2018 Network News Winter Newsletter Targeted Review List updates effective January 1, 2018 ... 9.9...
Embed Size (px)
Transcript of 2018 Network News Winter Newsletter Targeted Review List updates effective January 1, 2018 ... 9.9...
A publication for contracted community physicians
Dual-Member Cost Share
As required by Medicare regulations and as out- lined in your contract with Kaiser Permanente, providers are prohibited from collecting cost- sharing for Medicare covered services from members dually enrolled in the Medicare and Medicaid programs. This requirement also applies to individuals enrolled in the Qualified Medicare Beneficiary (QMB) Program, a program that pays for Medicare premiums and cost-sharing for certain low-income Medicare beneficiaries.
If you have questions about these requirements or regarding a Kaiser Permanente member’s eligibility status, please contact Member Services at 404-261-2590 or 1-888-865-5813.
Information You MUST Keep Up to Date
CMS requires quarterly outreach to ensure directories are complete and accurate. Providers are expected to maintain/update/validate all demographic info, in addition to complying with and responding to all outreach in a timely manner. Additionally, CAQH information should be kept up to date and accurate.
Please email Provider Contracting (ga.provider- firstname.lastname@example.org) at least ninety (90) days in advance to inform us of any changes to demographics including but not limited to:
• Provider status changes (additions or terminations or location changes)
• Practice/Provider name changes • Telephone/fax • Address
Fee Schedule Updates
It is the policy of Kaiser Permanente of Georgia’s Provider Contracting and Network Management Department (PC&NM) to review and update the fee schedules annually. PC&NM anticipates the 2018 updates will be effective in March, while the KPMFS and Enhanced Groupers will be effective in April.
Important Contact Numbers
Benefits & Eligibility (Member Services)
404-261-2590 or 1-888-865-5813
Claims Questions (Member Services)
404-261-2825 or 1-800-221-2131
Emergency Care Management Hub
Exchange Member Services
Provider Relations 404-364-4934
Referrals & Authorizations (QRM)
404-364-7320 or 1-800-221-2412
Self-Funded Member Services
60889516_NetworkNews_GA-MMC_GA_2018_NL.indd 3 1/26/18 1:45 PM
Kaiser Permanente periodically updates the Targeted Review List that contains medications and services that require Prior Authorization. The list can be found on the provider portal (providers.kp.org/ga). Please be sure to review the list carefully. As a reminder, failure to obtain authorization prior to providing the services listed will result in a denial of payment.
Medications added to the QRM list of Medications:
• Ixekizumab (Taltz) • Eluxadoline (Viberzi) • Ustekinumab (Stelara) • Interferon beta 1a (Rebif) • Teriparatide (Forteo) • Abaloparatide (Tymlos) • Nusinersen (Spinraza) • Eteplirsen (Exondys 51) • Miltefosine (Impavido) • C1 Esterase Inhibitor (Haegarda) • Brodalumab (Siliq) • Dichlorphenamide (Keveyis) • Alirocumab (Praluent) • Evolocumab (Repatha) • Edavarone (Radicava)
Medications for which criteria have been revised since August 2017 include:
• Denosumab (Prolia) • Glatiramer (Glatopa) • Ledipasvir/sofosbuvir (Harvoni) • Sofosbuvir/velpatasvir (Epclusa)
Medications removed from QRM list of Medications effective January 1, 2018:
• Linagliptin (Tradjenta) • Linagliptin/Metformin (Jentadueto) • Empagliflozin (Jardiance) • Glatiramer (Glatopa) 20 mg
Targeted Review List updates effective January 1, 2018
60889516_NetworkNews_GA-MMC_GA_2018_NL.indd 4 1/26/18 1:45 PM
Services Not Requiring Referrals
Certain services do not require referrals in KP Online-Affiliate. For example, members have direct access for certain services and do not have to seek care from their PCPs before scheduling an appointment with these specialists:
• Dermatology • Office-based behavioral health • Obstetrics and gynecology • Optometry/Ophthalmology • The Southeast Permanente Medical Group
(TSPMG) specialty services
When you see a member that has self-referred, you should verify the eligibility and benefits of the member. It is recommended that eligibility be verified prior to each visit. Eligibility may be verified online, or by calling Member Services Department at 404-261-2590 or 1-888-865-5813.
You must submit your laboratory service orders either to our contracted laboratory vendor (Quest Diagnostics) or to a Kaiser Permanente facility. Failure to do so will result in your office being liable for payment for services sent to a non-participating vendor. Orders for outpatient laboratory services sent to Quest Diagnostics or Kaiser Permanente do not require referrals, however they do require a separate form/requisition that can be found on the provider website (providers.kp.org/ga). Orders for Quest Diagnostics should be submitted using a Quest Diagnostics requisition. Orders for a Kaiser Permanente facility laboratory should be submit- ted using the Kaiser Permanente requisition. Your contract may require you to send all laboratory services orders to Kaiser Permanente facilities. Laboratory services cannot be referred through KP Online-Affiliate. We require you to provide diagnosis codes on all laboratory orders to either Kaiser Permanente or our contracted laboratory vendor.
Procedure for Radiology Services
Routine radiology services do not require referrals in KP Online- Affiliate. Most radiology services are available at multiple Kaiser Permanente locations throughout the Atlanta area, but visit kp.org for a full list that also includes other contracted facilities. PET scans require authorization. MRI and CT scans not performed at Kaiser Permanente medical centers require authorization.
Radiology Ordering Procedure: The external provider should order radiology exams using the KPGA Imaging Order Worksheet/Form/ Requisition found on the provider website (providers.kp.org/ga). The provider must complete and sign the order, and the order must contain, at a minimum, the following information:
• Diagnosis Code, symptom/and or disease • Clinical Information (Reason for Exam) • Physician Name, Office, and Fax Number
(either in comments or on the prescription).
The external provider must fax the order to 1-877-206-2482 and should provide the member with a hardcopy. The member can take the hard copy of the order to the nearest Kaiser Permanente contracted facility (listed on kp.org) or they can call the scheduling number located at the top of the form, 404-365-0966.
60889516_NetworkNews_GA-MMC_GA_2018_NL.indd 1 1/26/18 1:45 PM
Throughout: Updated Member Services Numbers:
Benefits & Eligibility (Member Services) 404-261-2590 or 1-888-865-5813
Claims Questions (Member Services) 404-261-2825 or 1-800-221-2131
Exchange Member Services 770-291-6897
Self-Funded Member Services 1-866-800-1486
Section 1: Introduction 1.1 History (updated)
1.2.1 Kaiser Foundation Health Plan of Georgia, Inc. (“Health Plan:” or “KFHPG) (reworded)
Section 2: Key Contacts 2.1 Fully Funded: Key Contacts (updated)
2.2 Self-Funded Key Contacts (updated)
2.6.1-2.6.10 moved to section 1.4
2.6.2 Urgent Care Centers (updated to Advanced Care Centers and added express care)
2.6.3 Kaiser Permanente Medical Offices (updated services)
2.6.8 Kaiser Permanente of Georgia Radiology Services (updated)
2.6.10 Kaiser Permanente of Georgia Outpatient Behavioral Health Services (updated and deleted provider directory and moved)
Section 3: Benefits & Eligibility 3.1.3 Clinical Trials (added for clarity)
3.4 Exclusions and Limitations
3.7 – 3.73 Self-Funded Products (updated along with new ID cards for Self-Funded products)
3.8 Dual Eligible members (added Medicare/ Medicaid cost sharing prohibition using national’s language)
3.10 Pharmacy (updated and added quick reference charts)
Section 4: Utilization Management 4.1 Decision Making for Medical Services
4.2 Concurrent Review Process
4.5.2 Referral Procedures (including addition of new referral intake form for those not referring using EDI)
4.6.2 Specialty to Specialty Referrals (deleted)
4.7.5 ICD-10 Transition – Prior Authorizations (deleted)
4.7.4 Scheduled or Elective Inpatient Admissions and Services
4.9 Transition of Care/Continuity of Care (new /added)
4.14 Hospital Admission, Discharge and Transfer Policy, Emergency Care Management Hub (ECM Hub)
4.15 Drug Formulary
4.16 Non-Formulary (NF) Exception Process
Section 5: Billing and Payment 5.11 Surgical and/or Obstetrical Procedures
5.16 Self-Funded: Paper Claims
5.17.2 Fully-Funded EDI Submissions (Emdeon is now Change Healthcare)
5.17.3 Self-Funded EDI
5.18.1 Self-Funded: Exclusions to TPA submission
5.21 Self-Funded: Supporting documentation for EDI claims
5.23 Fully-Funded: Electronic Funds Transfer (EFT) Payment
Changes To The Provider Manual