A Note from Dr. Wilson
COVID-19 Update
AltaMed is sensitive to the level of stress and anxiety the coronavirus is having on your practice and our patients. I know that you have been inundated with correspondence and position statements from many health plans and local, state, and federal agencies. With that in mind, I will be brief.
President Trump has declared a national emergency in relationship to the pandemic caused by the virus known as SARS-CoV-2 and the disease it causes named “coronavirus disease 2019” (abbreviated "COVID-19"). Current interventions center around slowing the spread of the disease, or flattening the disease progression curve. This is essential to prevent limited health care capacity from being overwhelmed if the disease is allowed to proceed unchecked. However, experts are predicting, if we are successful in flattening the curve, the disease will be with us until mid-summer (July-August time frame).
AltaMed encourages our provider community to take appropriate safeguards. Wear gloves, masks, and face shields when dealing with potentially contagious patients. See patients in an isolation room if possible. If and when you are able to test patients in your office, and they test positive, it is required that you report this to the Health Department. Please refer to the CDC or your local health department for the most up-to-date regulations and recommendations. Remember to protect yourself and your staff, and together we will get through this challenging time.
Quality Focus Areas
This year, AltaMed will maintain its focus on providing evidence-based high quality health care. While quality should permeate all aspects of health care this year, we have chosen to focus on the following five areas:
- Diabetes
- Hypertension
- Prevention
- Pediatric Care
- Reproductive Care
One of our goals for diabetes is to achieve optimum control of HgA1c measures. For HEDIS, this represents levels below eight at a minimum and less than seven to optimize health outcomes for our patients. People with diabetes should also receive an annual retinal evaluation and statin therapy when indicated.
Recently the American Heart Association issued new blood pressure targets. We will continue to strive for less than 140/90 as an organizational target, but we encourage all providers to stay abreast of current literature and continue to dialogue with their patients about the advantages of tighter control.
Prevention will focus on timely adult, adolescent-Combo 2, and pediatric-Combo 10 immunization. Flu and pneumococcal vaccinations should remain front of mind. Providers should also familiarize themselves with current guidelines for cervical cancer, breast cancer, and colorectal cancer screening. Depression screening should be done at least annually and in the postpartum period as well.
Pediatric Care should focus on capturing Well Child Visits at 0-15 months old, 18 months to 2 years old, 3-6 years old, 7-11 years old, and 12-21 years old. Patients should receive weight assessments and appropriate exercise and weight counseling.
Reproductive Care should include Prenatal Care beginning in the first three months of pregnancy. When indicated—and during postpartum visits between 21 and 56 days after delivery—28-week screenings should be completed. These screenings should include TdAP, RPR, Glucose testing, Rh screening, and RhoGAM. Patients should be given “same-day” access to birth control. Chlamydia testing should be done on appropriate candidates.
This is not a complete listing of relevant HEDIS and quality measures but rather a reminder that we should never forget our obligation to provide the best care for our patients and to stay abreast of age- and sex-appropriate clinical guidelines.
Thank you,
Keith Wilson, M.D., FACOG
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Network Management Updates
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Restricted Knox-Keene License
We are pleased to announce the Department of Managed Health Care (DMHC) has granted AltaMed Health Network its restricted Knox-Keene license. Effective January 1, 2020, AltaMed Health Network assumes financial responsibility for all facility claims for services rendered to LA Care Medi-Cal Only Members currently assigned to AltaMed Health Network.
Due to the change in financial responsibility for facility claims to AltaMed, submission of these claims should be directed to AltaMed.
For electronic claims, AltaMed has two PayerIDs:
ALTAM
95712
For paper claims and other claim correspondence, direct them to the following address:
AltaMed Health – Claims Department
P.O. Box 7280
Los Angeles, CA 90022-7280
Please read the following frequently asked questions regarding the address change.
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Frequently Asked Questions (FAQs)
Q. Why is it necessary to send my claim(s) to the new address?
A.
AltaMed will assume financial risk for facility and other covered services. In order to be properly reimbursed, it is imperative that you send your facility claims to AltaMed’s PayerID or the P.O. Box listed above.
Q. When will the change go into effect?
A. The change went into effect on January 1, 2020.
Q. Can I submit my LA Care Medi-Cal professional claims to the PayerID or P.O Box?
A. Yes. You should continue to submit these claims as you currently do today.
Q. What happens if I send my claim(s) to the wrong PayerID or address?
A. The claims will be denied with a Remittance Advice to the correct billing address.
Q. Will I be able to submit claims electronically?
A. Yes. Depending on your system, please select one of the two PayerIDs provided above.
Q. Who is at financial risk for members admitted in a facility prior to January 1, 2020 and discharged after January 1, 2020?
A. LA Care is at financial risk for facility services for the entire stay.
If you have any additional questions or concerns, please
call our Customer Support Center at (855) 848-5252.
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1099 Forms
There was an issue with the 1099 Form(s) that you received from AltaMed for payment year 2019. In addition to the tax form from AltaMed, you may have also received a 1099 from our payment processing vendor, Echo Health. The 1099 received from Echo Health
is correct;
however, the 1099 received from AltaMed
was not correct
. You will receive a corrected 1099 from AltaMed shortly.
Echo Health 1099
- This form
is valid
and will be reported to the IRS.
AltaMed 1099
- This form has been corrected and mailed again to providers. Keep the 1099 from AltaMed that has the “Corrected” box marked at the top as it will be reported to the IRS (in addition to the 1099 issued by ECHO).
Please call our Customer Support Center at (855) 848-5252 if you have any questions.
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New Hours at Our Customer Support Center
In our commitment to improving support for our contracted network of providers, our Customer Support Center is now open until 6:00 p.m. We are available Monday – Friday from 8:00 a.m. to 6:00 p.m. For assistance, call
(855) 848-5252
, Option 1 (Provider). Refer to the list below for additional phone menu options.
Option 1 (Provider) phone menu:
- Claims/Eligibility
- Prior Authorizations
- Inpatient Admissions
- Care Management
- PACE/Senior Buenacare Authorizations
- Other Departments
1. Portal Technical Support
2. Credentialing
3. Contracting
You may also obtain authorization and claims status using Connect, our provider web portal. There is a new feature on Connect, allowing users to see a claim “Received Date” when checking claim status. You may access the portal 24 hours a day, 7 days a week.
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Member Grievance & Appeals
When a member feels they have received less then excellent care or services, the member has a right to speak with the Clinic Administrator and/or Center Manager at their PCP’s office. The member’s concerns should be addressed and all attempts should be made to resolve the concern.
If the member is still unsatisfied, they have the right to make a formal complaint (grievance) and/or challenge the care provided to them (appeal) with their health plan. Please direct the member to contact their health plan’s Member Services department at the phone number located on the back of their membership card. The member may also contact AltaMed’s Customer Support Center for assistance at (866) 880-7805.
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Senate Bill 137 – Provider Directory Accuracy
In an effort to remain compliant with California Senate Bill 137 (SB 137), we are to provide current and accurate provider demographic information to patients via their respective health plan directories. Our bi-annual provider data validations were mailed out on January 31 to your Primary Office location. If you did not receive the form, and/or have any questions or concerns, please feel free to email
directoryvalidation@altamed.org
.
We ask that you adhere to your contract clause for termination notices and notify AltaMed at least 90 days in advance so that impacted members are notified at least 30 days prior to the effective termination date, as required by health plans.
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Timely Access to Care
The law requires health plans licensed by the California Department of Managed Health Care (DMHC) to make providers available within specific geographic and time-elapsed standards. Health plans must ensure their network of providers, including doctors, can provide enrollees with an appointment within a specific number of days or hours.
Plans should ensure telephone triage or screening services are provided in a timely manner appropriate for the enrollee’s condition and that the triage or screening waiting time does not exceed 30 minutes.
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Referral Requests and Requests for Items/Services
Inappropriate Request for Prior Authorization
The Utilization Management (UM) department has been in receipt of referral request for services that
do not
require prior authorization:
- Preventive Health Services, including immunizations
- Annual well women care (e.g., Pap smear)
- Basic Prenatal Care (e.g., Total OB Care), including OB/GYN in-network referrals and consults
- Family Planning (e.g., contraceptives)
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Urgent Referral Requests
The Utilization Management (UM) department will downgrade a pre-service referral request when it
does not
meet the definition of urgent care.
According to Health and Safety Code (HSC) subsection 1367.01(h)(2), “urgent care” means healthcare for a condition that requires prompt attention. This section requires that decisions to approve, modify, or deny providers’ requests to provide health care services to a member—either prior to or at the time of care—must be made in a timely fashion appropriate for the nature of the member’s condition and should not exceed 72 hours. The following are conditions that require a prompt decision:
- When the member’s condition is such that the member faces an imminent and serious threat to their health, including, but not limited to, the potential loss of life, limb, or other major bodily function
- When the normal time frame for the decision-making process would be detrimental to the member's life or health or could jeopardize the member's ability to regain maximum function
Providers should appropriately classify the referral to coincide with the member’s health care needs to eliminate delays in processing an authorization request for members who are in need of immediate care.
For example, making an appointment for the member to receive care on the next business day would be an inappropriate classification of an urgent referral.
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Standing Authorization
Should the Primary Care Physician (PCP) determine one of their members needs continuing specialty care over a prolonged period of time (requiring more than one visit), and/or extended access to a specialist for a life threatening, degenerative, or disabling condition that requires coordination of primary care by a specialty care physician (SCP), the PCP should submit the follow-up request for specialty care as a Standing Referral. A Standing Referral authorization can be granted for the duration of the prescribed treatment, or up to a year.
Determinations for standing specialty referral must be made within three (3) business days of the date of receipt of all medically necessary information.
Examples of qualifying conditions may include, but are not limited to:
- Terminal cancer
- Acute leukemia
- HIV infections and AIDS
- Severe and progressive neurological conditions
- Renal failure requiring dialysis
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Medicare Non-Covered Items/Services
The Utilization Management (UM) department is receiving requests for services or items that are
NOT
covered by Medicare. This only applies to members that have Medicare without Medi-Cal.
The following are examples of such requests:
- Disposable underpads
- Bath/shower chair
- Personal comfort items (i.e., iPads)
- Raised toilet seat
- Exercise equipment
- Incontinence garments of any type, (e.g., brief, diaper)
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Needed Medical Record Information
The Utilization Management (UM) department requires member information that is reasonably necessary to make a determination for services requested. Please ensure medical records provided for each request are complete and contain:
- Member demographic information
- History and physical exam
- Prior conservative treatment
- Pertinent test results
- Assessment and plan
For specific requirements on documentation, please refer to the following regulations:
- Health and Safety Code 1367.01 (g)
- Code of Federal Regulation 42 Section 438.208 (b)(5)
- California Code of Regulation 22 Section 75054
- California Code of Regulation 22 Section 70527
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Affirmative Statement
The Utilization Management (UM) department makes decisions regarding referral requests based only on appropriateness of care, service, and the existence of coverage. Additionally, AltaMed affirms:
- It does not award practitioners or other individuals conducting utilization review decisions that result in underutilization.
- UM decision-making is based only on appropriateness of care and service and existence of coverage.
- It 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.
- Providers and practitioners are not prohibited from acting on behalf of the member
- Physicians cannot be penalized in any manner for requesting or authorizing appropriate medical care.
- Practitioners are ensured independence and impartiality in making referral decisions that will not influence hiring, compensation, termination, promotion, or any similar matters.
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AltaMed’s Business Code of Conduct
The Business Code of Conduct is a vital part of how we achieve our mission, vision, and maintain our core values. It provides guidance to ensure we work in an ethical and legal manner. AltaMed’s policy is to promote ethical and lawful behavior as stated in the Business Code of Conduct. AltaMed board members, employees, contractors, and all other representatives of the organization must adhere to the Business Code of Conduct.
To ensure we continue meeting this common goal, we are reassessing and revising the
Business Code of Conduct
to enhance its contents, encourage engagement, and to demonstrate AltaMed’s strong commitment to uphold and support compliance with all required standards and expected conduct. We look forward to introducing our new version.
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Cultural & Linguistic Competency
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Using Person-First Language
In healthcare, we have the privilege of serving all persons and their families with dignity and respect. Persons with physical differences are oftentimes marginalized and disrespected. What can provider's and the health team do to enhance patient empowerment in understanding their health? We can:
- Use person-first language. For example, when interacting with a person with disability, avoid offensive language.
- Never call a person “handicapped.” They should be referred to as “a person with a disability.”
- A person who uses a wheelchair should not be referred to as “wheelchair bound.” They should be referred to as “a person who uses a wheelchair.”
- Persons with cognitive disabilities should be referred to as “a person with a cognitive disability.”
- Avoid asking underage family members to read to a member who is visually impaired or blind.
- Ask the person if they wish to receive assistance. Do not assume they do.
For further information, please contact
Evelyn González-Figueroa
, Director of Cultural & Linguistic Competency at
evelgonzalez@altamed.org
.
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