Network News
December 2014
In This Issue:
Optima Family Care Primary Care Physician
Supplemental Payments End December 31
P.1
Modifiers 59/XE/XP/XS/XU—Distinct
Procedural Service
P.2
Ambulatory Surgery Pre-Authorization Update
P.2
January 2015 Pharmacy Changes
P.3
Optima Health Partners With WebMD for Member
Wellness
P.6
Reminder: Panel Status Changes
P.7
Medicaid and FAMIS Dental Program
P.7
Optima Family Care Membership Grows
P.8
Cultural Competence
P.8
Helping Members Understand Patient-Centered
Medical Homes (PCMH)
P.8
New Department of Medical Assistance Services
Initiative: Health and Acute Care Program
P.9
Attention Deficit Hyperactivity Disorder (ADHD)
P.9
Verify Member Eligibility and Benefits on Provider
Connection
P.9
Optima Health Quality Improvement Program
P.10
Quality Improvement Highlights
P.11
HEDIS® 2015 Update NCQA Timeline
P.12
Authorization Updates
P.13
Pre-Authorization Fax Numbers
P.15
Important Phone Numbers
P.15
Optima Family Care Primary Care Physician
Supplemental Payments End December 31
As part of the Affordable Care Act, Medicaid agencies
and managed care organizations were required to pay
Medicare rates for Medicaid primary care physician
(PCP) services furnished by eligible physicians in
calendar years 2013 and 2014 through funding provided
by the Federal Government. To comply with this
requirement, Optima Family Care (OFC) chose to make
retroactive supplemental payments to providers on a
quarterly basis.
Federal funding for this program is scheduled to end on
December 31, 2014. Effective January 1, 2015, OFC
reimbursement for primary care services will continue
according to the contracted rates in your provider
agreement.
Optima Health allows up to one year (365 days) from
the date of service for timely filing of claims, so some
providers may continue to receive quarterly supplemental
payments through 2016 (for services rendered in 2013
and 2014). Claim payment detail for these payments
will continue to be posted on the “View Remits and Pend
Reports” section of Provider Connection on
optimahealth.com/providers.
If you have any questions regarding the OFC PCP
supplemental payments, please contact your Network
Educator.
P.2
Modifiers 59/XE/XP/XS/XU—Distinct Procedural Service
Under certain circumstances, physicians may need to indicate that a procedure or
service was distinct or independent from other services performed on the same day.
Starting with date of service January 1, 2015, providers should utilize the newly created
CMS modifiers XE, XP, XS, and XU in place of Modifier 59 when appropriate. The new
modifiers are more specific versions of the 59 modifier, and they should not be used on
the same line as Modifier 59. Modifier 59 should only be used when the new modifiers
are not appropriate for the procedure. Optima Health will continue to follow the most
current CMS policies for these modifiers.
Modifiers XE, XP, XS, XU, or 59 do not bypass multiple surgery fee reductions,
bilateral fee adjustments, or any other administrative policy other than clinical edits.
Documentation should be available in the patient’s record to support the distinct or
independent identifiable nature of the service and be provided in a timely manner for
review upon request.
If you have questions, please contact Provider Relations.
Ambulatory Surgery Pre-Authorization Update
Optima Health has implemented a 30-day authorization time span for ambulatory
surgery procedures. If the approved procedure is performed any day within the 30-day
time span, the claims will be paid.
Previously, ambulatory surgery authorizations were date specific and providers were
required to request authorization updates if the procedure date changed.
Any policy changes communicated in this newsletter are considered official
and effective immediately unless otherwise indicated, and will be reflected
in the next edition of the Optima Health Provider Manual.
We have attempted to identify each policy change by placing a red push pin
to the left of the corresponding language.
Network News
P.3
December 2014
January 2015 Pharmacy Changes
These changes apply to plans with pharmacy benefits administered by Optima Health.
The purpose of the following is to communicate pharmacy changes effective January 1, 2015.
Note: Pharmacy changes are made on a quarterly basis with effective dates of:
January 1, April 1, July 1, and October 1.
*For Groups without a Four-Tier pharmacy plan, drugs listed as moving to Tier 4 will remain at Tier 3.
Description of Change
(by Formulary Type)
Drug Name
Indication
Anoro™ Ellipta®
(umeclidinium and
vilanterol inhalation
powder)
respiratory/asthma
New Medication: Added to Preferred Tier
Commercial – Tier 2
Medicaid – Formulary
Generics Plus – Tier 3
QHP 4-Tier – Tier 2
Aveed®
(testosterone undecanoate)
Injection CII
hypogonadism
New Medication:
Medical Benefit with Prior Authorization – for all
formularies
Beleodaq™
(belinostat)
lymphoma
New Medication:
Medical Benefit for all formularies
Breo® Ellipta®
(fluticasone furoate and
vilanterol inhalation
powder)
respiratory/asthma
Change in Tier:
Commercial – Tier 2
Medicaid – Formulary
Generics Plus – Tier 3
QHP 4-Tier – Tier 2
Cambia™
(diclofenac potassium for
oral solution)
migraine headaches
Adjustment in Step-Edit Criteria – no change in
formularies
Cyramza™
(ramucirumab)
gastric cancer
New Medication:
Medical Benefit for all formularies
Dexilant™
(dexlansoprazole)
gastroenterology
Change in Step-Edit Criteria
Commercial – Tier 3
Medicaid – Non-Formulary
Generics Plus – Non-Formulary
QHP 4-Tier – Tier 3
Entyvio™
(vedolizumab)
gastroenterology
New Medication:
Medical Benefit with Prior Authorization – for all
formularies
Farxiga™
(dapagliflozin)
diabetes
Adjustment to Step-Edit Criteria
Commercial – Tier 4
Medicaid – Non-Formulary
Generics Plus – Non-Formulary
QHP 4-Tier – Tier 4
P.4
January 2015 Pharmacy Changes, Continued
Drug Name
Indication
Description of Change
(by Formulary Type)
Injectafer®
(ferric carboxymaltose)
Injection
hematology
New Medication:
Medical Benefit with Prior Authorization - for all
formularies
Invokana®
(canagliflozin)
diabetes
Adjustment to Step-Edit Criteria
Commercial – Tier 4
Medicaid – Non-Formulary
Generics Plus – Non-Formulary
QHP 4-Tier – Tier 4
Lidocaine Viscous
topical anesthesia
CHANGE IN CRITERIA – No Change in Tiers - Age and
quantity limits - Prior authorization for ages < 3 years old
and if authorized, limit of 10 mL daily
Nexium®
(esomeprazole
magnesium) 40 mg
gastroenterology
Change to Step-Edit Criteria
Commercial – Tier 3
Medicaid – Non-Formulary
Generics Plus – Non-Formulary
QHP 4-Tier – Tier 3
Northera™
(droxidopa)
cardiac
New Medication with Prior Authorization
Commercial – Tier 4
Medicaid – Non-Formulary
Generics Plus – Non-Formulary
QHP 4-Tier – Tier 4
Omeprazole 20 mg,
omeprazole/sodium
bicarbonate 20-1100 mg,
lansoprazole 15 mg,
Nexium® (esomeprazole
magnesium) 20 mg
gastroenterology
Change in Tiers – Remove from Coverage – for all
formularies EXCEPT FAMILY CARE
Omeprazole OTC
gastroenterology
Remove from coverage for all formularies
Otezla
(apremilast)
moderate to severe plaque
psoriasis
Adjustment to Prior Authorization Criteria:
Commercial – Tier 4
Medicaid – Non-Formulary
Generics Plus – Non-Formulary
QHP 4-Tier – Tier 4
ProAir® HFA
(albuterol sulfate)
bronchospasm
Added Step-Edit Criteria only no change in drug tier/formulary status
Prolia®
(denosumab)
treatment for postmenopausal osteoporosis
Remove Prior Authorization – No change in Medical
Benefit for all formularies
Proventil® HFA
(albuterol sulfate)
bronchospasm
Added Step-Edit Criteria only no change in drug tier/formulary status
Qnasl®
(bedomethasone
dipropionate)
nasal allergies
Added Step-Edit Criteria
Commercial – Tier 3
Medicaid – Non-Formulary
Generics Plus – Non-Formulary
QHP 4-Tier – Tier 3
®
Network News
P.5
December 2014
January 2015 Pharmacy Changes, Continued
Drug Name
Indication
Description of Change
(by Formulary Type)
Rayos®
(prednisone delayedrelease tablets)
endocrinology
Added Step-Edit Criteria
Commercial – Tier 3
Medicaid – Non-Formulary
Generics Plus – Non-Formulary
QHP 4-Tier – Tier 3
Sylvant™
(siltuximab)
Castleman’s disease (CD)
New Medication:
Medical Benefit for all formularies
Symbicort®
(budesonide/formoterol
fumarate dehydrate)
asthma/COPD
Added Prior Authorization Criteria:
Commercial – Tier 3
Medicaid – Non-Formulary
Generics Plus – Non-Formulary
QHP 4-Tier – Tier 3
Synagis®
(palivizumab)
treatment for respiratory
syncytial virus (RSV)
Adjustment in Prior Authorization Criteria – No change in
Medical Benefit for all formularies
Thyrogen®
(Thyrotropin alfa for
injection)
thyroid cancer
Remove Prior Authorization Requirement – No change in
Medical Benefit for all formularies
Torisel®
(temsirolimus)
kidney cancer
Remove Prior Authorization Requirement – No change in
Medical Benefit for all formularies
Vectibix®
(panitumumab)
metastic colorectal cancer
Remove Prior Authorization Requirement – No change in
Medical Benefit for all formularies
Xartemis™ XR
(oxycodone
HCI/acetaminophen)
acute pain
New Medication: Authorizations limited to 60 days
Commercial – Tier 3 with Prior Authorization
Medicaid – Non-Formulary
Generics Plus – Non-Formulary
QHP 4-Tier – Tier 3 with Prior Authorization
Xgeva®
(denosumab)
bone metastases from
solid tumors
Remove Prior Authorization – No change in Medical
Benefit for all formularies
Xopenex HFA®
(levalbuterol tartrate)
bronchospasms
Added Step-Edit Criteria only - No change in drug
tier/formulary status
Zetonna®
(ciclesonide)
allergic rhinitis
Added Step-Edit Criteria
Commercial – Tier 3
Medicaid – Non-Formulary
Generics Plus – Non-Formulary
QHP 4-Tier – Tier 3
Zontivity™
(vorapaxar)
myocardial infarction
(MI) or peripheral arterial
disease (PAD)
New Medication with Prior Authorization
Commercial – Tier 4
Medicaid – Non-Formulary
Generics Plus – Non-Formulary
QHP 4-Tier – Tier 4
P.6
January 2015 Pharmacy Changes, Continued
Drug Name
Indication
Description of Change
(by Formulary Type)
Zorvolex®
(diclofenac)
osteoarthritis
Added Step-Edit Criteria
Commercial – Tier 3
Medicaid –Non-Formulary
Generics Plus –Non-Formulary
QHP 4-Tier – Tier 3
Zykadia™
(ceritinib)
anaplastic lymphoma
kinase (ALK+) metastic
non-small cell lung cancer
New Medication with Prior Authorization
Commercial – Tier 4
Medicaid – Non-Formulary
Generics Plus – Non-Formulary
QHP 4-Tier - Tier 4
Compounded drugs
PRIOR AUTHORIZATION WILL BE REQUIRED;
SOME COMPOUNDS MAY BE EXCLUDED
Specialty drugs
SEE PLAN SUMMARY OF BENEFITS:
Commercial – Tier 4
QHP 4-Tier - Tier 4
On rare occasions, updates are made between content submission deadlines and newsletter publication dates.
For the most current list of pharmacy changes, please visit the drug lists section on optimahealth.com/members.
Optima Health Partners with WebMD for Member Wellness
We are excited to share with you that our new vendor and partner for wellness will be
WebMD!
WebMD wellness services will offer our members flexible programs, expert guidance,
and inspiration to take charge of their own health—whether they are continuing healthy
behaviors, or need to improve on unhealthy ones. WebMD has a comprehensive
Personal Health Assessment, which will create the foundation for the member’s Health
Record. WebMD also offers a comprehensive online activities manager, known as My
Health Assistant. The online health assistant delivers a personalized, interactive, and
motivational experience to help members take action and sustain healthy behaviors in a
fun way.
WebMD offers a huge library of information, online trackers, menu planners, and
telephonic coaching, and is backed by its excellent reputation and brand recognition.
Optima Health will transition members to WebMD on January 1, 2015. Members will still
have easy access to these services through our website, optimahealth.com/members.
P.7
Network News
December 2014
Reminder: Panel Status Changes
Optima Health requires written notice or email for any network panel status changes. All
changes will become effective 60 days after receipt of the written notice. Any member
that selects a PCP prior to the effective date of the panel limitation will be paneled to that
PCP. If you have questions, please contact your Network Educator.
Medicaid and FAMIS Dental Program
Smiles For Children (SFC) is Virginia’s Medicaid and FAMIS dental program providing
comprehensive dental benefits to members under age 21 (including pregnant members
under 21), and limited benefits to members over 21.
How can I help my Medicaid patients find a dentist?
Finding a dentist is easy. Members may:
• Call 1-888-912-3456. We can even help the member make an appointment. The call
center is available 8 a.m.–6 p.m., Monday through Friday.
• Visit the website at DentaQuest.com.
• Download the smartphone app by visiting your phone’s app store and searching for
“My DentaQuest Mobile.”
What services are covered under the Smiles For Children program (under age 21)?
Regular dental checkups (every six months)
X-rays (when necessary)
Cleaning and fluoride (every six months)
Sealants
Information and education about oral care
Space maintainers
Braces (if necessary)
Anesthesia
Extractions
Root canal treatment
Crowns
When should I talk with my Medicaid patients about visiting the dentist?
Children should see a dentist every six months, starting at age one.
If you have questions about incorporating oral health practices into your office or
questions about the Smiles For Children program please contact Jackie Wake, State
Outreach Coordinator, at [email protected].
P.8
Optima Family Care Membership Grows
Effective December 1, 2014, Optima Health welcomed new Optima Family Care
members in the Western, Roanoke, and Alleghany regions of Virginia. These members
are transitioning from MagestaCare, a managed care organization that has exited the
Medicaid market in those regions. We look forward to serving these new members
alongside our dedicated provider
network.
Cultural Competence
As the patient population grows and
becomes increasingly diverse, it is
essential that culturally competent
healthcare is delivered.
To stay current on topics that are
important to those we care for and for
tips that can improve patient encounters,
the U.S. Department of Health and
Human Services of Minority Health offers
“Think Cultural Health,” a free continuing
educational program for up to nine CME
credits.
This program can be accessed through
Optima Health at http://providers.optimahealth.com/qi/Pages/CME-Opportunities.aspx.
Helping Members Understand Patient-Centered Medical Homes (PCMH)
In recent newsletters to our brokers, benefits administrators, and members, we included
a brief article educating them about the definition of a Patient-Centered Medical Home
(PCMH). We know that the word “home” causes a lot of confusion to the average
person, and we are attempting to help make all of these new terms and acronyms more
understandable.
In addition, we have prepared this video to help promote education and understanding.
We have provided this information in case you or your staff receives additional questions
as a result of this education effort. Visit optimahealth.com for information about our plans,
health insurance, terms and acronyms, Health Care Reform, and more.
Network News
P.9
December 2014
New Department of Medical Assistance Services Initiative: Health and
Acute Care Program
The Department of Medical Assistance Services (DMAS) has launched the Health and
Acute Care Program (HAP) effective December 1, 2014. This program allows eligible
members who are enrolled in home and community based (HCBS) waiver services to
receive their acute and primary medical care through a managed care organization
(MCO). HCBS waiver services, such as Adult Day Health Care and Transition
Coordination, will continue to be reimbursed through fee-for-service Medicaid as “carved
out” services. As always, providers are encouraged to verify member eligibility prior to
rendering services.
Attention Deficit Hyperactivity Disorder (ADHD)
Follow-up care for children prescribed ADHD medication is a HEDIS®1 measure that
reports the percentage of children between the ages of 6-12 who were newly prescribed
ADHD medication and had at least three follow-up care visits within a 10-month period.
Also, one of the visits must occur within 30 days of when the first ADHD medication was
dispensed.
Below is a list of CPT Codes for ADHD follow-up care:
96150-96154
98960-98962
99078
1
99201-99205
99211-99220
99241-99245
99341-99350
99381-99384
99391-99394
99401-99404
99411-99412
99510
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA)
Verify Member Eligibility and Benefits on Provider Connection
Did you know that Provider Connection offers real-time member eligibility and benefit
information?
This secure, online provider tool gives you access to the same information our Provider
Relations team can provide over the phone, but is available 24 hours a day, 7 days
a week. Provider Connection also includes a convenient option to print the Member
Eligibility Detail screen if documentation of verification is needed.
Take advantage of Provider Connection today! Sign In.
Don’t have a login? Registration is open to all participating providers and office staff.
Register now.
P.10
Optima Health Quality Improvement Program
Optima Health has received NCQA Accreditation for its commercial HMO/POS health
plans and Medicaid HMO product1. NCQA Health Plan Accreditation evaluates how
well a health plan manages all parts of its delivery system—physicians, hospitals, other
providers, and administrative services—in order to continuously improve the quality of
care and services provided to its members2.
Optima Health offers a comprehensive Quality Improvement (QI) program that focuses
on objectively and systematically improving the quality of healthcare and services for our
members. The program is reviewed annually and developed to monitor services that are
high volume, high cost, high risk and/or problem prone.
Optima Health QI Program for 2015 includes:
• reminder cards and/or calls to members, and follow up communication with
physicians regarding recommended prevention screenings and care;
• health-risk assessment and welcome calling programs to identify specific chronic
conditions in our membership, with appropriate follow up activities;
• disease management programs for members with diabetes and asthma;
• programs focused on promoting healthy pregnancy;
• service activities to assess and improve access to healthcare, as well as satisfaction
with the health plan and with the care received from our practitioners and providers;
• evaluating complaints and occurrences to ensure that our members’ needs are met by
the highest level of care and service;
• investigating new procedures and treatments in medical and behavioral health
procedures, pharmaceuticals, and devices, through comprehensive technology
assessment review;
• credentialing and re-credentialing primary care and specialty care providers;
• medical record documentation review and provider education; and
• review and distribution of clinical guidelines.
As physicians, you can help improve quality of care by:
•
•
•
•
encouraging your patients to schedule preventive exams,
reminding your patients to follow up with ordered tests and procedures,
making sure necessary services are being performed in a timely manner,
submitting claims with proper HEDIS® codes, and
Network News
P.11
December 2014
• accurately documenting all services and results (if appropriate) in the patient’s medical
chart.
Working together to improve and maintain a higher quality of care for our members
benefits everyone!
For more information about QI at Optima Health, please contact the QI Department at
757-252-8400 or 1-866-425-5257. For more information regarding NCQA visit the
website at ncqa.org.
1
2
NCQA Accreditation documentaion
NCQA (September 2013). General Guidelines for Marketing and Advertising Health Plan Accreditation
Quality Improvement Highlights
As part of the Optima Health Quality Improvement (QI) program, clinical rates are
reviewed for appropriate action planning and improvement. Some of the rates monitored
in QI include:
HEDIS® Measure
Adolescent
Immunization
Childhood
Immunization
Breast Cancer
Screening
Cervical Cancer
Screening
Timeliness of Prenatal
Care
Postpartum Visit
Dilated Eye Exam
(Diabetes)
Cholesterol
Management
Controlling High Blood
Pressure
Commercial
HMO/POS
CY
CY
2012
2013
Commercial PPO
Medicaid
CY
2012
CY
2013
CY
2012
CY
2013
61.37%
61.65%
51.55%
58.33%
55.41%
57.71%
80.79%
84.03%
77.38%
69.03%
70.58%
70.60%
70.44%
74.69%
51.55%
73.30%
50.27%
57.43%
75.18%
79.16%
69.29%
78.07%
73.05%
72.33%
88.17%
88.17%
84.36%
81.09%
83.66%
83.66%
83.04%
83.04%
81.09%
84.36%
65.34%
65.34%
57.96%
61.06%
60.72%
53.54%
48.61%
47.22%
88.69%
88.12%
87.56%
83.28%
78.00%
79.52%
62.92%
57.14%
60.81%
52.41%
51.18%
54.33%
P.12
Customer service is also a priority for QI. Optima Health conducts member satisfaction
surveys to assess satisfaction levels with our health plans and initiate appropriate action
plans if necessary.
The Consumer Assessment of Health Plans Survey (CAHPS®1 5.0H) is a member
satisfaction survey conducted each spring as a part of our National Committee for
Quality Assurance (NCQA) accreditation process. Below are the latest results for
Commercial and Medicaid populations from Optima Health:
Composite Category
Getting Needed Care
Getting Care Quickly
Customer Service
Rating of Health Care
Rating of Health Plan
Rating of Personal
Doctor
Rating of Specialist
Commercial
HMO/POS
CY
CY
2012
2013
86.4%
88.8%
88.6%
86.2%
87.0%
89.4%
77.6%
80.6%
69.2%
67.3%
Commercial PPO
Medicaid
CY
2012
88.3%
86.8%
87.3%
74.4%
58.9%
CY
2013
88.3%
83.3%
85.6%
78.2%
58.2%
CY
2012
80.6%
81.8%
86.0%
76.0%
83.8%
CY
2013
85.6%
82.5%
89.7%
77.1%
80.2%
87.5%
86.6%
85.0%
88.5%
81.0%
80.9%
86.1%
86.2%
84.7%
86.2%
81.4%
81.1%
For more information regarding the HEDIS® or CAHPS® measures, please visit
optimahealth.com. If you have questions, please contact the QI Department at 757-2528400 or 1-866-425-5257.
1
CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
HEDIS® 2015 Update NCQA Timeline
In order to meet NCQA’s timeline for submission of all HEDIS® data, Optima Health must
complete all data collection and onsite medical record reviews by May 8, 2015.
Optima Health is contracting with a medical record review vendor, Enterprise Consulting
Solutions (ECS), to assist us in collecting medical records in select areas. Please
respond to their request for medical record information on our behalf. If you do not wish
to provide records to us via the vendor, please contact us as soon as possible.
The Quality Improvement (QI) team thanks you in advance for your cooperation. For
additional information on HEDIS® measures, or the medical record review process, please
contact the QI Department at 757-252-8400 or 1-866-425-5257.
Network News
P.13
December 2014
Authorization Updates
Optima Health would like to notify you of the following authorization updates, made since
the last version of Network News:
TOPIC
DETERMINATION/COVERAGE
Continuous Subcutaneous Insulin Infusion—
DME Policy
•
•
Clarified age indication for children/adolescents is
children 12 yrs of age or older with type 1 diabetes
Pre-Authorization Required
Left Atrial Appendage Occlusion or
Ablation—Surgical Policy
•
•
No change to policy criteria
Pre-Authorization Required
Breast Reduction Surgery—Surgical Policy
•
Clarified criteria to read: If BMI is greater than 30,
there must be PHYSICIAN DOCUMENTATION that
member has complied with a medically supervised
weight loss program over a period of at least six
consecutive months within the previous 12 month
period and has failed.
Pre-Authorization Required
•
Assistive Devices—DME Policy
•
•
MRI Cervical (CPT 72141/2) or Lumbar
Spine (CPT 72148/9)
•
•
Respiratory Devices—DME Policy
•
•
Proton Beam and Neutron Beam Radiation
Therapy—Medical Policy
•
•
Pet Scans—Imaging Policy
Policy updated to include grab bars and tricycles as not
medically necessary
Pre-Authorization Required
Revised and updated policy criteria to reflect
compliance with failure to improve after six or more
weeks of non-operative treatment
Pre-Authorization Required
Revised and updated coverage policy to reflect vest
requirements to follow the FDA approval/indication for
a chest wall circumference of equal to or more than 19
inches
Pre-Authorization Required
Revised and updated coverage criteria to follow NCCN
guidelines and exclude Proton Beam therapy for all
sites of squamous cell cancer
Pre-Authorization Required
•
Revised and updated coverage criteria to follow NCCN
guidelines regarding Neuroendocrine tumors
Pre-Authorization Required
Skin Lesions—Surgical
•
•
No change to policy criteria
Pre-Authorization Required
Respiratory Diagnostics and Treatments
(Niox Mino Airway Inflammation Monitor)—
Medical Policy
•
Coverage criteria revised to include clinical indications
for Bronchial Thermoplasty for the treatment of Asthma
Pre-Authorization Required
•
•
P.14
TOPIC
DETERMINATION/COVERAGE
Vascular Interventions—Surgical 93
•
•
Stereotactic Radio Surgery (SRS)—Surgical
Policy
•
•
Incontinence—Urinary, Fecal, and Oral—
Medical Policy
•
Thermal Capsulorrhaphy—Surgical
•
•
•
External Prosthetic DME Devices (Non
Diabetic)—DME Policy
•
•
Radiofrequency Ablation (RFA)—Surgical
Policy
•
•
•
Cochlear Implant—Surgical Policy
•
•
Ingestion Challenge Test or Double Blind
Food Challenge—Medical Policy
•
•
Criteria for coverage reviewed and conservative
treatment defined
Pre-Authorization Required
Coverage criteria were updated to reflect compliance
with most recent NCCN recommendations endorsing
SBRT for patients with prostate cancer as treatment
alternative
Pre-Authorization Required
Criteria for coverage reviewed and conservative
treatment defined
Pre-Authorization Required
Considered investigational/experimental and therefore
not medically necessary
Pre-Authorization Required
Criteria for coverage reviewed and conservative
treatment defined for Optima Health Medicare and
Medicaid members
Pre-Authorization Required
Technology Review continues to support Left
Ventricular Sympathetic Denervation (LVSD) to be
investigational/experimental for all indications and
therefore not medically necessary
Percutaneous Transcatheter Renal Sympathetic
Denervation for resistant Hypertension, unilateral and
bilateral is also supported as unproven and continues
to be considered not medically necessary
Pre-Authorization Required
Technology Review supports Tinnitus Masking Devices
as experimental/investigational for all indications
Pre-Authorization Required
Updated policy definition for Ingestion Challenge Test
following source review research
Pre-Authorization Required
Copies of all criteria are available by calling Medical Care Services at:
757-552-7540 or 1-800-229-5522
Network News
P.15
December 2014
Pre-Authorization Fax Numbers
New Optima Health pre-authorization fax numbers became effective November 7, 2014.
The new numbers are included at the top of each pre-authorization form on
optimahealth.com/providers. If you use pre-programmed fax numbers, please remember
to update your information for Optima Health.
As a reminder, please obtain and submit the most current pre-authorization form from
optimahealth.com/providers for every request to ensure your submission is routed to
the appropriate specialty team for timely review and processing. Secure sign in is not
required to access these forms.
If you have questions, please contact Provider Services at 1-800-229-8822.
Important Phone Numbers
Provider Relations
757-552-7474 or
1-800-229-8822
Provider Relations Fax
757-961-0565
Optima Behavioral Health Provider 757-552-7174 or
Relations
1-800-648-8420
Medical Care Management
(Pre-Authorization)
757-552-7540 or
1-800-229-5522
Network Educators
Hampton Roads/Central Virginia
757-552-7085 or
1-877-865-9075
Roanoke/Southwest Virginia
540-562-8220 or
1-855-562-8220
BriovaRx
1-855-577-6512
BriovaRx Fax
1-877-292-5799
Optima Health and Preventive
Services
757-687-6000
Please note the new Provider Relations fax number.
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