Fall 2016 
Doctor's Note

Greetings, Colleagues. 
I am pleased to inform you that I have been promoted to Chief Medical Officer. In this new role, I will continue to focus on developing programs and services to help you and your office staff to simply and efficiently get what you need from Arise Health Plan. Our goal is to provide you with helpful, meaningful data you can use to better care for your patients.

This issue highlights a number of pharmacy programs designed to help with coordination and safety, and, when possible, to decrease patients' out-of-pocket costs. Our Pharmacy Director, Mike Chester, explains these programs and is here to help you and your patients should questions arise.

Other highlights in this issue include:
  • Medical Policy updates are provided to be sure you and your staff are kept up to date with the latest technology and coverage topics.
  • Allison Alt and Jessica Thompson from Quality Improvement explain the HEDIS quality measures that we track for NCQA compliance.
Feel free to contact me with any questions.
Best of health,

Michael Ostrov, M.D., M.S.
Medical Director, Network and Quality

Include a cover sheet for corrected claims

Effective Oct. 1, 2016, Arise Health Plan asks that you include a cover sheet with any corrected claims you submit on paper. This will allow us to process your corrected claims in a more timely manner. Paper corrected claims sent without a cover sheet will be returned to you.
Our website has a sample Corrected Claim Cover Sheet on the Provider Forms page you are welcome to use. You may also use your own version as long as it has provider information, member information, the original claim number, and the items and reasons for the correction.
These can be sent to our updated paper claims address, along with any other claims or claim-related correspondence you have, at:
Arise Health Plan
P.O. Box 21352
Eagan, MN 55121

Using ERA? Paper PRAs being phased out Sept. 1

Effective Sept. 1, 2016, providers who previously received Electronic Remittance Advice (ERA) will no longer receive the paper Provider Remittance Advice (PRA). To view your electronic PRAs via the website, please log in to your Provider Portal account .
If you would like to switch from paper to Electronic Funds Transfer (EFT), electronic claim submissions, or have further questions regarding Electronic Remittance Advice (ERA), please contact our Health Insurance EDI department at 1-800-782-2680, option 1, or visit  wpsic.com/edi/edi_contact.shtml or wpsic.com/edi/index.shtml for details and enrollment forms.
Secure messaging is available

Providers often have questions about secure messaging. Did you know that our Provider Portal allows secure messaging directly with our Customer Service Department? To take advantage of this function, Select Home from the top menu bar, click on the Message Center link, and then click on the New Message link.

The feature allows up to 480 characters, so please clearly state your question, along with the member number, claim number, and any other pertinent information. This enables our Customer Service team to immediately begin researching your issue.

When you use our Message Center, you can expect a response within the next business day. Please note that replies are accessed via the Message Center rather than your email account.
You can access our Message Center Tip Sheet for a step-by-step guide.

If you are not currently using our Provider Portal, you may register by email at register@wpsic.com . Please include the administrator name, email address, tax ID, practice name, and a list of all clinic location names and addresses.
What you need to know about Diplomat

Most providers know Diplomat as the nation's largest independent specialty pharmacy--meaning it dispenses expensive drugs that require a high level of member education and monitoring. Arise Health Plan chose to partner with Diplomat in 2014 because of its long-standing history of providing a superior customer experience. In fact, your patients using specialty drugs provided by Diplomat enjoy, on average, 40 "touches" with Diplomat per year. Those same patients show a medication adherence rate well over 90%, which is phenomenal. These patients are also happy, with a surveyed satisfaction rate of Diplomat services of 99%.

The care Diplomat provides is equally important. Since care is evaluated at least monthly to determine whether members are experiencing issues, a Diplomat pharmacist is promptly engaged to address any clinical issue, such as how to mitigate an adverse reaction. They also initiate outreach to you, as the member's provider, as the situation dictates.

Diplomat also serves in three other capacities:
1) A division of Diplomat called PA Navigator establishes evidence-based criteria and reviews prior authorization requests for specialty drugs for appropriateness
2) Diplomat Infusion coordinates home infusion services for members requiring such treatments as IVIG (intravenous immunoglobulin) or Remicade (infliximab)
3) Diplomat can supply specialty drugs to provider offices that do not want to purchase and stock these expensive agents on their own; in this scenario, Diplomat ships the drug to your office and bills Arise directly (also known as "white-bagging"); the provider bills any administration fees

Providers can easily initiate a prior authorization request for a specialty drug by contacting Diplomat at 1-888-515-1357. The list of drugs requiring prior authorization is located under the Provider section of our website at wpsic.com/files/drugpreauth.pdf .

To initiate home infusion services through Diplomat, or to establish a "white-bagging" arrangement, contact Diplomat at 1-866-500-6500.

Contact Arise at 1-920-490-6959 with any other questions regarding Diplomat services.

FluMist® not recommended for 2016-17 flu season

The Centers for Disease Control and Prevention (CDC) recently announced that the live attenuated influenza vaccine (LAIV), best known as nasal spray or by the trade name FluMist Quadrivalent, should not be used during the 2016-2017 influenza season. The CDC's Advisory Committee on Immunization Practices voted to recommend it not be used after data showed poor or relatively low effectiveness of the nasal spray from 2013 through 2016.

Check the CDC website for Frequently Asked Flu Questions to obtain additional information about the 2016-2017 influenza recommendations.

Please also see cdc.gov/vaccines/hcp/vis/index.html for information about the use of CDC Vaccine Information Statements (VISs) to provide to your patients. The VISs are available in multiple languages for all vaccines.

Update on colorectal cancer (CRC) screening

On June 20, 2016, our Medical Directors approved changes to Colorectal Cancer Screening (CRC screening) indications and coverage. These changes were based, in part, on the final United States Preventive Services Task Force (USPSTF) recommendations published in June. USPSTF recommendations dictate Affordable Care Act (ACA) plan coverage of preventive services. A decision was made to follow the recommendations for our other plans as well.
The USPSTF identified low rates of CRC screening as a major public health problem. Early treatment of colorectal cancer can save lives. USPSTF expanded its list of acceptable CRC screening tests in the hopes of improving screening rates.
CRC screening coverage (without prior authorization) will include:
  • Traditional (optical) colonoscopy (continued coverage)
  • Screening CT colonoscopy (expanded coverage)
  • FIT and other stool-based occult blood tests (continued coverage)
  • Cologuard DNA test on stool (newly covered)
  • Epi-Pro Colon DNA blood test (newly covered)
Please see our website for Medical Policies and prior authorization information.

Arise uses HEDIS ® for quality improvement 

Arise Health Plan annually reviews and evaluates our Quality Improvement (QI) program and develops a QI work plan that helps us continually improve the quality of care given by our contracted providers. The Arise QI program and work plan include both clinical and quality service initiatives. For information about our QI program, visit Quality Improvement - Arise Health Plan.  

To evaluate program effectiveness, Arise uses the Healthcare Effectiveness Data & Information Set (HEDIS ®). HEDIS is developed and maintained by the National Committee for Quality Assurance (NCQA), a non-profit health care quality organization.

Why is HEDIS important to physicians? HEDIS measures track a health plan's and physician's ability to manage health outcomes. Generally, strong HEDIS performance reflects enhanced quality of care. With proactive population management, physicians can monitor care to improve quality while reducing costs.

It's not just about the scores. It's about the woman whose Pap smear led to early detection and treatment of her cervical cancer. Or the toddler who didn't get whooping cough during last year's outbreak because he got his shot on time. Or the grandfather who kept up with his cholesterol screenings and avoided another heart attack.

We would like to take this opportunity to review two HEDIS measurements we feel are important: colorectal cancer screenings and comprehensive diabetes care.

Colorectal cancer screening (COL) HEDIS definition: The percentage of commercial and Medicare members ages 50-75 who had appropriate screening for colorectal cancer during the measurement year. Any of the following tests meet the criteria: fecal occult blood test; flexible sigmoidoscopy; colonoscopy.

The following chart outlines our scores in this area:

HEDIS, Colon CA Screening 
National: 10th Percentile
Arise Health Plan 2015
National: 25th Percentile
National: 50th Percentile
Arise Health Plan 2016
Wisconsin Average
National: 75th Percentile
National: 90th Percentile

Between 2015 and 2016, the Arise Health Plan HEDIS score for colon cancer screening improved more than 8%, which is excellent. Our rate, however, is still slightly below the average for Wisconsin, and only in the 50 th percentile nationally. Our goal is to move up to the 90 th percentile, which will require more than 10% further improvement. You can help us reach this goal by encouraging members who are resistant to having a colonoscopy to have a stool test that they can complete at home (e.g., gFOBT or iFOBT). The iFOBT (immunochemical fecal occult blood test) has fewer dietary restrictions and samples, so it may be a better option for members.

Comprehensive diabetes care HEDIS definition: The percentage of members 18-75 years of age with diabetes (type 1 and type 2) who had each of the following: hemoglobin A1c (HbA1c) testing; diabetic eye exam; medical attention for nephropathy; blood pressure control.

At Arise Health Plan, our HbA1c screening rate is outstanding, and actually increased in 2016 to rank in the 90 th percentile nationally. Our HbA1c control rates, however, fall off sharply, as can be seen in the plot above. We need to highlight to members the importance of controlling their HbA1c level, and work with them in follow-up care to better control these rates.

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.

The Wisconsin Chronic Disease Program to focus on hypertension

The Wisconsin Chronic Disease Program, sponsored by the Wisconsin Department of Health Services, helps coordinate quality improvement projects for health plans across the state. This year the focus is on improving treatment for people with hypertension, as 30% of adults have some form of hypertension and 50% of those diagnosed are uncontrolled according to the National Health and Nutrition Examination Survey (NHANES). Hypertension remains the most common risk factor for heart attack and stroke.
With this in mind, Arise Health Plan has embarked on a quality improvement project to:
1) Identify members who:
    • Have hypertension
    • Are not under treatment
    • May benefit when we notify providers to potentially initiate treatment

2)    Improve adherence of those taking anti-hypertensive medications

3)    Improve the number of members whose blood pressure is under control


The hypertension project involves member and provider communications. Additionally, Express Scripts, our pharmacy benefit manager, has been engaged to assist with impacting medication adherence. Express Scripts offers free consultations with pharmacists who are specially trained in hypertension, as well as other tools to help members overcome challenges to taking their medications (e.g., medication alerts). Please also take advantage of the Clinical Practice Guidelines references for hypertension, which are available on our website.
Arise is pleased to offer this comprehensive hypertension program to support and reinforce what you are doing in your offices.


Arise uses evidence-based medical decision-making tools and processes

The Arise Health Plan Medical Affairs Department uses both internally developed medical policies and science evidence-based resource products, such as MCG Health and Hayes, to form the basis for clinical review. Both our medical policies and use of resource products are approved by our Medical Policy Committee and Quality Improvement Committee.
Our Medical Policy Committee is composed of clinicians, including practicing providers from the community. The committee meets quarterly to consider scientific evidence and current practice standards for review and approval of new medical policies and those policies due for annual review. Nationally published and internally developed guidelines are reviewed annually, or more frequently if significant changes in standards of care are identified.
Our Quality Improvement Committee oversees the Medical Policy Committee. Members include clinicians and representatives from multiple departments at Arise, as well as practicing providers from the community.
As previously mentioned, primary evidence-based clinical resources used include:
  • MCG Health: Formerly known as Milliman, this company offers a compendium of annually updated, evidence-based guidelines that supports clinical decision-making and care planning for providers and payors. The guidelines are developed through extensive review, analysis, and rating of published clinical literature, as well as expert practitioner reports and protocols.
  • Hayes: This independent research organization evaluates and provides evidence-based ratings on a wide range of medical technologies, procedures, devices, pharmaceuticals, and tests to determine the impact on patient safety and health outcomes.
Additional reference sources include, but are not limited to:
  • BlueCross BlueShield Technology Evaluation Center
  • Clinical Guidelines posted through the National Guideline Clearinghouse (NGC), an initiative of the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services
  • Government agencies and regulatory bodies
  • National Comprehensive Cancer Network (NCCN)
  • National Institute for Health Care Excellence (NICE)
  • Specialty society guidelines and standards
  • The Cochrane Library
  • The U.S. Preventive Services Task Force (USPSTF)
  • UpToDate®
  • Washington State Health Care Authority Health Technology Assessment
Internally developed Medical policies are available on the Arise website.
If you have questions or comments regarding evidence development or general content of Arise medical policies, contact us at medical.policies@wpsic.com . For specific patient- related criteria inquiries, please contact Arise with the applicable patient name and member number, along with the procedure, service, or treatment in question, at:

Arise Health Plan
Attn: Medical Management Department
P.O. Box 11625
Green Bay, WI 54307-1625
Phone: 1-920-490-6901 or toll-free 1-888-711-1444, ext. 76901
Fax: 1-920-490-6943

Quarterly Medical Policy Updates

The Medical Policy Committee meets quarterly to approve medical policies due for annual review and revision.  
Click here  for the most recent updates to medical policies. 
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!
Reminder: Genetic Testing is mentioned in multiple medical policies and always requires prior authorization. To ensure your request is addressed in a timely manner, please provide documentation directly from the ordering provider.
If you have specific questions or comments regarding development of policy content, contact the Medical Policy Editor by email at medical.policies@wpsic.com or call 1-800-333-5003 ext. 64133. 

When is prior authorization needed?

Prior authorization, also known as pre-service authorization, pre-authorization, and pre-certification, is required for a variety of health services. Please refer to the Prior Authorization List , which is updated regularly on our website. Helpful tips about filing prior authorization requests may be found in our Prior Authorization Tip Sheet .
The majority of updates for July 2016 were improved organization, clarifications within service categories requiring prior authorization, and updates of the Medical Policy references.
  • Acupuncture was deleted as routinely requiring prior authorization. For many member certificates, acupuncture is not a covered benefit. Please contact Customer Service to verify benefits. If the member's certificate does include coverage for acupuncture, prior authorization is required.
  • Prior authorization for intensive outpatient behavioral health treatments is not required. However, records are reviewed for continued services. Check with Customer Service regarding when records are needed.
  • Durable Medical Equipment (DME): The list of specific DME needing prior authorization has not changed. The dollar cap for DME rental and purchase was changed to reflect the most common member certificate/plan language with the caveat that the individual member plan dollar amounts for prior authorization prevail: "Prior authorization rental above $750 per month or purchase above $1,000 threshold (or lower if required per member health plan)."
  • Infertility services and treatments: Please contact Customer Service to verify benefits and limitations.
Arise will review a prior authorization request if it is submitted when a member or provider is unclear if a service will be covered. This may include new and emerging technology and procedures that may be a certificate exclusion or benefit since medical language is complicated and many procedures sound alike. When in doubt, prior authorize. We make determinations based on the specific service that is requested and not solely on a service billing code. The member maintains the right for a review determination and an appeal to that determination prior to services rendered.   
Customer Service may be reached by calling 1-888-711-1444 or using the Message Center in our Provider Portal.  

In our Summer issue, we incorrectly stated the phone number for Stacy Willems, our new Provider Relations contact for the north-central region of Wisconsin. Her correct phone number is 1-608-977-6697. We apologize for the error.

Arise Health Plan | P.O. Box 11625 | Green Bay, WI | AriseHealthPlan.com
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