Winter 2016
Doctor's Note

Greetings, Colleagues.
 
As this year comes to a close, we hope you have found our provider newsletter to be a useful tool and have been sharing it with your team. Please read on for information about upcoming drug formulary changes for 2017, information related to telemedicine, how to document BMI for HEDIS, Disease Management services available to your patients with asthma, hypertension, and low back pain, new features available to you and your team to help with radiology prior authorization, and credentialing.

Feel free to contact me with any questions at 1-608-977-8981 or Michael.Ostrov@wpsic.com.
 
Sincerely,


Michael Ostrov, M.D., M.S.
Vice President and Chief Medical Officer

Updates made to Prescription Drug Program

Inform ation regarding Arise Health Plan's Prescription Drug Program can be found on our website, arisehealthplan.com . Specifically, you can access:
  • Our Drug Program Policy, which includes how the formulary is developed and maintained, the prior authorization program and how to pursue an exception, as well as information on generic substitution and quantity limits
  • The Drug Prior Authorization List which identifies the applicable medications as well as who to contact to initiate the process
  • Specialty drug approval policies (this is part of our website's Medical and Pharmacy Policy section)
  • Formulary/Preferred Drug List
Formulary/Preferred Drug List changes for 2017

Preferred Drug List Additions*
IMPADIVO
NARCAN NASAL
OCALIVA
TECENTRIQ
UPTRAVI
VITOGARD
VENCLEXTA
VONVENDI
XURIDEN
* May be subject to prior authorization requirements.
 
Preferred Drug List Exclusions with Alternatives**
Preferred Drug List Exclusion
Preferred Alternatives
Preferred Drug List Exclusion
Preferred Alternatives
ABSTRAL
Fentanyl lozenges, LAZANDA
NUTROPIN AQ
GENOTROPIN, HUMATROPE, NORDITROPIN
ACCU-CHEK Meters and Strips
ONETOUCH Meters and Strips
OLYSIO
VIEKIRA, TECHNIVIE
ACUVAIL
Bromfenac drops, diclofenac drops, ketorolac drops, ILEVRO, NEVANAC, PROLENSA
OMNARIS
Budesonide, flunisolide, fluticasone, mometasone, QNASL
ADVOCATE Meters and Strips
ONETOUCH Meters and Strips
OMNITROPE
GENOTROPIN, HUMATROPE, NORDITROPIN
ALVESCO
ARNUITY, ASMANEX, FLOVENT, PULIMCORT, QVAR
ONGLYZA
JANUVIA, TRADJENTA
APIDRA
HUMALOG
ORENCIA
ACTEMRA, COSENTYX, ENBREL, HUMIRA, OTEZLA, REMICADE, STELARA, XELJANZ, XELJANZ XR
ARANESP
PROCRIT
PANCREAZE
CREON, ZENPEP
ASACOL HD
Balsalazide, sulfasalazine, APRISO, LIALDA, PENTASA
PERTZYE
CREON, ZENPEP
BECONASE AQ
Budesonide, flunisolide, fluticasone, mometasone, QNASL
PRECISION Meters and Strips
ONETOUCH Meters and Strips
BREEZE Meters and Strips
ONETOUCH Meters and Strips
PROVENTIL HFA
PROAIR HFA, VENTOLIN HFA
CETRAXAL
Ciprofloxaxin otic, ofloxacin otic, CIPRODEX
SAIZEN
GENOTROPIN, HUMATROPE, NORDITROPIN
CIMZIA
ACTEMRA, COSENTYX, ENBREL, HUMIRA, OTEZLA, REMICADE, STELARA, XELJANZ, XELJANZ XR
SIMPONI
ACTEMRA, COSENTYX, ENBREL, HUMIRA, OTEZLA, REMICADE, STELARA, XELJANZ, XELJANZ XR
CONTOUR Meters and Strips
ONETOUCH Meters and Strips
SOVALDI
VIEKIRA, TECHNIVIE
DAKLINZA
VIEKIRA, TECHNIVIE
SUBSYS
Fentanyl lozenges, LAZANDA
DELZICOL
Balsalazide, sulfasalazine, APRISO, LIALDA, PENTASA
TALTZ
ACTEMRA, COSENTYX, ENBREL, HUMIRA, OTEZLA, REMICADE, STELARA, XELJANZ, XELJANZ XR
DIPENTUM
Balsalazide, sulfasalazine, APRISO, LIALDA, PENTASA
TANZEUM
BYDUREON, BYETTA, TRULICITY
DUEXIS
Ibuprofen plus famotidine
TESTIM
ANDROGEL, AXIRON
EMBRACE Meters and Strips
ONETOUCH Meters and Strips
TRUETEST Meters and Strips
ONETOUCH Meters and Strips
ENDOMETRIN
CRINONE
TRUETRACK Meters and Strips
ONETOUCH Meters and Strips
EPOGEN
PROCRIT
ULTRESA
CREON, ZENPEP
ESTROGEL
DIVIGEL
UNISTRIP Meters and Strips
ONETOUCH Meters and Strips
EVZIO
Naloxone syringe, NARCAN nasal spray
VELTIN
Clindamycin/benzoyl peroxide, clindamycin/tretinoin, ACANYA, ONEXTON
FENTORA
Fentanyl lozenges, LAZANDA
VERAMYST
Budesonide, flunisolide, fluticasone, mometasone, QNASL
FORTESTA
ANDROGEL, AXIRON
VICTORY Meters and Strips
ONETOUCH Meters and Strips
FREESTYLE Meters and Strips
ONETOUCH Meters and Strips
VICTOZA
BYDUREON, BYETTA, TRULICITY
GLUMETZA and Generics
Metformin extended-release
VIMOVO
Omeprazole plus naproxen
ISTALOL
Betaxolol drops, levobunolol drops, timilol drops, ALPHAGAN P, COMBIGAN
VOGELZO
ANDROGEL, AXIRON
KAZANO
JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR
XOPENEX HFA
PROAIR HFA, VENTOLIN HFA
KINERET
ACTEMRA, COSENTYX, ENBREL, HUMIRA, OTEZLA, REMICADE, STELARA, XELJANZ, XELJANZ XR
ZEPATIER
VIEKIRA, TECHNIVIE
KOMBIGLYZE XR
JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR
ZETONNA
Budesonide, flunisolide, fluticasone, mometasone, QNASL
MIRCERA
PROCRIT
ZIOPTAN
Latanoprost drops, travoprost drops, LUMIGAN, TRAVATAN Z
NATESTO
ANDROGEL, AXIRON
ZOMACTON
GENOTROPIN, HUMATROPE, NORDITROPIN
NESINA
JANUVIA, TRADJENTA
ZYCLARA
Diclofenac gel, fluorouracil cream, imiquimod cream, CARAC, PICATO
NOVOLIN
HUMULIN
 
 
NOVOLOG
HUMALOG
 
 
**Arise has a pharmacy exception process. Exceptions must be approved in advance for coverage.
 
If you would like a copy of this information, please contact our Provider Contact Center at 1-888-711-1444.
 
Quarterly Medical Policy Updates

The Medical Policy Committee met on Sept. 9, 2016, this quarter and approved medical policies due for annual review.  
 
View the Medical Policy Updates on the Newsletters page of our website or in the Provider Portal. View the November 2016 updates.  
 
Please be sure all doctors, other clinical staff, and office staff are aware of these changes before submitting requests for coverage. Please also share these policy changes with providers who may be ordering or performing services and clinicians who may be referring patients for services.
 
The complete library of our medical policies can be found at:
No password required!
 
If you have specific questions or comments regarding development of policy content, contact the Medical Policy Editor by email medical.policies@wpsic.com
or call 1-800-333-5003, ext. 77196.

For questions regarding medical coding related to policies, please contact the Code Governance Committee at codegovernance@wpsic.com. This email and other contact information can be found on our website as well as in the Provider Portal.

The Prior Authorization List on our website has a new look and logo but the same content, which means you can continue to use it now and after the effective date of Jan. 1, 2017.

Reminder regarding genetic testing: Prior authorization is required for genetic testing. To expedite authorization, please provide documentation directly from the ordering provider.  

Telemedicine coverage can vary among members

As of Jan. 1, most 2017 Member Certificates include coverage for telemedicine services. Covere d telemedicine services are defined as:
  1. Telemedicine services provided by a health care provider at a distant site to a covered person at an originating site via interactive audio-visual telecommunication. The originating site and the distant site must be:
    • A physician's office or the office of another health care provider, such as a nurse practitioner, physician assistant, certified nurse-midwife, or psychologist
    • A convenient care clinic
    • A hospital
    • A skilled nursing facility
     
    Excluded from coverage are:
    • Telemedicine services that do not include direct, in-person audio/visual contact between the health care provider and the covered person
    • Telephone evaluation and management services
    • Transmission fees
    • Website charges for online patient education material
    • Online medical evaluations

  2. Phone and internet consultations provided by our approved telehealth service provider, Teladoc®.
We provide various plans, so coverage of telemedicine benefits may vary from member to member. To verify telemedicine benefits for your patient, please contact the phone number listed on the member's ID card or our Provider Contact Center at 1-920-490-6900 or 1-888-711-1444.   
Arise ID cards indicate provider networks

As an Arise provider, you will notice Arise members have ID cards that identify one of two networks: the Arise Standard Network, our geographically broad choice, or the AboutHealth Network, our narrow network.



 
Should you come across an older Arise member ID card that does not list a network, or if you are unsure as to whether or not your office participates in either network, we encourage you to check our Find a Doctor tool on our website or call our Provider Contact Center Monday through Friday from 7:30 a.m. to 5 p.m. at 1-920-490-6900 or 1-888-711-1444.

Clean claims are important for timely processing

A clean claim is defined as a request for payment for covered services that is accurate, complete, and in the manner and format prescribed by the insurer. It is also a claim that contains no substantial issue regarding the insurer's responsibility for payment, including, but not limited to, subrogation or coordination of benefits issues. Clean claims must be submitted using current UB-04 and CMS 1500 forms (or any successor forms) for paper claims; current HIPAA standard professional or institutional claim formats for electronic claims, as applicable; and accepted coding standards.
 
The number of days to file a claim is counted from the date of service to the date of our receipt of a clean claim. If you receive a letter from us indicating a claim was not accepted, resubmission is necessary; it refers to an unclean claim and is not considered a received claim. In this scenario, we suggest you address the issue of missing or invalid information. Correct the error and resend as soon as possible to meet the timely filing parameters outlined in our Agreement.

How to improve HEDIS scores

Please share this article with your primary care and OB/GYN providers caring for children and adolescents.

What is HEDIS?

Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more than 90% of America's health plans to measure performance on important dimensions of care and service. Health plans also use HEDIS results themselves to see where they need to focus their quality improvement efforts.

 

HEDIS measures address a broad range of important health issues. One measure is the "Effectiveness of Care and Preventive Screening measure: Weight Assessment & Counseling for Nutrition & Physical Activity for Children/Adolescents (WCC)."

 

This measurement applies to members ages 2-17 who had an outpatient visit with a PCP or OB/GYN and who had evidence of BMI percentile documentation, counseling for nutrition, and counseling for physical activity during the measurement year.

 

HEDIS Tip: Documentation is key! Did you know that missing documentation can lower HEDIS scores? To obtain HEDIS data, chart reviews are conducted using faxed, electronic, or on-site records.

 

The following information must be documented in the patient's medical record to meet this HEDIS measurement:

  • BMI percentile with date of measurement
  • Weight with date of measurement
  • Height with date of measurement
Example:




AND
  • Discussion, anticipatory guidance, counseling or referral for counseling about diet and nutrition
  • Discussion, anticipatory guidance, counseling or referral for counseling about current physical activities, or need for increased activity
Physical activity example:
Does not meet criteria: John is interested in soccer.
Meets criteria: John practices team soccer for two hours every day after school.
 
Thank you for giving our members the highest quality of care possible! Working together to meet these benchmarks, we have the best chance of improving our members' health outcomes and, ultimately, their quality of life. We want to expand our collaboration efforts in supporting providers' offices. Please have someone from your office or Quality Department contact the Arise Quality Department via email at GBQualityDept@AriseHealthPlan.com to pursue collaborative opportunities.
 
Coordination of care is crucial among behavioral health and primary care practitioners

Coordination of care among providers is a vital aspect of good treatment planning to ensure appropriate diagnosis, treatment, and referral. The importance of communicating with the member's other health care practitioners cannot be overstated. This includes primary care practitioners (PCPs) and medical specialists, as well as behavioral health practitioners.

Coordination of care is especially important for members with high utilization of general medical services and those referred to a behavioral health specialist by another health care practitioner. All practitioners should obtain the appropriate permission from these members to coordinate care among behavioral health and other health care practitioners at the time treatment begins. We expect all health care practitioners to:
  • Discuss with the member the importance of communicating with other treating practitioners
  • Obtain a signed release from the member and file a copy in the medical record
  • Document in the medical record if the member refuses to sign a release
  • Document in the medical record if you request a consultation
  • If you made a referral, transmit necessary information; and if you are furnishing a referral, report appropriate information back to the referring practitioner
  • Document evidence of clinical feedback (i.e., consultation report) that includes, but is not limited to:
    • Diagnosis
    • Treatment plan
    • Referrals
    • Psychopharmacological medication (as applicable)
With this collaborative approach, we can achieve excellent coordination of care and help improve health outcomes.
 
Disease management programs assist your patients

BENEFITS
Supported Self-Care
A case manager designated to help the member feel better soon and coordinate services
Access to pharmacists who can help address member medication needs and concerns
Simple ways to help members record symptoms and vital signs by phone or computer
Support Tools
Additional information obtained from monitoring comorbid conditions
Timely alerts regarding changes in a member's condition and vital signs
Information for members to self-manage effectively to prevent an emergency
Information and resources on managing conditions, medication management, healthy eating, exercise, and more
As a physician, it can be difficult to manage care f
or patients with low back pain, hypertension, or asthma. That's why we're excited to let you know we are here t o help with these common conditions. 

Arise Health Plan offers FREE disease management programs to members diagnosed with these conditions. These programs encompass a number of initiatives designed to help patients reach and maintain good health, such as supporting the doctor-patient relationship and a plan of care that emphasizes the control of the disease and its complications. 

Our commitment to our members means providing the very best service. That's why members with these conditions are automatically enrolled in the program and receive an information kit in the mail to help answer any questions. For more information or answers to your questions, please call 1-800-333-5003, Monday through Friday, 8 a.m. to 4:30 p.m., or visit the Disease Management page at arisehealthplan.com.  
Affirmative Statement on Incentives

Utilization Management (UM) decision-making is based only on appropriateness of care and service and existence of coverage. The organization does not specifically reward practitioners or other individuals for issuing denials of coverage. Financial incentives for UM decision-makers do not encourage decisions that result in underutilization. 
Utilization Management follows timeliness standards

As a health plan accredited by National Committee for Quality Assurance (NCQA), Arise Health Plan adheres to the timeliness standards specified by NCQA for review of requested services. The standards include:
  • Non-urgent pre-service decisions are determined within 15 calendar days of receipt of the request.
  • Urgent pre-service decisions are determined within 72 hours of receipt of the request.
  • Urgent concurrent review decisions are determined within 24 hours of receipt of the request.
  • Post-service decisions are determined within 30 calendar days of receipt of the request.
These time frames are dependent on the inclusion of necessary clinical information upon receipt of the request. Arise may request additional medical records if the information submitted to make a determination is not sufficient. Prior authorization requests and clinical information should be submitted via iExchange , fax at 1-608-226-4777, or mail to:
Arise Health Plan Preauthorization 
P.O. Box 11625 
Green Bay, WI 54307-1625
 
If Arise cannot make a decision by our standard deadlines, we notify the affected member and requesting provider that an extension is necessary. The date by which we expect to make a decision is included in that notice.
 
We consistently strive to exceed these standards and meet the needs of our members.

Radiology Benefit Management to be updated

We continue to use NIA Magellan (National Imaging Associates Magellan), an accredited leader in the management of outpatient radiology benefits in the utilization management (UM) process. Updated NIA Radiology guidelines become effective in January 2017.

As of Dec. 5, 2016, providers can preview the complete set of the updated 2017 advanced imaging clinical guidelines through the RadMD portal prior to the implementation date of Jan. 2, 2017. You can continue to view all of the current guidelines by accessing your RadMD account.
 
Highlights of the guideline changes to be implemented in January 2017 are as follows:
 
Global Change to applicable guidelines:
  • Cancer surveillance in the "known tumor, cancer, or mass" section was rewritten without specific time frames applied.
  • More concise indications for the evaluation of neurologic symptoms or deficits.
  • For back or neck pain on all spine guidelines: Radicular symptoms are no longer required to be present if an EMG or nerve conduction study indicates a spinal abnormality.
  • Removed specific references to gender in several of our guidelines based on information from Section 1557 of the Affordable Care Act.
Cardiac (Heart) MRI 
  • Stress Cardiac MRI scenarios, tissue characterization, and specific valvular management scenarios were added.
To access the Preview link on RadMD, you can also follow these steps (signing in is not required):
  • Go to the home page at radmd.com.
  • Click on the Solutions tab from the home page main menu bar.
  • From the Solutions drop-down list, click on Advanced Imaging.
  • Click on the link for Preview of NIA's 2017 Standard Guidelines, listed under the Document section.
  • The Table of Contents begins on page 3 of the PDF document.
  • Click once on the study to be viewed.
  • To return to the Table of Contents, click on TOC in the upper right corner above the heading of each guideline.
Effective Jan. 2, 2017, NIA will replace the current clinical guidelines with the updated 2017 version.

Check your RadMD portal and our website for additional information, coming soon.

Member Rights and Responsibilities

The Member Rights and Responsibilities listed below set the framework for cooperation among covered persons, practitioners, and insurer.
 
Member Rights as a Health Plan Member
  • The right to be treated with respect and recognition of your dignity and right to privacy.
  • The right to a candid discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage.
  • The right to participate with practitioners in making decisions about your health care.
  • The right to receive information about us, our services, our network of health care practitioners and providers, and your rights and responsibilities.
  • The right to voice complaints or appeals about us or the care we provide.
  • The right to make recommendations regarding the members' rights and responsibilities policies.
Member Responsibilities as a Health Plan Member
  • The responsibility to supply information (to the extent possible) that we and our practitioners and providers need in order to provide care.
  • The responsibility to understand your health problems and participate in developing mutually agreed-upon treatment goals to the degree possible.
  • The responsibility to follow the treatment plan and instructions for care that have been agreed on with your practitioners.
Do you know your practitioner credentialing rights?

Credentialing of practitioners is performed by the Arise Health Plan/WPS Health Insurance Credentialing Department upon initial contracting of practitioners and every three years thereafter. Practitioners undergoing the credentialing process have the following rights:

  • You have the right to review a summary of outside information obtained by the Credentialing Department for the purpose of evaluating your application.
    • Requests to review a file shall be made to the Credentialing Manager. The review will take place on site during normal office hours.
    • Providers shall not have access to references from other practitioners/health care facilities, recommendations, or peer-review protected information received as part of the credentialing process.
    • Providers may receive a copy of only those documents provided by or addressed personally to the provider. A written summary of all other information shall be provided to the practitioner by the Medical Director or his/her designee.
  • You will be promptly notified of information that varies significantly from the information you have provided and be given the opportunity to submit updated/additional documentation or corrections to the Credentialing Department. The correction of erroneous information must be done in writing within 10 days of being notified of the varying information. The Credentialing Department is not obligated to reveal the source of information if disclosure is prohibited by law.
  • You have the right, upon request, to be informed of the status of your application at any time. Requests shall be directed to the Credentialing Manager. Credentialing Manager shall promptly provide applicant with information regarding date of application receipt, general category of items outstanding, and target approval date.
  • You will be notified of the Credentials Committee decision regarding your application via written letter within 60 calendar days of the committee's credentialing or recredentialing decision.
If you have any questions regarding the credentialing process, please contact the Credentialing Manager at 1-920-490-6952. If you have any questions regarding the contracting process, please contact Network Management at 1-888-711-1444.
 
Arise Health Plan | P.O. Box 11625 | Green Bay, WI | arisehealthplan.com
27886-085-1612
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