1. health and fitness

P L E A S E C I R C U L AT E T O A L L S AT E L L I T E S I T E S , O F F I C E S T A F F, P R A C T I T I O N E R S , A N D B I L L I N G V E N D O R S
GATEWAYReview
A P R O V I D E R N E W S L E T T E R P U B L I S H E D B Y G AT E W AY H E A LT H P L A N
Visit us at our website @ www.gatewayhealthplan.com
DECEMBER 2006
ISSUE 55
CHILDREN’S COMMUNITY PEDIATRICS TARENTUM AND BUTLER
MEDICAL ASSOCIATES-CHICORA EARN 100% CLUB DISTINCTION
Children’s Community Pediatrics (CCP) Tarentum and Butler Medical Associates (BMA) Chicora were
recently inducted into Gateway Health Plan’s 100% Club. These practices surpassed peer averages in all
preventive health and utilization measures in the Spring 2006 Gateway Health Plan Practice Portfolio.
Furthermore, they distinguish themselves by their commitment to their patients and communities.
(L-R): Margaret Lagnese, MD, Keith Pirl, MD, Laurie Kovar (Office
Manager), Carol Brand, MD, Rebecca Slaunwhite, MD, Peggy Foster,
Debora Mehelic, and Pat Cisar.
(L-R) Back Row: Don Halpin, PA-C, David Evanko, MD, Tracy Deal,
Debbie McCune, Ruthann Spahn, Kim Whitling, Terri Miller, Genny Rowles,
Pete Keim, MD-Gateway Health Plan VP and Chief Medical Officer,
Caesar DeLeo, MD- Gateway Medical Director. Front Row: Vickie Maley,
Vern Dowdy, Arica Davis.
Children’s Community Pediatrics Tarentum
Butler Medical Associates-Chicora
Children’s Community Pediatrics (CCP) relocated to Tarentum in
May 2004 from New Kensington where Drs. Keith Pirl and Benja
Assanasen delivered general pediatric care for many years. Following
Dr. Assanasen’s retirement in August 2004, Dr. Pirl has been assisted
by Drs. Carol Brand, Margaret Lagnese and Rebecca Slaunwhite.
Butler Medical Associates (BMA) in Chicora, staffed by David
Evanko, MD and Don Halpin, PA-C, has served the medical needs
of northeastern Butler County for the past twenty years. The
practice specializes in family medicine, providing additional services
to nursing homes, residential facilities for juvenile offenders and
offers a drug addiction management program.
“CCP Tarentum focuses on general pediatric care with each physician
keenly interested in preventive care, growth and development, and
parent education” according to Dr. Pirl. “We stress the importance
of routine well child visits and adherence to the AAP recommended
vaccine schedules.”
What is striking to both visitor and patient alike is the familyfocused culture at CCP Tarentum. Physicians and staff strive to
accommodate their families’ hectic schedules and maintain close
relationships to their patients and families. The practice provides after
hours evening and weekend appointments and routinely squeezes
patients into the daily schedule. Close relationships pay off in terms
of more efficient and effective communication in the office and on
after hours emergency calls.
“Comprehensive health care” is Dr. Evanko’s aim as Medical
Director of the Butler Medical Associates group and full-time
physician in the Chicora location. He points out: “New services
have been added by the Butler Health System for on-site
laboratory, x-ray, physical therapy, retail pharmacy and outreach
from Butler Hospital specialists.” The practice also offers extended
evening hours and recently instituted a “quick care” system to see
patients the same day for urgent medical matters.
Longevity, relationships, comprehensive service and a holistic
philosophy are common themes among successful practices and
these two award recipients in particular. Gateway Health Plan
salutes these practices for their commitment and outstanding service.
G AT E W AY R E V I E W • D E C E M B E R 2 0 0 6 • I S S U E 5 5
CONFIDENTIALITY OF
PATIENT INFORMATION
AFFIRMATIVE ABOUT
INCENTIVES AND
OVER-UNDER
UTILIZATION STATEMENT
Health care fraud is a serious and growing crime. Having alert and
involved employees can prevent or detect health care fraud. Gateway
Health Plan takes its responsibility to protect member information very
seriously. As such, Gateway provides ongoing communication with its
employees regarding protection and use of member information. During
the past year the communication plan included the following:
• Implementing a new tool to annually remind each employee of key
compliance components and to rate each employee’s understanding of
his/her compliance duties.
Gateway’s Utilization
Management (UM) decisions are
• Training materials on higher risk topics such as identity theft, the
based only on the appropriateness
importance of shredding documents with PHI on them, and protecting
of care and services and
computer passwords.
existence of coverage.
• Sharing real life stories in the news from across the country to
Gateway does not
better educate our employees about risks and things to be aware
of in the health care fields. Stories included billing for
specifically reward
CORRECTION
services not rendered, providing services not medically
practitioners or other
REGARDING
necessary, improper use of health identification cards, etc.
individuals for issuing
POST-PARTUM HOME
• Celebrating National Compliance and Ethics Week
denials of coverage
HEALTH VISITS
and providing all employees with a flyer including
or service. Financial
helpful hints for identifying and reporting concerns.
Effective February 1, 2006, Gateway is allowing up to 2
incentives for UM
• Walking around and asking employees how they
post-partum home health visits within 180 days of the
decision makers
would report issues and requesting they demonstrate how
first visit without a Gateway Authorization. The May
they would locate policies to help them.
do not encourage
2006 Gateway Review Newsletter stated that 4 visits
decisions that
• Adding a “Compliance Corner” on our employees’
were permitted without a Gateway Authorization.
computers
so we can display short messages and also
result in
This information was incorrect. Please
provide easy on-line access to compliance policies.
update your records and forward this
underutilization.
information to any pertinent staff.
Gateway Health Plan is proud to work with our providers
Gateway monitors for
and our members to provide a high quality health care program.
both over and under
We want you to know we manage our members’ health care needs
AND protected health information (PHI) with utmost care.
utilization of care to prevent
inappropriate decision-making,
identify causes and corrective
action, and to indicate
inadequate coordination of
care or inappropriate use of
services. Gateway is particularly
concerned about underutilization
and monitors utilization
activities to assure members
receive all appropriate and
necessary care.
CCP TARENTUM PRACTICE MANAGER LAURIE
KOVAR ON RECIPES FOR EPSDT SUCCESS
• Annually send postcard reminders for all families to
schedule their child’s well visit, indicating when it is due.
• Get parents to schedule well visits for their children
when they are in for sick visits, medication refills and
form completions.
• Establish relationships with families. “Knowing our
families makes asking them to come in for a routine
well visit easier.”
• Having practitioners who diligently work to educate
families on the importance of vaccinations and routine
well care.
• “If you achieve the recommended 6 well visits prior
to the 15 month mark then timely lead levels and
vaccinations fall into place.”
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G AT E W AY R E V I E W • D E C E M B E R 2 0 0 6 • I S S U E 5 5
2006 PRACTITIONER ACCESSIBILITY
STANDARDS AND STUDY RESULTS
The following standards are relevant to all Pennsylvania Medicaid Primary are Practitioners:
Requirement
Standard
Wait time for an Emergent Appointment . . . . . . . . . . .Immediately, and not inappropriately referred to the ER
Wait time for Urgent Care Appointment . . . . . . . . . . .Within 24 hours
Wait time for Regular or Routine Appointments . . . . .Within 10 business days
Wait time for a Preventive Care Appointment . . . . . . .Within 3 weeks of enrollment
After-hours Care Accessibility . . . . . . . . . . . . . . . . . . .Access to a practitioner 24 hrs/7 days a week
Waiting Time in the Waiting Room . . . . . . . . . . . . . . .No more than fifteen (15) minutes or up to one (1) hour when the MD encounters an
unanticipated urgent visit or is treating a member with a difficult need.
The following standards are relevant to all Pennsylvania Medicaid Specialty Care Practitioners:
Requirement
Standard
Wait Time for Emergent Appointment . . . . . . . . . . . . .Immediately from the date of referral
Wait time for an Urgent Care Appointment . . . . . . . . .Within twenty-four (24) hours from the date of referral
Wait time Asymptomatic Regular/Routine Appointment . . .Within ten (10) business days from the date of referral
Waiting Time in the Waiting Room . . . . . . . . . . . . . . .No more than fifteen (15) minutes or up to one (1) hour when the MD encounters an
unanticipated urgent visit or is treating a member with a difficult need.
The following standards are relevant to all Pennsylvania Medicaid OB/GYNs and Certified Nurse Midwives:
Requirement
Standard
First Trimester . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Within (10) business days of the member being identified as being pregnant
Second Trimester . . . . . . . . . . . . . . . . . . . . . . . . . . . . Within (5) business days of the member being identified as being pregnant
Third Trimester . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Within (4) business days of the member being identified as being pregnant
High-Risk Pregnancies . . . . . . . . . . . . . . . . . . . . . . . . Within twenty-four (24) hours of identification of high-risk by Gateway or the maternity
care provider, or immediately if an emergency exits
The following standards are relevant to all Medicare Assured Primary Care Practitioners:
Requirement
Standard
Wait time for Urgent, but Non-Emergent Care Appointment . . . . . . . . . . . .Within 24 hours
Wait time for Non-Urgent Care, but in need of Attention Appointments . . .Within 1 week
Wait time for a Routine or Preventive Care Appointment . . . . . . . . . . . . . .Within 30 days
After Hours Care Accessibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Access to a practitioner 24 hrs/7 days a week
Waiting Time in the Waiting Room . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .No more than fifteen (15) minutes or up to one (1) hour when the
MD encounters an . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .unanticipated urgent visit or is treating a member with a difficult need.
The following standards are relevant to all Medicare Assured OB/GYNs and Certified Nurse Midwives:
Requirement
Standard
Wait time for an Urgent, but Non-Emergent Care Appointment . . . . . . . . . Within twenty-four (24) hours from the date of referral
Wait time for a Non-Urgent, but in need of Attention Appointment . . . . . . Within 1 week from the date of referral
Wait time for a Routine Care Appointment . . . . . . . . . . . . . . . . . . . . . . . . . . Within 30 days from the date of referral
Waiting Time in the Waiting Room MD encounters an. . . . . . . . . . . . . . . . . No more than fifteen (15) minutes or up to one (1) hour when the
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . unanticipated urgent visit or is treating a member with a difficult need.
Continued on page 4
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G AT E W AY R E V I E W • D E C E M B E R 2 0 0 6 • I S S U E 5 5
Continued from page 3
In 2006, Gateway assessed compliance with the Primary Care Practitioner
and Specialty Care Practitioner Accessibility Standards via review of member
complaints and results of the CAHPS Member Satisfaction Survey for
Pennsylvania Medicaid practitioners. The Pennsylvania Medicaid OB/
GYN and Certified Nurse Midwife Standards are assessed during the initial
credentialing site visit and, due to their being a critical factor that must
be passed, an annual assessment is not conducted. Medicare Assured
practitioner accessibility will be measured beginning in 2007.
2006 Pennsylvania Medicaid Accessibility Study Results:
PRIMARY CARE PRACTITIONER RESULTS
Standard
Wait time for an
Emergent Appointment
Wait time for Urgent
Appointment
Wait time for Routine
Appointments
Wait time for a Preventive
Care Appointment
After-hours Accessibility
Waiting Time in the
Waiting Room
Immediately, and not inappropriately
referred to the ER
Within 24 hours
2006
Rate
49.3%
2007
Goal
75%
67.7%
75%
Within 10 business days
72.5%
75%
Within 3 weeks of Enrollment
Access to a practitioner 24 hrs/
7 days a week
No more than fifteen (15) minutes
or up to one (1) hour when the
MD encounters an unanticipated
urgent visit or is treating a member
with a difficult need.
Data not 100%
yet available
60.3%
75%
48.1%
75%
Immediately, and not inappropriately
referred to the ER
Within 24 hours
2006
Rate
74.5%
2007
Goal
78.2%
74.5%
78.2%
Within 10 business days
73.4%
77.1%
No more than fifteen (15) minutes
or up to one (1) hour when the MD
encounters an unanticipated urgent
visit or is treating a member with a
difficult need
64.6%
75%
PRIVACY
PRACTICES
Gateway Health Plan is
committed to protecting
the privacy of protected
health information.
So that members are fully aware of how
Gateway may use or disclose information,
each member is sent a “Notice of Privacy
Practices” after their enrollment in the plan,
as well as receiving the notice annually in
subsequent years.
The “Notice of Privacy Practices” also
provides information to members regarding
how they can file a complaint if they
believe Gateway has violated their
privacy rights. It is important to note that
a member’s benefits are not affected
by filing such a complaint.
Members may view the notice on Gateway’s
web site, www.gatewayhealthplan.com or
contact the Member Services Department
at 1-800-392-1147 to request a paper copy.
SPECIALTY CARE PRACTITIONER RESULTS
Standard
Wait time for an Emergent
Appointment
Wait time for Urgent
Appointment
Wait time for Routine
Appointments
Waiting Time in the
Waiting Room
The 2006 study is a new baseline study. Gateway has developed an action
plan to help improve these rates for 2007.
If you would like additional information regarding this study or actions
to be taken, please contact Gateway’s Provider Services Department at
1-800-392-1145.
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GLUCOMETER
COVERAGE
UPDATE
Effective January 1, 2007, Gateway will
now cover Roche Diagnostics glucometers,
glucose test strips, and supplies. Along with
the currently covered LifeScan products,
this addition of Roche's Accu-Chek
glucometers and supplies adds choice
for our diabetic members. Members can
receive their new meters directly at the
pharmacy with a valid prescription from
their physician.
G AT E W AY R E V I E W • D E C E M B E R 2 0 0 6 • I S S U E 5 5
WHAT GATEWAY DOES WITH
MEMBER INFORMATION
Gateway Health Plan is required to protect personal medical and non-public information obtained
from its members. As such, Gateway uses and provides information with utmost care and
according to the HIPAA Privacy Rules (45 CFR 160,164). For example, employees
authenticate callers to determine if the caller is authorized or entitled to receive information
and disclose minimum necessary information.
HIPAA permits healthcare providers to disclose protected health information (PHI) to health
plans and other providers for the purposes of treatment, payment and operations. In fact, one
of the most common types of inquiries received at Gateway requires sharing of information
between Gateway and a provider relating to a member’s care. In these instances, written
authorization from the patient is not needed.
There are also times when Gateway may use or provide medical information without the
need for an authorization from the member. One example is for public health activities, such
as reporting disease outbreaks. Other examples permit Gateway to use or give medical
information for government healthcare oversight activities (such as fraud investigations) or
for judicial and administrative proceedings (such as a court order).
If you have a member who would like more details on how information may be used and
disclosed by Gateway Health Plan, please see the article “Privacy Practices” located within
this newsletter for a member’s options to obtain another copy of Gateway’s “Notice of
Privacy Practices”.
CAHPS® - MEMBER
SATISFACTION SURVEY
Each year, Gateway performs the CAHPS®
(Consumer Assessment of Health Plans Survey)
Survey, which rates member satisfaction with
our services.
Not only does the study point out areas
where our members feel we need to improve,
but our CAHPS® scores are reported to
NCQA, our accrediting organization. This
score is included in our accreditation rating.
Improving our scores enables us to maintain
our ‘Excellent’ rating.
The CAHPS® survey assesses our members’
experiences in the quality of and access to their
health care services through the following
measures:
• Getting needed care
• Getting care quickly
• How well doctors communicate
• Courteous and helpful office staff
• Customer service
• Rating of personal doctor
WORKING TOWARDS HEALTHY
PEOPLE 2010 GOAL….
Gateway Health Plan encourages practitioners to be
part of the Pennsylvania Statewide Immunization Information
System (PA-SIIS). The system was developed to achieve
complete and timely immunizations for all people, particularly
in the age group most at risk: birth through two years of age. It
also helps to serve the public health goal of preventing
the spread of vaccine preventable diseases. A major barrier
of reaching this goal is the continuing difficulty keeping
immunization records accurate and up to date. The PA-SIIS
addresses this problem by capturing immunization information
from health care providers and storing this information in one
central location. If a patient receives immunizations from
more than one health care provider, the PA-SIIS consolidates
the immunization information from all providers to create a
complete and current record. This assists health care providers
to age-appropriately immunize all patients in their care and
enable them to achieve the Healthy People 2010 goal.
For more information about PA-SIIS, please contact
Pennsylvania Dept. of Health/Division of Statistical
Registries at (717) 783-2548 or (800) 323-9613.
You can also receive additional information regarding the PA-SIIS
by visiting Gateway's website at www.gatewayhealthplan.com
and choosing For Providers.
• Rating of specialist
• Rating of health care
• Rating of health plan
These areas are considered Effectiveness of
Care measures:
• Advising smokers to quit
• Discussing smoking cessation medications
• Discussing smoking cessation strategies
This year our composite scores were lower in
all categories except “Rating of Specialist.”
However, practitioners’ interventions and
increased educational efforts improved two of
the Effectiveness of Care measures, “Discussing
Smoking Cessation Medications” and
“Discussing Smoking Cessation Strategies.”
Gateway will continue to work with our
practitioners to improve the care and
services our members receive. We appreciate
the efforts of you and your staff toward
reaching this goal.
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G AT E W AY R E V I E W • D E C E M B E R 2 0 0 6 • I S S U E 5 5
MEDICAID HIGH VOLUME SPECIALIST
MEDICAL RECORD REVIEWS
Gateway’s Quality Improvement Department conducts a medical record review of
high volume specialists every two years. The high volume specialties selected for
medical record review this year were Cardiology, Oncology, Neurology, General
Surgery, Gastroenterology and Obstetrics/Gynecology. The overall scores exceeded
Gateway’s standard of 85% with 98.2% for specialists and 97.0% for OB/GYNs.
FLU CODE
UPDATE
The following flu codes will be covered
by Gateway:
• 90655-Influenza virus vaccine,
split virus, preservation free, 6-35
months dosage, for intramuscular
or jet injection use.
• 90656-Influenza virus vaccine, split
virus, preservation free, 3 years and
above dosage, for intramuscular or
jet injection use.
• 90657-Influenza virus vaccine, split
virus, 6-35 months dosage, for
intramuscular or jet injection use.
• 90658-Influenza virus vaccine, split
virus, 3 years and above dosage,
for intramuscular or jet injection
use for children and adults.
• 90659-Influenza virus vaccine,
whole virus, for intramuscular or jet
injection use for children and adults.
• 90660-Nasal Flu vaccine, ages
5-49 only. Practices should follow
CDC recommendations for use of
this vaccine.
In addition:
• Children under 9 years old should
get 2 doses the first year they
receive the flu vaccine. Gateway
will now pay an administration fee
for both doses.
If you have any questions/concerns
please contact our Provider Services
Department at 1-800-392-1145 or your
Provider Relations Representative.
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Although the overall scores were good, of the 20 standards reviewed, some individual
indicators did not meet the performance standard, also 85%. Cardiology, Oncology
and OB/GYN practitioners scored high for the indicators for notation of use or non-use
of tobacco, alcohol and drugs in members 14 years and older. The other three did
not meet the 85% standard. The only other deficiency noted was for continuity and
coordination of care by the OB/GYN practices. This is measured by documentation
of a report or communication to the Primary Care Practitioner of the specialist’s findings.
Gateway would like to remind our practitioners of the importance of documenting use
or non-use of tobacco, alcohol and drugs in the medical record for those ages 14 and
older. To assist with coordination of care between practitioners, communication
of findings should be sent to the member’s primary care practitioner.
Since members may self refer to an OB/GYN office for routine
services, a referral form may not be available to identify
the primary care practitioner. However, Gateway
member identification cards indicate the member’s
primary care practitioner. Two forms are available
to assist in the communication of findings to the
primary care practitioner. They can be accessed
on our website, www.gatewayhealthplan.com,
under the PA Medicaid tab. Click on
“Providers”, “Forms and References”, and
then choose the Patient (Gynecology)
Visit Summary Form or the Physician
Communication Form. The Medical
Record Standards are also available on
the provider section of the website under
Clinical Guidelines. If assistance is
needed in obtaining the name or
address of the current primary care
practitioner, contact Gateway’s Provider
Services Department at 1-800-392-1145.
G AT E W AY R E V I E W • D E C E M B E R 2 0 0 6 • I S S U E 5 5
CMS COMPLIANCE ISSUE: DELIVERING A NOTICE OF MEDICARE NON-COVERAGE (NOMNC)
Do you represent a skilled nursing,
home health or comprehensive outpatient
rehabilitation facility (CORF) provider? If
so, the Center for Medicare and Medicaid
Services (CMS) requires you to deliver a
notice of Medicare non-coverage (NOMNC)
to every Medicare and Gateway Health Plan
Medicare Assured patient in your care at least
two days prior to the end of the needed care.
It is important to follow the CMS process for
delivering a NOMNC. Why? CMS can
choose to audit Medicare providers to
determine compliance. Also, CMS demands
that Gateway Health Plan Medicare Assured
monitor its providers’ compliance with the
NOMNC process. Gateway Health Plan
wants you to be successful in meeting all
CMS requirements.
You can learn more about being compliant
with the CMS requirements for delivering
a NOMNC in several ways. First, CMS
provides instructions for completing and
delivering a NOMNC on its website at
www.cms.hhs.gov/MMCAG/Downloads/
NOMNCInstructions.pdf. The instructions
are detailed to address almost any scenario.
Additionally, Gateway offers instructions for
completing a NOMNC in its 2007 Provider
Manual and on the Gateway Health Plan
website at www.gatewayhealthplan.com.
Gateway’s UM staff is available to assist you
with questions or concerns about the
NOMNC delivery during your phone calls for
authorization of the skilled nursing, home
health and rehabilitation care. If you are
calling for a Pennsylvania Medicare Assured
member, please call 1-800-685-5207. If
calling regarding an Ohio Medicare Assured
member, please dial 1-888-447-4375 effective
January 1, 2007.
In order to meet its obligation to monitor
compliance with the NOMNC process,
Gateway Health Plan Medicare Assured
requires providers to fax a copy of all signed
NOMNC forms to 1-800-685-5231.
Gateway Health Plan Medicare Assured
welcomes opportunities to support its
providers, particularly in the area of CMS
compliance. Further information will be
shared through provider mailings and
newsletters.
2ND AND 3RD QUARTER OFFICE
MANAGER INCENTIVE PROGRAM WINNERS
Congratulations to the winners of the 2nd and 3rd Quarter 2006 Primary Care Office
Manager Incentive Program! The winners are as follows:
CLAIM SUBMISSION
REMINDER
2nd Quarter 2006
• FIFTH AVENUE MEDICAL ASSOCIATES
• MICHAEL G. LAMB, M.D.-GRP
• NALLATHAMBI MEDICAL ASSOCIATES
• CENTER PEDIATRICS MONACA
• PEDIATRIC ALLIANCE-NORTH HILLS
PEDS DIVISION
• SHADYSIDE FAMILY HEALTH CENTER
Please do not highlight information
on any attachment forwarded along
with a claim. Highlighting the text
blocks it and renders it unreadable
when scanned into Gateway’s system.
Instead, providers submitting information
should circle the information that
needs to be identified or flagged on
the attachment or claim.
3rd Quarter 2006
• THE DOCTOR`S OFFICE SMITHFIELD
• SEETHA CHANDRA, M.D - GRP
• FAMILY PRACTICE CENTER
• N. B. KRISHNAPPA, MD, FAAP
• LAWRENCEVILLE FAMILY HEALTH CENTER
• CHI-EBANDJIEFF/PARK HILL
As a reminder, the criteria for participation includes the following:
1. Submission of claims electronically.
2. Submission of greater than or equal to the peer average of encounters per member per year.
3. Maintenance of a member transfer rate that is equal to or less than the peer average.
4. Submission of EPSDT forms and preventive health encounter forms.
The winners received a gift basket. The winners of the 4th Quarter will be announced
in the next issue of the Gateway Review. Good Luck!
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G AT E W AY R E V I E W • D E C E M B E R 2 0 0 6 • I S S U E 5 5
GATEWAY HEALTH PLAN
MEMBERS’ RIGHTS AND
RESPONSIBILITIES STATEMENT
Pennsylvania Medicaid Member
Rights and Responsibilities
10. Request a fair hearing from the
Department of Public Welfare.
Member Rights
11. Prepare a Living Will and/or Advance
Directive.
As a Gateway Member, you have the
right to:
1. Get information about Gateway, the
services Gateway provides, doctors and
other health care providers giving you
care, and your rights and responsibilities
as a Gateway member.
2. Be treated with respect and recognition
of dignity and right for privacy when
receiving health care.
3. Work with your doctor or other
health care provider in making decisions
about your health care and to express
preferences about future treatment
decisions.
4. Openly discuss without any limitations
by Gateway appropriate or medically
necessary treatment choices for your
condition with a doctor or other health
care provider, including treatment
options, risks of treatments, alternative
therapies, and consultations or tests that
may be self administered, regardless of
the cost or if it is a benefit.
5. Receive your medical and nursing care
without regard to race, color, religion,
sex, age, disability, national origin, or
without regard to whether you have
an advance directive.
6. Pick your own doctor from Gateway’s
network of doctors.
7. Refuse care from certain doctors.
8. File a complaint or grievance about
Gateway or the care it provides.
9. Make recommendations regarding
Gateway’s members’ rights and
responsibilities policies.
8
12. See, or have your medical record
copied, within Federal and State laws,
and to request that your medical
record be changed or corrected within
Federal laws.
13. Have your medical records kept private
and confidential.
Member Responsibilities
As a Gateway Member you have a
responsibility to:
1. Give information to your doctor, other
health care provider, or Gateway so they
can provide care to you.
2. Follow the instructions and treatment
plans that you agreed on with your
doctor or other health care provider.
3. Provide consent to healthcare providers
and Gateway to help them manage
your care, to improve your health or
for research.
4. Understand your health problems. As
much as you can, take part in making
a plan for treatment goals with your
doctor or other health care providers.
5. See the doctor you picked on a
regular basis.
6. Treat the people giving you medical care
with the same respect and kindness you
expect for yourself.
Gateway Health Plan Medicare Assured
Members Rights and Responsibilities
can be found on Gateway’s website at
www.gatewayhealthplan.com.
WHAT IS A
“CORRECTED
CLAIM”?
When submitting corrected claims,
please be sure to include all services
that were previously billed on the
original claim to ensure appropriate
adjustments and payments are made.
Gateway reprocesses corrected claims
by retracting the original claim payment
in its entirety and then processing
the “corrected claim”. In addition,
the claim must be clearly marked
“Corrected Claim” and submitted for
reprocessing within 90 days from the
payment date of the original claim.
G AT E W AY R E V I E W • D E C E M B E R 2 0 0 6 • I S S U E 5 5
GATEWAY
MEDICARE ASSURED
NATIONAL IMAGING ASSOCIATESRADIOLOGY AUTHORIZATIONS
Gateway delegates the service of authorizing the following radiology procedures to
National Imaging Associates (NIA):
• MRI/MRA • CT Scans • Bone Densitometry • Nuclear Cardiology • PET Scans
To obtain authorizations for these services please contact NIA at 1-888-879-5922
Monday through Friday between the hours of 8:00 AM and 8:00 PM.
Gateway practitioners and providers can also receive up-to-the hour information on a
member’s authorization, including date called, date approved, exam category, valid
billing codes and much more by visiting NIA’s website, www.radmd.com. An account
with a password will need to be established on the first visit, otherwise, receiving this
information is as easy as logging in.
CHIROPRACTIC CHANGES
Gateway Health Plan’s Utilization
Management Department will apply
MCAP criteria to requests for
chiropractic care. This change does
not impact the need to call and
obtain authorization for care or the
information that is needed when
making a request. As always if a
request does not meet the criteria
requirements it would be routed
to a physician for review and there
would be an opportunity for a
peer-to-peer discussion of the request.
Effective January 1, 2007, Gateway
Health Plan Medicare Assured will
require all hospitals, including acute
care hospitals, rehabilitation facilities,
and long-term care hospitals, to submit
inpatient readmissions, interrupted
stays, or leave of absence (LOA)
charges on separate claims. Gateway’s
Utilization Management Department
must be contacted to authorize each
confinement separately. Providers
should bill with the appropriate
condition, patient status, revenue, and
occurrence codes used to indicate
readmissions, transfers, interrupted
stays, and LOA, as appropriate.
Inpatient confinements processed
using CMS PRICER software (i.e.
applicable acute care hospitals,
rehabilitation facilities and long-term
care hospitals) or contracted DRG
rates will be subject to the Gateway
readmission and transfer procedures.
Hospitals reimbursed on a per diem
basis, critical access and sole community
hospitals, as well as a LOA from
a behavioral health facility, are not
subject to this policy.
In order to comply with CMS
guidelines and Gateway Health Plan
Medicare Assured readmission and
transfer policies and procedures, a
retrospective review will be performed
to combine and adjust applicable
claims payable under one DRG
payment.
9
G AT E W AY R E V I E W • D E C E M B E R 2 0 0 6 • I S S U E 5 5
2006 PRACTITIONER AND
PROVIDER SATISFACTION SURVEY RESULTS
The results of the 2006 Practitioner and Provider Satisfaction Survey are in! The practitioner
survey was mailed to a random sample of primary care practitioners and specialty care
practitioners, and the provider survey was mailed to all Gateway participating hospitals
and ancillary providers in August 2006. An overview of results is as follows:
PCP
Rate
SCP
Rate
Hospital
Rate
Ancillary
Rate
Knowledge of which services require an authorization
86.5%
86.7%
87.5%
82.7%
Knowledge of which services require a referral
92.0%
89.0%
89.7%
76.2%
Ease of use/completion of the paper referral form
90.2%
84.5%
N/A
N/A
Timeliness of UM Staff
80.6%
87.5%
74.2%
80.4%
Clinical knowledge of UM Staff
89.2%
91.9%
86.7%
86.9%
Consistency of UM Staff
87.8%
89.1%
80.0%
81.9%
Medical appropriateness of Gateway’s Physician Reviewer
76.3%
83.6%
59.3%
73.1%
Professionalism/courtesy of UM Staff
93.5%
96.2%
93.3%
92.9%
Overall Satisfaction with the UM Process
85.4%
89.5%
82.8%
82.8%
Professionalism/courtesy of Pharmacy Staff
88.7%
96.0%
81.8%
97.1%
Consistency of Pharmacy Staff
83.4%
92.1%
81.8%
93.8%
Timeliness of Pharmacy Staff
79.3%
90.3%
54.5%
90.6%
Understanding of Pharmacy Authorization Process
80.7%
73.8%
90.9%
87.5%
Overall Satisfaction with the Pharmacy Authorization Process
76.3%
85.0%
72.7%
87.5%
Overall Satisfaction with Gateway Health Plan
84.8%
83.0%
71.9%
75.4%
Gateway utilized a survey vendor, The Myers Group, to
conduct the surveys again in 2006. Gateway met the goal
established for specialists in regards to clinical knowledge
and professionalism/courtesy of the UM Staff Representative,
and professionalism/courtesy and consistency of the
Pharmacy Representative. The goal for specialist’s overall
satisfaction with the Pharmacy Authorization Process was
also met. No other goals were met in 2006.
Gateway has developed an action plan based on the 2006
results that focuses on areas for improvement. Gateway
will continue to take great strides to meet the needs of the
practitioner and provider populations through education
and assessment of internal policy.
Question
If you would like to receive additional information regarding
the survey results, action plan or goals, please contact
Gateway’s Provider Services Department at 1-800-392-1145.
WINNERS OF THE PRACTITIONER SATISFACTION SURVEY DRAWING
Congratulations to the winners of the
2006 Practitioner Satisfaction Survey
Drawing. The winners returned their
surveys to The Myers Group, an
independent survey vendor, by the
date specified and qualified for the
10
random drawing. All surveys were
blinded, therefore Gateway received no
specific results.
1. STOKEN OPHTHALMOLOGY
2. THE HEART CARE GROUP, PC
3. GREENGATE ORTHOPAEDIC GROUP
4. HIGHLANDS PEDIATRICS
5. PENNSBORO PEDIATRICS
6. GIRARD FAMILY HEALTH CARE CENTER
The winners received a Harry & David Gift Basket
for their staff. Gateway appreciates your response
to the survey and will work to improve our
processes and policies to better serve your needs!
G AT E W AY R E V I E W • D E C E M B E R 2 0 0 6 • I S S U E 5 5
GUIDELINES AND
REVIEW STANDARDS ON
GATEWAY’S WEBSITE
NATIONAL
PROVIDER
IDENTIFIER (NPI)
May 23, 2007 marks the date all
healthcare providers who utilize HIPAA
standard electronic transactions must
have an NPI number and it is also the
date all health plans and payers must
be able to accept and use the NPI.
Gateway encourages all providers who
have not already applied for an NPI to do
so immediately. For additional information,
and to complete an application, visit
https://nppes.cms.hhs.gov on the web.
A year ago the Quality Improvement (QI)
Department sent updated Quality Improvement
Manual inserts to each of Gateway’s
Pennsylvania Medicaid Primary Care
Practitioner offices. The manual includes our
clinical and preventive guidelines as well as
Medical Record Review and Medical
Record Keeping Standards. Any revisions
since that time have been made to the
documents on our website.
These documents and any revisions
may be accessed on Gateway’s
website, www.gatewayhealthplan.com,
by choosing either the PA Medicare
Assured or PA Medicaid tabs,
Provider and then Clinical
Guidelines or Medical Record
Standards. To request a hard
copy, call 412-255-1144.
More information will be forthcoming
over the next few months on Gateway’s
implementation of the NPI.
REMINDER REGARDING
MEDICAID CO-PAYMENTS:
Co-payments do not apply to any member who is
pregnant. In order to correctly identify a pregnant
member and ensure that the co-pay is not deducted
from your claim payment, please be sure that you are
including the appropriate pregnancy-related diagnosis
code on your claim.
11
US Steel Tower, Floor 41; 600 Grant Street; Pittsburgh, PA 15219
www.gatewayhealthplan.com
Important Phone Numbers
PROVIDER SERVICES
Medicaid 1-800-392-1145
Medicare 1-800-685-5205
MEDICAL MANAGEMENT
Medicaid 1-800-392-1146
Medicare (PA) 1-800-685-5207
Medicare (Ohio) 1-800-447-4375
MEMBER ELIGIBILITY/DIVA VERIFICATION LINE
Medicaid and Medicare 1-800-642-3515
EPSDT
Medicaid 1-800-642-3550, Option 4
PHARMACY
Medicaid 1-800-528-6738
Medicare 1-800-685-5215
NATIONAL IMAGING ASSOCIATES
Medicaid and Medicare 1-888-879-5922
TABLE
OF
CONTENTS
Cover:
Page 6:
• Children’s Community Pediatrics Tarentum
and Butler Medical Associates-Chicora
Earn 100% Club Distinction
• Flu Code Update
• Medicaid High Volume Specialist Medical
Record Reviews
Page 2:
Page 7:
• Affirmative Statement about Incentives and
Over-Under Utilization Statement
• Correction Regarding Post-Partum Home
Health Visits
• Confidentiality of Patient Information
• CCP Tarentum Practice Manager Laurie
Kovar on Recipes for EPSDT Success
• CMS Compliance Issue: Delivering a Notice of
Medicare Non-Coverage [NOMNC]
• 2nd and 3rd Quarter Office Manager Incentive
Program Winners
• Claim Submission Reminder
Page 3:
• 2006 Practitioner Accessibility Standards
and Study Results
Page 4:
• 2006 Practitioner Accessibility Standards
and Study Results (continued)
• Privacy Practices
• Glucometer Coverage Update
Page 5:
ICON KEY
MEDICAID ONLY
MEDICAID & MEDICARE
MEDICARE ONLY
• What Gateway Does with Member
Information
• Working Towards Healthy People 2010
Goal…
• CAHPS® - Member Satisfaction Survey
Page 8:
• Gateway Health Plan Members’ Rights and
Responsibilities Statement
• What is a “Corrected Claim?”
Page 9:
• National Imaging Associates-Radiology Authorizations
• Chiropractic Changes
• Gateway Medicare Assured
Page 10:
• 2006 Practitioner and Provider Satisfaction
Survey Results
• Winners of the Practitioner Satisfaction Survey
Drawing
Page 11:
• National Provider Identifier [NPI]
• Guidelines and Review Standards on Gateway’s
Website
• Reminder Regarding Medicaid Co-Payments