October 2019 Edition

A Note from Dr. Wilson Your primary care clinic can adequately meet the majority of your patients' physical and mental health needs. It’s imperative that you use Cozeva (population health tool) to identify all visit types. Those visit types may be for: primary care acute care mental health assessments chronic care If the conditions you encounter are complex, attempt to identify and document as soon as possible and refer to all care coordinators (specialist, case managers, or outside support agencies).   Cozeva's use as a population tool is most helpful if used in two methods:   1. Attribution: Assigning patients to your practice via Health Plan and Medical Group (each member should be outreached to within 60 days of enrollment).   2. Maximizing quality improvement opportunity at all visits: Do not have "sick-episodic visits" (use the Cozeva tool prior to seeing patients to track the HEDIS/RAF/Health Plan Gap). Have your staff document all visits as HEDIS (quality measure needed) vs. Non-HEDIS (all measures previously met). Pay attention to all immunizations, FOBT, Chlamydia, and cervical cancer screenings. Know and use your chronic care codes: Asthma, Hypertension, Diabetes, etc.   Recently, we sent you a Provider Satisfaction survey via email asking about your experiences with AltaMed. If you have already responded, we thank you for your feedback. If you have not had time to respond, please take a few minutes to complete the survey now. Your participation in answering the questions will help us to improve the quality of service we provide. It should take only a few minutes to answer these questions. The information you provide will be kept completely private and confidential and your answers will never be matched with your name.   With your completion of the survey you will receive a $5 Starbucks gift card. The more people who respond, the greater our ability to improve the quality of service you receive. We hope you will take this chance to tell us about your experiences with AltaMed.  Sincerely, Keith Wilson, M.D., FACOG

Network Management Updates

New Provider Portal AltaMed is no longer utilizing AltaMed Net as the provider portal, effective April 1, 2019. As previously communicated, the new provider portal is AltaMedConnect . Attached is a quick reference to help you register and navigate through the new portal.   Training Registration is ongoing thru December via WebEx. Please sign up using this online registration site. We highly encourage Providers to use the Connect portal for submission of authorizations and not FAX authorization requests. Authorizations received from the Provider portal are processed more efficiently.   If we identify your office as an office that continuously sends authorizations via fax, we will reach out to your office for further training.

Claims Address On April 1, 2019, AltaMed Health Services has a new claims address. Please send claims to: AltaMed Health Services Corporation Attn: Claims Department P.O. Box 7280 Los Angeles, CA 90022-7280 855-848-5252, Option 1, 1                 For Electronic Claims: Office Ally – ALTAM        Change Healthcare – 95712 We highly encourage Providers to send claims electronically and not FAX claims. Claims received electronically are processed more efficiently. If we identify your office as an office that continuously sends claims via fax, we will reach out to your office for further training.

Payments Simplified Effective July 22, 2019, as part of our ongoing commitment to simplifying and improving payment transactions for your business, AltaMed is offering more choices in payment methods. Recent feedback from our network indicates quicker reimbursement and more efficient payment reconciliation are high priorities for our providers, and we are excited to offer additional payment solutions to enable these priorities.   AltaMed will collaborate with Change Healthcare and ECHO Health, Inc. to provide these new electronic payment methods. Many of our providers already work with Change Healthcare today.    Outlined below are the payment options and any action items needed by your office:   Virtual Card Services If you are not currently registered to receive payments electronically, beginning the week of July 22 , you will automatically receive Virtual Credit Card payments with your Explanation of Benefits (EOB). Your office will receive fax notifications, each containing a virtual credit card with a number unique to your payment transaction, and an instruction page for processing. The steps for processing this payment are similar to how you manually key-in patient payments today. Be sure to enter the payment information for the full amount of the card's value and do so prior to the expiration date on the card. Normal transaction fees apply based on your merchant acquirer relationship. Action: None is needed to start receiving your Virtual Credit Card payments.  Please note: Going forward, payment will appear as “HNB – ECHO.” Electronic Funds Transfer (EFT) Payments Setting up EFT is a fast and reliable method to receive payment. AltaMed employees interested in receiving payment via EFT can visit this link , and Non-AltaMed can click here . Action: Provide your banking account information, ECHO payment draft number, and payment amount as part of the enrollment authentication process. Please note: Going forward, payment will appear as “HNB – ECHO.”   Paper Check To receive paper checks and paper explanation of benefits. Action: Elect to opt out of Virtual Card Services or remove your EFT enrollment.   In addition, we want to make you aware of another enhancement. You can now log into Provider Payments to access a detailed explanation of payment for each transaction.    We appreciate your support as we roll out these new payment options to deliver a positive experience for your patients. If you have additional questions regarding your payment options, please contact ECHO Health at 833-629-9725.

Customer Support Center In the spirit of commitment and continuous improvement to support our contracted network of providers, a new Customer Support Center has been created effective April 4, 2019. To aid in navigation efforts, the prompts are as follows:  855-848-5252.      For Providers: Option 1  Menu:                             Claims/Eligibility Prior Authorizations Inpatient Admissions Care Management PACE/SBC Authorizations Other Departments:                            Portal Technical Support Credentialing Contracting

Member Grievance and 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 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.

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 by October 10 to your Primary Office location. Please remain alert for the notice, as your completion of the document is both required and appreciated, even if there are no changes. If you do not receive the form, and/or have any questions or concerns, please feel free to contact us at  directoryvalidation@altamed.org

Behavioral Health Treatment (BHT) Coverage for Members Under the Age of 21 L.A. Care is pleased to announce additional Behavioral Health support. Please see the attached document for more information regarding Behavioral Health Treatment (BHT) coverage for members under the age of 21. Services may potentially include: Behavioral Health Treatment (BHT) / Applied Behavior Analysis (ABA) Early Periodic Screening, Detection, and Treatment (EPSDT) Occupational, physical, and speech therapy Vision, dental, and hearing services Should you have any questions, please call Mahsa Hesari, Manager – Behavioral Health at: 213-694-1250 Ext. 5381 or contact L.A. Care Health Plan’s Behavioral Health Department at: 888-347-5054.

Timely Access to Care The law requires health plans licensed by the 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.   Links have been provided for you to see the DMHC standards: Appointment availability   After-hours and appointment availability Plans shall ensure that 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.

Inappropriate Requests for Prior Authorization The Utilization Management (UM) department has been in receipt of referral requests for services that do not require prior authorization. Preventive Health Services, including immunizations Annual well-woman 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)

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.    “Urgent care” means healthcare for a condition which requires prompt attention, consistent with subsection (h)(2) of Section 1367.01 of the Act. When the enrollee's condition is such that the enrollee faces an imminent and serious threat to his or her health, including, but not limited to, the potential loss of life, limb, or other major bodily function. The normal time frame for the decision making process would be detrimental to the enrollee's life or health or could jeopardize the enrollee's ability to regain maximum function. Decisions to approve, modify, or deny urgent requests by providers prior to, or concurrent with, the provision of health care services to enrollees shall be made in a timely fashion appropriate for the nature of the enrollee's condition, not to exceed 72 hours.   Providers should appropriately classify the referral to coincide with the member’s healthcare needs to eliminate delays in processing an authorization request for members who are in need of urgently needed care. An example of an inappropriate classification of an urgent referral: The member has an appointment the next business day

Standing Authorization Should the Primary Care Physician (PCP) determine one of their member 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, the PCP should submit the follow-up request for specialty care as a standing referral.  With 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

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 MediCal. Some examples are: 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)   Visit the links for more information about Medicare Non-Covered Items and Medicare Non-Covered Services .

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: 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

Affirmative Statement The Utilization Management (UM) department makes decisions 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 similar matters.

Quality Improvement

Introducing… your NEW Quality Improvement Portal! The Quality department is excited to announce the latest update in our ongoing endeavor to provide optimal support to your office’s improvement efforts. AltaMed’s NEW Quality Improvement Portal is now your “one-stop-shop” for accessing our most important information – no login required! Click here to view the new Quality Improvement Portal, and remember to bookmark this site for one-click access to our most important information and materials in the future.

Review the 2019 Quality Improvement & Incentives Program. Sign up for COZEVA® and register for an upcoming training. Download our COZEVA® workflow guides and “cheat sheets.” Access our ever-expanding library of QI resources. View the member incentives currently offered by health plans. Obtain important information by health plan on interpretation, transportation, and other key services (coming soon!).

Compliance Corner

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 that 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 upholding and supporting compliance with all required standards and expected conduct. We look forward to introducing our new version soon. Visit our website to access the Business Code of Conduct, located under the Regulatory Notices link.

Cultural & Linguistic Competency Update

Enhance Your Communication Skills Respectful communication is central to connecting with members and their families. This in turn fosters patient-centered communication. Being responsive to individuals’ values and how they think about health can enhance patient participation in their health care management. What can providers do to enhance patient empowerment in understanding their health? Providers and the health care team can: Enhance their own self-awareness of biases and views to prevent stereotyping patients. Learn more about the communities from which their patients come. Respect cultural values and language preferences. Foster a feeling of connection with patients by communicating health in a manner the patient understands. For additional information on resources that foster respectful communication, you may visit and participate in self-guided e-Learnings:   Health Literacy Universal Precautions Toolkit  CLAS Standards Training and Resources  Cultural and Linguistic Competency   For further information, please contact Evelyn González-Figueroa, Director of Cultural & Linguistic Competency at evelgonzalez@altamed.org .