May 2013 Aetna Completes Acquisition of Coventry Health Care, Inc. One Last Reminder – Kansas City Office Has Moved! We’re pleased to announce that Aetna’s acquisition of Coventry Health Care, Inc. (“Coventry”) is now complete. Aetna and Coventry share a commitment to creating mutually beneficial relationships with providers. And, we share your goal of arranging for the delivery of the highest quality care to our members. Our Coventry office moved from Kansas City, Missouri to Overland Park, Kansas in April. You are welcome to visit us in our new “home” located at: Keep working with us as you have in the past There is nothing to do at this time. Please continue to work with your local Coventry provider relations representative. We will keep you updated as we integrate the two companies. 9401 Indian Creek Parkway, Suite 1300 Overland Park, Kansas 66210 Ph: 913-202-5000 Toll free: 866-629-3975 Congratulations to our Drawing Winner! How to Contact Us Congratulations to Michelle Yarnall, with Pediatric Associates of Southwest Missouri! Michelle joined us at the Missouri Medical Manager’s Conference on May 7, 2013 and won Coventry’s $100 giveaway! Website ........................................................ chckansas.com Website (PHS) ............................................. phsystems.com Provider Relations Email ... [email protected] Provider Relations Hotline .............................. 866-427-9719 Submit Your Email to Receive Provider News Customer Service Operations Coventry (Overland Park)............................... 800-969-3343 Coventry (Wichita) .......................................... 877-609-2467 Advantra ......................................................... 800-727-9712 First Health ..................................................... 800-937-6824 Provider Relations Department Irene Hermreck, Director ................................ 316-609-2434 Sue Busch, Manager (Wichita) ....................... 316-609-2341 Brenda Cook, Manager (Overland Park) ........ 913-202-5241 Representatives Overland Park Lynne Drummond ........................................... 913-202-5248 Jonette Johnson ............................................. 913-202-5247 Sherri Smitley ................................................. 913-202-5242 Bobbie Travis ................................................. 913-202-5143 Springfield Debbie Bowling .............................................. 417-520-4251 Susan Howell ................................................. 417-837-0327 Wichita Marie Goelz .................................................... 316-609-2799 Jessica Warren .............................................. 316-609-2362 Network Connection Email alerts will replace the current fax blast format before the end of 2013. If you are registered with directprovider.com, you will receive an email from Coventry in the near future. We will ask you to go onto our Web link to register an email account for you and/or your staff. This will be a one-time email – if you do not register with us you will not continue to get electronic messages. Please visit this Web link to enter your email information now: http://bit.ly/provider-email The process takes less than 30 seconds to complete. You will then start to receive important provider information electronically. You may enter as many emails for your staff as you wish. Thanks for your help! New Provider Representative in Wichita We welcome Marie Goelz to the team. Her territory includes providers located in the western half of Kansas (west of I-135 to the Colorado border). With more than 12 years of experience, Marie has worked extensively with Medicaid including Family Health Partners/Coventry Cares of Kansas. You may contact Marie at 316-609-2799 or [email protected]. 1 “Keep it Current” – Council for Affordable Quality Healthcare® (CAQH) CAQH makes it easy for practitioners to access, manage and revise credentialing and recredentialing information and eliminates redundant paperwork. In order to eliminate Coventry’s requests for a re-credentialing application, please keep your CAQH application/attestation and supporting documents current and grant access to Coventry. If you have questions regarding Coventry’s credentialing process, please call the Provider Hotline at 866-427-9719. Summer Training Sessions Now Available for directprovider.com You or your office staff may be interested in participating in a directprovider.com training session identified below. Please register by sending an email with “directprovider.com Training” with 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. Topics Dates/Times Section 1 Registration Process Manage Accounts EFT Registration Resource Library News ePrescribing Feedback Tuesday, June 11th 2 to 3:30 p.m. Central Time* Tuesday, June 25th 2 to 3:30 p.m. Central Time* Wednesday, June 12th 2 to 3:30 p.m. Central Time* Wednesday, June 26th 2 to 3:30 p.m.Central Time* and/or preferences  Medications that require prior authorization, and applicable coverage criteria  Medications that require step-therapy, including the medications that must be tried/failed prior to coverage  Explanation of medications that have limits or quotas  Copayment and coinsurance requirements, and the medications or classes to which they apply  Procedures for step-therapy, prior authorization, generic substitution, preferred-brand interchange and therapeutic interchange  Use of pharmaceutical management procedures  Criteria used during the evaluation of new medications for inclusion on the formulary  A description of the process for requesting a medication coverage exception Complex Case Management Medicare Providers Only Case management enhances client wellness and autonomy through advocacy, communication, education and the identification and facilitation of services. All dual-eligible, special needs plan members are followed by a case manager who assists with the coordination of Medicare and Medicaid benefits. The manager will: including performance goals, monitoring and follow-up  Complete a comprehensive assessment of the member's condition  Ensure services are provided at the most appropriate setting health care team Thursday, June 13th 2 to 3:30 p.m. Central Time* Thursday, June 27th 2 to 3:30 p.m.Central Time* Utilize That Care Plan Registry (CPR) The CPR is a secure online access site that is available to you to view the care plans and member profiles that have been created once a health risk assessment is completed. It provides secure online access to enrollee profiles and individualized care plans to providers. By logging into this secure site, providers and their support staff may access the information. Please contact your provider relations representative regarding access to these important tools. Network Connection  Preferred pharmaceuticals, including any restrictions  Provide care coordination between the patient and her Section 3 Member Eligibility Member ID Card Authorizations/Referrals HEDIS Reports State/Product Specific Reporting You can access the following pharmacy information at chckansas.com by selecting “Providers” and then “Prescription Documents.” You will find:  Develop and implement a case management plan Section 2 Claim Inquiry Remittance Advices Message Center PPO Fee Schedule Client Listings Workers’ Comp First Health/TPA Access Prescription Information Online  Facilitate open communication, understanding and involvement in the treatment plan  Provide educational materials to help members selfmanage their conditions  Facilitate and provide communication of planned and unplanned transitions from one care setting to another. This will support the best overall outcome. To request a copy of your patient’s care plan or to speak to her assigned case manager please contact Coventry’s Special Needs Plan at 877-691-8138. May 2013 • 2 NOTICE OF CHANGE: National Coverage Determination (NCD) (Medicare Providers Only) TITLE: Transcatheter Aortic Valve Replacement (TAVR) – Implementation of Mandatory Reporting of Clinical Trial Number EFFECTIVE: July 1, 2013 For additional information, please see: http://www.cms.gov/Outreach-and-Education/ Medicare-Learning-Network-MLN/MLNMattersArticles/ Downloads/MM8255.pdf http://www.cms.gov/Regulations-and-Guidance/Guidance/ Transmittals/2013-Transmittals-Items/R2689CP.html? DLPage=2&DLSort=1&DLSortDir=descending http://www.cms.gov/medicare-coverage-database/ overview-and-quick-search.aspx Claims Processing Policy Spotlight This new feature section highlights specific claims processing procedures. Read more to learn about Coventry’s policies: Calculation of Anesthesia Time Units Anesthesia time begins when the anesthesia provider begins to prepare the patient for the induction of anesthesia in the operating room (or in an equivalent area). Anesthesia time ends when the anesthesiologist is no longer in personal attendance. Total time must be indicated for the procedure (for example, 0800-0845 or 45 minutes). Time is calculated for payment based on 15-minute intervals. Each interval of 15 minutes equals one unit (four units per hour). Anesthesia time of five minutes or more will count as one unit. Less than five minutes is rounded down to the next lowest unit. Anesthesia units submitted on a claim are validated against the standard 15-minute unit. Partial units will be rounded up or down as noted. Sublingual Immunotherapy – E/I Designation For the remainder of 2013, Preferred Health Systems and Coventry (collectively “Coventry”) will grandfather any members currently receiving sublingual immunotherapy that has been covered by their current or previous health plans (Coventry or other carrier). The grandfathering of sublingual immunotherapy for these members will end on January 1, 2014. After that date, all requests (both new and ongoing) to initiate sublingual immunotherapy for Coventry and Preferred Health Systems members will be denied as experimental/investigational per Coventry’s designation. The health plan will convey this information to affected members in writing. Network Connection Hospital Readmission Policy Clarification Facilities reimbursed per MS-DRG pricing methodology were recently notified of Coventry’s implementation of a readmission review policy effective July 1, 2013. The policy incorporates readmission review guidelines from the Centers for Medicare & Medicaid Services (“CMS”). The review is designed to help promote quality and improved outcomes. The hospital readmission policy was outlined in the FAQ document that accompanied the announcement. The contracting provider manual is currently being updated. For your reference, the policy states: Hospital Readmission Policy Coventry Health Care incorporates readmission review based upon Quality Improvement Organization Manual, Chapter 4 - Case Review, 4240 - Readmission Review (Rev. 2, 07-11-03) guidelines from the Centers for Medicare and Medicaid Services (“CMS”). The review is not in place to address questions of medical necessity but instead is designed to help promote quality and improved outcomes. This policy will be applied to facilities reimbursed at MSDRG pricing methodology. Readmissions are reviewed when they occur during the concurrent review process (in order to perform review, the discharge summary along with medical records may be requested):  Within 48 hours of the initial discharge  Because of the same diagnosis, or a similar or related diagnosis  At the same facility Filing a Claim Reconsideration  Please contact us first to try to resolve the issue. You may call Commercial Customer Service at 800-969-3343 or Advantra Customer Service at 800-727-9712.  If the issue cannot be resolved, you must use the Administrative Reconsideration form located at chckansas.com (or physystems.com) > Provider > (Your region) > Document Library.  Reconsiderations can also be submitted via DirectProvider.com and attachments can be sent in a secure manner. You can mail the Provider Administrative Reconsideration form to: Coventry Health Care of Kansas P.O. Box 7708 London, KY 40742 Fax: 701.250.5392 Medicare providers should mail the form to: P.O. Box 7371 London, KY 40742 May 2013 • 3 Healthways SilverSneakers® (Medicare Providers Only) Coventry’s Medicare Advantage members have access to a ® fitness benefit through Healthways SilverSneakers Fitness Program. SilverSneakers is a leading wellness program designed exclusively for Medicare beneficiaries. Eligible members receive a basic membership with access to amenities and fitness classes including the signature SilverSneakers classes designed to improve muscular strength and endurance, mobility, flexibility, range of motion, balance, agility and coordination. Providers may find these programs appropriate for patients preparing for surgery, recovering from surgery or who need general lifestyle improvement activity. For more information and to find a participating location, visit silversneakers.com or call 888-423-4632. As an alternative for members who can’t get to a ® SilverSneakers participating location, SilverSneakers Steps is available. Steps is a self-directed physical activity program that allows members to measure, track and increase physical activities. The program provides the equipment, tools and motivation necessary for members to achieve a healthier lifestyle. Eligible plan members may register for Steps at silversneakers.com/member. View Prior Authorizations and Referrals on Directprovider.com Please remember that prior authorizations and referrals may be viewed on Coventry’s secure provider Web portal, directprovider.com. Once you have signed in to the site, click “Authorizations & Referrals” from the left menu. You may search for authorizations by status (approved, pending or denied), by authorization or referral number or by member. This self -service feature gives you immediate access to the most current information. If you have questions or need assistance navigating the site, contact your provider relations representative. ICORE Drug Management Changes for July 1, 2013 (Coventry of Kansas plans only; not applicable to PHS plans) ICORE has been providing prior authorization reviews for certain drugs since May 2010. ICORE manages specific drugs requiring administration by health care professionals, while ensuring quality care and affordability for our members. The program supports a “buy and bill” model for reimbursement of injectable drugs. ICORE encourages the use of medically indicated lower cost alternatives with equivalent quality and clinical outcomes. Drug Name Code Aloxi J2469 Aranesp J0881 Avastin J9035 (oncology) Epogen/Procrit J0885 Herceptin J9355 Leukine J2820 Neupogen J1440/J1441 Neulasta J2505 If you have questions about criteria or processes, ICORE can be reached at 800-424-4157 or at ICOREhealth.com. You can also contact your provider relations representative at 800-562-5792. Why Do We Ask You for Records? This time of year, your office often gets requests for medical record information. The request may be regarding a specific claim or situation (member appeal or quality review), or one of the following projects:  Medicare retrospective chart review – This is the evaluation of charts to validate submitted diagnosis codes. These requests came from Verisk, formerly known as Health Risk Partners. You may securely fax your submissions to their attention at the number indicated on the request form. For alternative submission information, please contact your provider relations representative.  Commercial and Medicare HEDIS data collection – This is the evaluation of a number of clinical metrics (e.g., blood pressure control for individuals diagnosed with hypertension). Coventry’s quality improvement team initiates these requests. You may confidentially fax your submissions to the fax number indicated on the request for information.  Many primary care physician (PCP) offices may have received their annual Medicare Data Quality Improvement (also referred to as Physician Education Program) requests. These are sent to PCPs who are not participating in other quality programs for our Medicare Advantage plans. We appreciate your assistance and participation in these initiatives, which focus on improving the quality of your patient’s health plans. Effective July 1, 2013, Coventry will be expanding the reviews that ICORE performs to the outpatient facility setting. ICORE currently performs the prior authorization for the drugs identified below in the physician office setting. Network Connection May 2013 • 4