Summer 2012
sl ett er # 1 5
S t a f f N ew
Telephone
Access
Standards
Page 4
HIPAA Case File
Page 5
Cultural Corner:
Caring for
Adolescent
Patients
Page 7
How to support your
provider with patient care
In today’s busy practices it’s important to find ways to help support your
provider with patient care. How? Use IEHP’s online provider alerts.
When you check these alerts daily and share them with your provider, you
help improve patient care, allowing providers to better respond to IEHP
patient needs. By logging on to the IEHP secure Provider Website, you can
view all five of these Provider Alerts:
Nurse Advice Line Alert
Members who have called the IEHP 24-hour Nurse Advice Line in the past
five days. The alert includes the date of the call, reason for the call and what
medical advice and instructions were given.
Behavioral Health Specialist Alert
Members who have seen a behavioral health specialist in the
past 30 days and which members have agreed to share this
information with their PCP to help coordinate care.
Hospital/ER Services Alert
3 Members
who may have accessed a hospital or
emergency room in the past five days,
including the date of service
and name of the hospital.
Continued on Page 2
How to use the NEW
online P4P form
for IEHP Medicare
DualChoice Members
In February 2012, IEHP rolled out the new online P4P
form for IEHP Medicare DualChoice members. For
annual physical exam visits, IEHP will continue to
pay $300 per visit.
Better care from page 1
4
This form was developed to meet many HEDIS
required elements. With your use of the form, we aim
to decrease medical record reviews from your office
during HEDIS chart collecting.
If you handle the billing for your provider, here are
some tips to help you submit a complete P4P form:
• Print out the P4P form before the patient comes
into the exam room; the form contains information
specific to each patient
• Remind your provider to fully complete the P4P form
• Verify that all ICD-9 codes are documented
on the patient’s medical record and the
P4P form
Care Plan Alert
Members (seniors and people with
disabilities, adult day healthcare recipients
and Medicare DualChoice members) who
have care plans, which are based on Health
Risk Assessment (HRA) surveys developed by
IEHP. The surveys are a self-assessment of the
member’s medical and behavioral needs.
To view an example of a care plan go to the
Secure Provider Website.
Print out these care plans
and add them to the patient’s
medical record.
5
Medicare DualChoice
Annual Visit Alerts
Members who are due for a DualChoice
Annual Visit.
You must use the new form in order
to be reimbursed.
1. Log on to the Secure Provider Site
1. Navigate to the P4P screen
2. Click on the P4P entry link
3. Click on the DualChoice
annual visit link
Since the new form was
introduced, there has been an
increase in member diagnoses
submitted. IEHP appreciates
your commitment to
supporting your
providers. You
make a difference.
2
Provider Relations Team Contact Information
(909) 890-2054
This Summer Be Prepared with
First Aid Kits
While on a road trip, a woman felt intense pain in her neck, causing her to pull over to the side of the road.
She quickly realized she had been stung by a bee, which was still buzzing about near the rear window where
her child was sitting. She quickly let the window down so the bee could fly out and pulled the stinger out of
her neck. Her neck was swollen and itchy.
Accidents like this can happen — anywhere, anytime. This summer, protect you (and your family) with a first
aid kit you can carry with you as you travel to the beach, park or campsite. A first aid kit can help prevent
infections, excessive blood loss or swelling.
You can buy a first-aid kit or make your own by putting some basic items in a small plastic bag, tool kit or
tote bag (be sure to keep it out of the reach of children).
Top 10 Essentials forHeadache
a First Aid Kit
Reliever
Headache
Reliever
1. Band-Aids in various sizes
2. Gauze pads/rolls and adhesive tape
3. Elastic bandage (ACE bandage)
4. Antibiotic ointment & hydrocortisone cream
5. Alcohol or alcohol wipes
Headache
6. Instant hot and cold packs
Reliever
7. First-aid booklet
All ergy Reliever
8. Over-the-counter pain reliever
9. Antihistamine like Benadryl for allergic reactions
Headache
Headacheor diarrhea
10. Over-the-counter medications
that relieve nausea
Reliever
Reliever
FIRST
Headache
Reliever
Antiseptic Ointment
All ergy Reliever
Head
Relie
AID
Once you put your kit
together, recheck it every
year for items that may
ergyreplaced.
need to Allbe
Reliever
Headache
Reliever
Antiseptic Ointment
Provider Relations Team Contact Information
Headac
Relieve
(909) 890-2054
3
Are you following the Claim NE
W
Submission Requirements?
In May, IEHP began using its new submission
requirements for processing claims. In February, your
office should have received a set of laminated sample
claim forms, highlighting the new requirements.
If you submitted claims after May 1 that were
denied, you may have forgotten to include the
correct requirements. If you need help with using the guides or need more samples of required fields, call the
Provider Relations Team at (909) 890-2054.
The new claim submission
requirements help:
• Expedite the handling of your claims
• Ensure data completeness
• Improve submission of encounter data to regulators
Telephone Access Standards
Although we live in an era where people communicate through multiple channels, such as text messaging and
social media, members still rely on the telephone to reach their doctor. That’s why you should ensure your phone
system follows these standards (which come from Provider Policy 9A):
Answer time
All calls must be answered within six rings. An automated system may answer if it provides
an option for members to speak to a live person.
Hold time
If you have to put callers on hold, tell them the reason for the delay and offer
to let them wait or have the call returned. Avoid leaving a member on hold for
more than five minutes. Non-urgent calls must be returned within three business
days. Urgent but non-emergency calls must be returned the same day. You must
attempt to return the member’s call at least three times.
After hours PCP access
All IEHP PCPs and IPAs must provide 24/7 telephone access for members.
The IEHP 24-Hour Nurse Advice Line cannot be used as an substitute for
access to PCP after hours.
Automated answer system
All providers must have an after-hours answering system. Here’s a suggestion for
your automated message:
Thank you for calling Dr. Xxx’s office. Our office is currently closed. If this is a
life-threatening emergency please hang up and dial 9-1-1 or go to the nearest emergency
room. If this is not a life-threatening emergency, you may leave a message after the tone
and your call will be returned shortly. You may also call back during regular office hours
[ provide your office hours ]. The IEHP 24-hour Nurse Advice Line
is also available, at 888-244-4347. This number is on your IEHP Member ID Card.
4
Provider Relations Team Contact Information
(909) 890-2054
HIPAA Case File
HIPAA rules are now tougher and penalties steeper. To see how you can protect your practice from HIPAA
violations, read on to see how one medical practice fell short in exercising good HIPAA practices.
A small cardiac medical practice in Phoenix had a complaint filed against them, alleging that the practice
was posting patient names and surgery appointments online. The practice responded to the complaint by
saying that someone forgot to turn on their computer’s software privacy settings. But this was more than
a single mistake.
When the Office of Civil Rights (OCR) investigated, it found
a long history of non-compliance:
• On a daily basis, the practice sent ePHI over the internet to their staff 's personal email accounts.
• There was no documentation that showed office staff had received
training on HIPAA policies, procedures and PHI.
• The practice lacked safeguards (administrative and technical) to
protect the privacy of patients.
As a result, the practice was
fined $100,000, and issued a one year
Corrective Action Plan.
How can you help your practice avoid HIPAA violations?
1
2
3
Create written office policies and procedures to address patient information and its release.
Ensure each staff member receives HIPAA training when hired and attends a refresher
course every year.
Review your office layout to identify potential HIPAA hazards, such as a receptionist who
can be overheard by patients in the waiting room; computer screens that can be seen by
patients or charts left out in clear view.
IEHP offers free on-site HIPAA training programs.
Sign up today. Call the IEHP Compliance Department at
909-890-1282. Ask for Lori.
Provider Relations Team Contact Information
(909) 890-2054
5
IEHP Scrub of
the Month
AS
Her eagerness to share
her knowledge with
co-workers and patients
for the last three years
has earned Elva Ramos
the honor of “Scrub of
the Month.”
K
Working as the office
manager for Dr. David
Lozano’s primary
care practice in Moreno Valley, Elva is like a jack- of- all
trades, handling P4P, staff training and patient referrals.
She also supports Dr. Lozano with documentation.
Elva Ramos
Her passion to see co-workers grow in their jobs is
appreciated in the office. Office staff members say Elva
recognizes individuals who are doing a great job and
kindly points out areas where improvement can be
made. Sweet and responsible, Elva’s dedication to the
job has made a difference.
Nominate a co-worker
Do you work with a winner? A hard worker who
brightens your office with kindness, inspiring your
team to do its best?
Tell us why: Write your reason why you think this
person should be Scrub of the Month. Keep it under
500 words. If you give us the best reason, we’ll give
you and your co-worker a $50 Target gift card.
Send your name, office location and work phone
number. Fax, mail or e-mail your entry:
Fax: (909) 890-5652. On cover sheet,
write ScrubTalk - Scrub of the Month Nomination.
Mail: IEHP ScrubTalk - Scrub of the Month Nomination,
P.O. Box 19026, San Bernardino, CA 92423-9026.
E-mail: [email protected]
6
Susie
am the office manager for an OB/GYN
Q. Iphysician.
Could you advise if we
are obligated to provide CPSP
(Comprehensive Perinatal Services
Program) for IEHP members?
ensures that Medi-Cal pregnant women
A. CPSP
receive extra care in the areas of nutrition,
psychosocial and health education. These
services reduce low birth weight rates of
babies and health care costs for women and
infants.
All Medi-Cal IEHP members must be offered a
CPSP risk assessment once during each trimester
and at their postpartum visit. Once a risk
assessment is completed, an Individual Care Plan
(ICP) must be created based on the findings.
Since a Perinatal Notification Outcome (PNO)
is not a full risk assessment, it shouldn’t be used
as a substitution for the CPSP risk assessment.
If your office refers members to a CPSP program
for services, please remember, you must fully
document in the member’s medical record the
referral and obtain the risk assessments and ICP
to ensure appropriate care coordination.
Ask Susie about IEHP procedures or programs:
• Call (909) 890-2054.
• Fax to “Ask Susie” at (909) 890-5652.
• Email: [email protected]
Provider Relations Team Contact Information
(909) 890-2054
Cultural
Corner
Caring for Your Adolescent Patients
Adolescents are a diverse and challenging group –
a culture unto themselves. They are at a vulnerable
time in their lives – no longer children, not yet
adults. They are questioning beliefs that they have
accepted at face value up until now as their values
and sense of identity begin shifting away from
family and toward their peers.
• Ask the teen if he or she prefers to have a parent
present or not during the exam. Younger
adolescents may feel more comfortable with a
parent in the room, while older teens may want
privacy to discuss more sensitive issues. However,
never assume what the patient
may want based on age.
Always ask.
It is not always easy to establish rapport with teens
when they visit your office. It may be a challenge in
some cases,but responding with sensitivity to young
patients’ concerns can open doors to providing the
important medical care and guidance they need.
• To further make
adolescents feel “at home,”
provide age-appropriate
materials in the waiting
area as well as in the
clinical office. Provide
interest-based
teen magazines
(fashion, music,
sports, etc.).
Here are some general
guidelines to keep in mind:
• When greeting teens and their parents or
guardians, acknowledge the teen first, whether
through eye contact, a handshake, or a simple
hello. This will show respect for the teen and
enhance rapport.
• Take the teen’s questions or comments seriously.
Keep a positive attitude toward the teen, avoiding
judgmental responses or responses that make
light of their concerns (“when you grow up…”,
“you’re too young to worry about that…”).
• Avoid medical jargon. When asked, explain any
procedure or test in simple terms that a teen can
understand.
• Make educational
materials available.
Place brochures on
topics such as puberty,
STDs, sexuality, and
contraception in the
examination room
(or waiting room, if
appropriate). Or have
materials on hand to
distribute if the teen
has questions.
• Be attentive and empathic. If the teen seems
anxious, show genuine concern to ease any fears
he or she may have.
Provider Relations Team Contact Information
(909) 890-2054
7
P.O. Box 19026
San Bernardino, CA 92423-9026
Staff Newsletter
©2012 Inland Empire Health Plan. All Rights Reserved. PS 01526-0412-1
Information you should know
IEHP P4P Web Site - To print copies of current P4P
overviews, correspondence, forms, schedules and
information below, go to http://ww2.iehp.org/IEHP/
Providers/P4Pprogram.htm.
2012 Recommended Immunization Schedule
Shows ages for routine administration of current licensed
childhood vaccines for children up to 18 years old.
2012 Recommended Preventive Pediatric Healthcare
Details Well Child Screening Procedure and
recommended age bands in which service should
be performed.
2012 Recommended Catch-Up Immunization Schedule
Provides minimum intervals between doses for children
whose vaccinations have been delayed.
2012 Reimbursable PM160 Immunization Codes
IEHP quick reference guide for reimbursable PM160
Immunizations and Rates.
2012 Vaccine Reimbursement Schedule - Pays for IEHP
members not enrolled in the Medi-Cal Program.
Provider Manuals available by lines of business:
• 2012 Healthy Families/Healthy Kids
• 2012 Medi-Cal
• 2012 Medicare DualChoice (HMO SNP)
Please adhere to provisions in this manual.
To visit this page, go to: http: //ww2.iehp.org/
IEHP/Providers/Information+Resources/
HandbooksandManuals/ProviderPNPManuals.htm
IEHP Benefit Manuals - offered as guidelines to
determine benefit eligibility not as a standard of
medical care or as a contractual agreement for payment.
Standards of medical care are determined on the basis of
all facts and circumstances for each case.
Benefit Manual Information - Subheadings “Examples
of Covered Benefits” and “Examples of Non-Covered
Benefits” give specific examples but are not meant to be
all-inclusive list of examples, unless specified in text
of benefit.
*If a benefit question is not addressed in the Benefit
Manual, contact the IEHP Provider Relations Team at
(909) 890-2054.
Reimbursement Process: Submit a CMS1500
claim form with CPT code, quantity dispensed
and billed amount to...IEHP Claims Department
P.O. Box 10129, San Bernardino, CA 92423
IEHP Provider Policy and Procedure Manual
Rules and regulations that IEHP and its contracted
Providers must comply with, as governed by
these state agencies:
• The California Department of Health Care Services (DHCS)
• California Department of Managed Health Care (DMHC)
• California Managed Risk Medical Insurance Board (MRMIB)
• The Centers for Medicare and Medicaid Services (CMS)
Moving Your Office?
Please give the IEHP Provider Relations Team
(and your IPA) a 60-day notice. Member
notification is required by DHCS and DMHC.
Your IEHP patients will be notified, so they can
keep receiving their medical care.
Questions? Ideas? Reach Your Provider Relations Team at (909) 890-2054 • Fax: (909) 890-5652