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Provider News
February 2018 - In this issue:
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Reminder: Upcoming MassHealth Changes on 3/1/18
As a reminder, the MassHealth landscape will be changing on March 1, 2018 and many MassHealth patients will be switching health plans based on their primary care provider. The changes in MassHealth do not impact NHP's commercial line of business. Here's a look at what to expect:
MassHealth ACO Program
Greater Lawrence Health Center, Lawrence General Hospital and NHP have formed an ACO partnership known as
My Care Family
. My Care Family will serve MassHealth patients who reside in the Merrimack Valley region. Beginning March 1, 2018, MassHealth patients who have a primary care provider (PCP) in the My Care Family network will stay with or switch to NHP coverage. My Care Family members will have a Blue banner (see example ID card on the right).
MassHealth MCO Program
Beginning March 1, 2018, NHP will no longer be participating in MassHealth's MCO program. Current NHP members in the MCO program will have health care coverage based on their PCP:
- Members with a PCP in the My Care Family network will stay with NHP through the ACO program
- Members with a PCP in another ACO network will switch to the affiliated health plan
- Members with a PCP in an MCO network will be covered through an available MCO
- Members with a PCP in MassHealth's Primary Care Clinician (PCC) Plan network will be covered through the PCC Plan
Commercial Line of Business
The changes in MassHealth do not impact your participation as a Commercial provider with
NHP.
We
are proud to continue to be one of the fastest growing commercial health plans in Massachusetts! Commercial members will present N
HP's ID card with a green banner (See example ID card on the right).
Commercial members can purchase NHP coverage through small and large employer groups, brokers/intermediaries and the Health Connector.
Additional Reminders
Prior to office visits and delivering services, remember to always:
- Verify that the member has active NHP eligibility. Use NHPNet for the most up to date eligibility information.
- Verify that the appropriate referrals and/or prior authorizations are in place (if required).
- Verify member benefits to ensure the service is covered.
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Use NHPNet To Support Your NHP Patients
NHP's best-in-class provider portal, NHPNet, gives you instant access to a variety of self-service options to effectively manage your NHP patients. As more commercial members switch to NHP, its now important more than ever to access all the resources available on NHPNet.
NHPNet's functionalities include:
- Verifying member eligibility
- Reviewing claims status
- Accessing your Explanation of Payments
- Registering to receive Electronic Funds Transfer and Electronic Remittance Advice transactions
- Submitting referrals and prior authorizations
- Updating your practice information through the Provider Enrollment Portal
- Viewing enrollment and clinical reports
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Reminder: Use NHP's Somerville Address For Mail Correspondence
NHP moved to our Assembly Row, Somerville location in December 2016. When mailing correspondence, please do not send correspondence to our old address in Boston (253 Summer St).
NHP's corporate address is now:
Neighborhood Health Plan
399 Revolution Drive, Suite 810
Somerville, MA 02145
Claims Submissions: NHP recommends the electronic submission of claims (Payer ID: 04293). If submitting an original paper claim, mail your submission to:
- For HMO Claims: P.O. Box 853908, Richardson, TX 75085-3908
- For PPO Claims: P.O. Box 852099, Richardson, TX 75085-2099
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The Course and Treatment of Psychiatric Illness During Pregnancy
The following presentation discusses the course and treatment of psychiatric illness during pregnancy.
Training objectives:
- Increase understanding of the course of psychiatric illness during pregnancy
- Increase understanding of the process for identification by screening and treatment of depression during pregnancy, and risk for postpartum depression
- Have a better understanding of the use of SSRIs and other antidepressants during pregnancy
- Have a higher level of understanding of the use of mood stabilizers and antipsychotics during pregnancy
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Provider Directory Survey
In December, NHP conducted an annual assessment to validate the accuracy of data in the provider directory. Incorrect data contributes to patient dissatisfaction and can result in claims payment problems. Providers were asked to verify their information on the provider directory and submit any changes to NHP on the Standardized Provider Information Change Form.
Thank you to all participants of this survey. Completed responses were entered into a raffle drawing. Congratulations to
Agnes Nunziato from Mount Auburn Professional Services for winning an iPad Mini!
How To Update Information Found In NHP'S Provider Directory
- Use NHP's self-service Provider Enrollment Portal located in NHPNet. For more information, including step-by-step instructions, please review the user guide. If you do not have access to the Provider Enrollment Portal, contact NHP's Provider Service team (855-444-4647 or prweb@nhp.org) to get access today.
-OR-
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Pharmacy & Therapeutics Updates
The Pharmacy & Therapeutics Committee regularly reviews and updates NHP's formulary. Remember to always visit the Drug Lookup Tool for the latest information.
The following drugs will require prior authorization beginning March 1, 2018:
- Diclofenac Gel 3%
- Docetaxel
- Exjade Tablet
- Herceptin
- Jadenu Sprinkle
- Jadenu Tablet
- Perjeta Vial
- Velcade SDV
- Zoladex
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2018 Codes and Reimbursement Updates
Annual Updates to Physician and Outpatient Reimbursement
NHP reviews its physician and outpatient fee schedules quarterly, to ensure that they are current, comprehensive and consistent with industry standards, to the extent supported by its systems. In most cases, changes involve adding fees for new or existing codes to supplement the fees already on the fee schedule.
Consistent with prior years, NHP will update its Commercial (HMO & PPO) physician, ambulance, drug, DME, laboratory, radiology and outpatient hospital fee schedules to incorporate new codes, effective January 1, 2018. Rate updates to existing CPT and HCPCS codes will occur on April 1, 2018.
With a few exceptions, NHP will continue to base fees on the Centers for Medicare & Medicaid Services (CMS) and MassHealth fee schedules, adjusted to achieve the contracted level of reimbursement.
Commercial (HMO & PPO) Physician Fee Schedules
- NHP will continue to base physician reimbursement on CMS RVU's and conversion factors
- NHP will continue to base drug, vaccine and toxoid reimbursement on CMS Part B levels, as indicated on the CMS Part B drug quarterly notices. If no CMS pricing is available, drug pricing will be set in relation to average wholesale price (AWP). Reimbursement for vaccines and toxoids will continue to be updated on a quarterly basis.
Commercial (HMO & PPO) Outpatient Fee Schedules
- Consistent with prior years, reimbursement will be based on a combination of ancillary and surgical fee schedules.
- NHP will continue to base drug, vaccine and toxoid reimbursement on CMS Part B levels, as indicated on the CMS Part B drug quarterly notices. If no CMS pricing is available, drug pricing will be set in relation to average wholesale price (AWP). Reimbursement for vaccines and toxoids will continue to be updated on a quarterly basis.
Medicaid Fee Schedules
- NHP will continue to base physician reimbursement on MassHealth published rates, where a published rate exists.
- Consistent with prior years, NHP will update its Medicaid physician, ambulance, drug, DME, laboratory, radiology and outpatient hospital fee schedules to incorporate new codes, effective January 1, 2018. Rate updates to existing CPT and HCPCS codes will occur within 30 days of receipt of notification of rate change from MassHealth.
New 2018 HCPCS Codes
Below is a summary of coverage, prior authorization and reimbursable status updates related to new HCPCS codes effective January 1, 2018. Note: This is not an all inclusive list of new HCPCS codes.
The following codes are not covered for all lines of business:
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CODE
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DESCRIPTION
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Q4176
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Neopatch, per square centimeter
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Q4177
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Floweramnioflo, 0.1 cc
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Q4178
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Floweramniopatch, per square centimeter
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Q4179
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Flowerderm, per square centimeter
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Q4180
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Revita, per square centimeter
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Q4181
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Amnio wound, per square centimeter
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Q4182
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Transcyte, per square centimeter
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The following codes are covered with prior authorization for all lines of business:
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CODE
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DESCRIPTION
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C9014
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Injection, cerliponase alfa, 1 mg
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C9015
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Injection, c-1 esterase inhibitor (human), haegarda, 10 units
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C9016
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Injection, triptorelin extended release, 3.75 mg
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C9024
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Injection, liposomal, 1 mg daunorubicin and 2.27 mg cytarabine
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C9028
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Injection, inotuzumab ozogamicin, 0.1 mg
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C9029
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Injection, guselkumab, 1 mg
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J0565
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Injection, bezlotoxumab, 10 mg
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J0606
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Injection, etelcalcetide, 0.1 mg
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J1428
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Injection, eteplirsen, 10 mg
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J1555
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Injection, immune globulin (cuvitru), 100 mg
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J1627
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Injection, granisetron, extended-release, 0.1 mg
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J1726
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Injection, hydroxyprogesterone caproate, (makena), 10 mg
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J1729
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Injection, hydroxyprogesterone caproate, not otherwise specified, 10 mg
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J2326
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Injection, nusinersen, 0.1 mg
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J2350
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Injection, ocrelizumab, 1 mg
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J3358
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Ustekinumab, for intravenous injection, 1 mg
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J7210
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Injection, factor viii, (antihemophilic factor, recombinant), (afstyla), 1 i.u.
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J7211
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Injection, factor viii, (antihemophilic factor, recombinant), (kovaltry), 1 i.u.
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J7345
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Aminolevulinic acid hcl for topical administration, 10% gel, 10 mg
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J9022
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Injection, atezolizumab, 10 mg
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J9023
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Injection, avelumab, 10 mg
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L8625
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External recharging system for battery for use with cochlear implant or auditory osseointegrated device, replacement only, each
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L8694
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Auditory osseointegrated device, transducer/actuator, replacement only, each
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Q0477
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Power module patient cable for use with electric or electric/pneumatic ventricular assist device, replacement only
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Q2040
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Tisagenlecleucel, up to 250 million car-positive viable t cells, including leukapheresis and dose preparation procedures, per infusion
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The following HCPCS codes represent services that are covered; however, NHP reimburses the established CPT codes for these services:
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CODE
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DESCRIPTION
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G0513
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Prolonged preventive service(s) (beyond the typical service time of the primary procedure), in the office or other outpatient setting requiring direct patient contact beyond the usual service; first 30 minutes (list separately in addition to code for preventive service)
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G0514
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Prolonged preventive service(s) (beyond the typical service time of the primary procedure), in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes (list separately in addition to code g0513 for additional 30 minutes of preventive service)
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G0515
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Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes
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The following HCPCS code represents a service that is covered but reimbursed for commercial members when billed with CPT codes. Chronic care management is not reimbursed by MassHealth:
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CODE
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DESCRIPTION
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G0511
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Rural health clinic or federally qualified health center (rhc or fqhc) only, general care management, 20 minutes or more of clinical staff time for chronic care management services or behavioral health integration services directed by an rhc or fqhc practitioner (physician, np, pa, or cnm), per calendar month
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The following HCPCS codes represent services that are not separately reimbursed across all lines of business:
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CODE
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DESCRIPTION
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C9738
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Adjunctive blue light cystoscopy with fluorescent imaging agent (list separately in addition to code for primary procedure)
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C9748
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Transurethral destruction of prostate tissue; by radiofrequency water vapor (steam) thermal therapy
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Radiation Therapy Pathways Worksheets
To align with the case build process for other cancer types, evicore has updated the interactive worksheets for the following:
- Small Cell Lung Cancer
- Skin Cancer
- Soft Tissue Sarcoma
- Non-Small Cell Lung Cancer
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Medical Policies
The following medical policy updates are effective February 1, 2018:
- Kymriah (New Policy)
- Yescarta (New policy)
- Opdivo
- Provenge
- Keytruda
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Hospital Inpatient Utilization Report
The latest quarterly hospital inpatient utilization report is now available. To review this report, click on the Reports tab in NHPNet and select Clinical Reports. if you do not have access to NHPNet, you may register online at
nhpnet.org.
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On behalf of all of us at Neighborhood Health Plan, we thank you for the excellent care provided to our members and the continued collaboration extended to our staff.
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