax: 866-603-5534
After Hours Emergency: 877-513-2744
Mental Health Network: 877-227-3520
Medical Director: 314-506-1670
(8 a.m. to 5 p.m., Monday through Friday, CT)
Provider Relations Department
MO
Cindy Derr, Director: 314-506-1824
Marilyn Bowers, Representative: 314-506-1881
Tammy Lewis, Senior Representative: 314-506-1449
Lisa Mankowich, Senior Representative: 314-506-1864
Kim Wresinski, Representative: 314-506-2467
Linda Fulford, Representative: 314-506-2431
Stephanie Williams, Representative: 314-506-1557
Joyce Walker, Representative: 314-506-1871
Current versions of our prior authorization requirements
and related schedules are available on our website at
www.chcmissouri.com or www.chcillinois.com. The following
materials are modified throughout the year:
VerNessa Smith, Representative: 314-506-2488
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Mary Tague, Senior Representative: 217-366-5533
Medical injectable prior authorization list
Prior authorization list for prescription drugs
Self-administered injectable medications list
All new injectable drugs require prior authorization unless you
are otherwise notified. Contact Provider Relations if you have
any questions or would like paper copies of our schedules
IL
Lisa Meehan-Schuerger, Manager: 217-366-5554
Heather Dickson, Senior Representative: 815-721-2105
Nancy Roots, Senior Representative: 309-686-3806
Cathy Baack, Senior Representative: 309-686-3827
Deana Johnson, Supervisor: 630-737-7653
Kelly Best, Senior Representative: 630-737-7103
Coventry Health Care of Missouri, Inc./Coventry Health Care of Illinois, Inc. (“Coventry”) Network Connection
March 2014 • 4
Provider Access Standards
Access to Care
When scheduling care, our members should be able to see
participating providers according to the guidelines below:
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Routine preventive care - 30 Days
Routine non-symptomatic care - Two weeks
Non-urgent symptomatic care - One week
Urgent care - 24 hours
After-Hours Care
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Providers or covering practitioners must be available for
urgent or emergency care 24 hours a day.
Providers or covering practitioners must return after-hours
phone calls within one hour.
Waiting Time
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Upon arrival for a scheduled visit, our members must not
wait more than 30 minutes to see a provider.
Continuity and Coordination of Medical and
Behavioral Health Care
Coventry members may self-refer for behavioral
health/chemical dependency services. These services must be
provided through the appropriate behavioral health/substance
abuse provider. We have a multi-disciplinary team of
behavioral health professionals available 24-hours a day, 7
days a week to care for our members. Members can contact
MHNet toll free at 877-227-3520. Primary care physicians are
requested to ask members who see a behavioral health
provider to sign a release of information so they can be kept
up-to-date on their progress.
Requirements for Participation
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Our providers will cooperate with Coventry’s medical
management and quality improvement activities and
procedures. This includes returning phone calls, answering
correspondence and responding to our staff as needed so
they can perform their duties.
Providers will freely communicate with patients about their
treatment, regardless of benefit coverage.
Provider will allow the plan access to medical records as
needed to process claims, make benefit determination,
complete medical management and QI activities.
Providers will ensure the completeness, truthfulness and
accuracy of all claims and encounter data submitted to
Coventry including medical records data required and
ensuring that information is submitted on the prescribed
form.
Important Network Information Specialty
Pharmacy Program
As we announced to our provider community earlier,
Aetna Specialty Pharmacy® will be the preferred specialty
pharmacy provider for specialty medications covered
under the pharmacy benefit for all Coventry Commercial
Health Plans, effective January 1, 2014.
In January, your new patients and all new specialty
medicine prescriptions will be served by Aetna Specialty
Pharmacy. Also, current prescriptions for specialty
medicines being filled through Accredo will be transitioned
to Aetna Specialty Pharmacy. We will send letters to
affected patients notifying them of this change and Aetna
Specialty Pharmacy representatives will call to help them
transition their prescriptions.
Your patient, or an Aetna Specialty Pharmacy
representative, may contact you if a refill authorization is
required. There is no change to the preauthorization
process for specialty medicines. Preauthorization from
Coventry is still required prior to your patient obtaining the
medicine. As a reference, enclosed is a list of the most
commonly prescribed drugs Aetna Specialty Pharmacy
provides. The Aetna Specialty Pharmacy Medication
Request form can be found on our website.
Summary of Specialty Pharmacy Program Changes
Note: These changes do not impact the Coventry Medicaid or
Medicare members.
Coventry Commercial Medical Benefit – Effective
October 1, 2013
Specialty Pharmacy Aetna Specialty Pharmacy –
vendor
optional
What is covered?
Health care professional
administered medications
For Preauthorization Health plan pre-certification
call
number on back of member ID
card Providers in Florida,
Nevada and Utah call 877-2154100
Coventry Commercial Pharmacy Benefit – Effective
January 1, 2014
Specialty Pharmacy Aetna Specialty Pharmacy –
vendor
preferred
What is covered?
Self-administered specialty
medications
For Preauthorization Coventry Pharmacy call center
call
at 877-215-4100 or fax request
to 877-554-9137
Our complete formulary is available at the website address
found on your patient’s ID card. Thank you for your
continued support of our pharmacy program.
Coventry Health Care of Missouri, Inc./Coventry Health Care of Illinois, Inc. (“Coventry”) Network Connection
March 2014 • 5
Most commonly prescribed medications
that Aetna Specialty Pharmacy provides
effective January 1, 2014
Actimmune
Adcirca
Afinitor
Ampyra
Apokyn
Aranesp
Aubagio
Avonex
Betaseron
Bosulif
Bravelle
Buphenyl
Cetrotide
Cimzia
Copaxone
Copegus*
Egrifta
Enbrel
Epogen
Erivedge
Exjade
Extavia
Firazyr
Follistim AQ
Forteo
Fuzeon
Gammagard Liquid
Gamunex-C
Ganirelix
Genotropin
Gilenya
Gleevec
Gonal-F RFF
Humatrope
Humira
Hycamtin
Iclusig
Incivek
Increlex
Infergen
Inlyta
Intron A
Kalydeco
Kineret
Kynamro
Leukine
Lupron*
Mekinist
Menopur
Neulasta
Neupogen
Nexavar
Norditropin
Novarel*
Nutropin/ Nutropin AQ
Omnitrope
Orencia
Ovidrel
Pegasys
Peg-Intron
Pomalyst
Procrit
Promacta
Pulmozyme
Rebetol*, Rebetol Soln
Rebif
Repronex
Revatio*
Revlimid
Ribasphere*
Saizen
Sandostatin*
Serostim
Simponi
Somatuline Depot
Somavert
Sprycel
Stelara
Stimate
Stivarga
Sutent
Sylatron
Tafinlar
Tarceva
Tasigna
Tecfidera
Temodar *
Tev-Tropin
Thalomid
TOBI, TOBI Podhaler
Tracleer
Tykerb
Victrelis
Votrient
Xeloda
Zelboraf
Zolinza
Zorbtive
Zytiga
Coventry Health Care of Missouri, Inc./Coventry Health Care of Illinois, Inc. (“Coventry”) Network Connection
March 2014 • 6