2018 Network News Winter Newsletter · Targeted Review List updates effective January 1, 2018 ......

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Network NEWS A publication for contracted community physicians Winter 2018 providers.kp.org/ga 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- [email protected]) 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 SERVICE PHONE 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 404-365-4254 Exchange Member Services 770-291-6897 Provider Relations 404-364-4934 Referrals & Authorizations (QRM) 404-364-7320 or 1-800-221-2412 Self-Funded Member Services 1-866-800-1486 60889516_NetworkNews_GA-MMC_GA_2018_NL.indd 3 1/26/18 1:45 PM

Transcript of 2018 Network News Winter Newsletter · Targeted Review List updates effective January 1, 2018 ......

Page 1: 2018 Network News Winter Newsletter · Targeted Review List updates effective January 1, 2018 ... 9.9 Ineligibility to Participate in Government Health Care Programs 60889516_NetworkNews_GA-MMC_GA_2018_NL.indd

NetworkNEWS

A publication for contracted community physicians

Winter 2018

providers.kp.org/ga

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- [email protected]) 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

SERVICE PHONE

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

404-365-4254

Exchange Member Services

770-291-6897

Provider Relations 404-364-4934

Referrals & Authorizations (QRM)

404-364-7320 or 1-800-221-2412

Self-Funded Member Services

1-866-800-1486

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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

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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.

Laboratory Services

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.

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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: Introduction1.1 History (updated)

1.2.1 Kaiser Foundation Health Plan of Georgia, Inc. (“Health Plan:” or “KFHPG) (reworded)

Section 2: Key Contacts2.1 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 & Eligibility3.1.3 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 Management4.1 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 Payment5.11 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

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5.30 Fully-Funded Claims Adjustments/ Corrections (Retrospective or Otherwise) (fixed wording)

5.31 Self-Funded: Claims Adjustments/ Corrections (Retrospective or Otherwise) (fixed wording)

5.33 Self-Funded: Incorrect Claims Payments (updated process)

5.36 Member Cost Share (added Medicare/ Medicaid cost sharing prohibition using national’s language)

5.38 Visiting Members (Updated)

5.40 Coding Standards (Updated)

5.41 Modifiers in CPT and HCPCS

5.42 Modifier Review

5.43 Fully Funded: Coding & Billing Validation

5.44 Self-Funded: Coding & Billing Validation

5.45 Fully-Funded: Coding Edit Rules

5.47 Medical Claims Review

5.48 National Clinical Review (added)

5.60 Explanation of Payment (EOP) (updated copies)

Section 6: Provider Rights and Responsibilities6.1 Primary Care Physicians’ (PCP) Responsibilities

(Removed hospital requirement)

6.1.2 Changing Primary Care Providers

6.2 Specialty Care Providers’ Responsibilities (Removed hospital requirement)

6.5 Change of Information

6.6 Adding a New Provider to Your Group

6.6.1 Credentialing with Kaiser Permanente of Georgia

6.12 Complaints/Grievances between Members and Providers

6.15 Informed Consent (added here)

6.16 Advanced Directives (added here)

Section 7: Members Rights and ResponsibilitiesNo Changes

Section 8: Quality Assurance and Improvement8.1 Achieving our Goal (detail added)

8.2 Unusual Occurrences

8.4 Participating Practitioner Credentialing

8.4.1 Credentialing and Re-credentialing Processes

8.5 Risk Management (removed)

8.6 Peer Review

8.7 Compliance with Facility and Office Site Reviews

8.8.2 Non-Compliance with Medical Records Standards

8.8.3 Submission of Consultation Notes and Discharge Summaries

8.9 Accessibility Standards

Section 9: Compliance9.3 Provider and Vendor Code of Conduct

(deleted duplications and updated wording)

9.5 Privacy and Security

9.6 Gifts and Business Courtesies

9.8 Fraud, Waste and Abuse

9.9 Ineligibility to Participate in Government Health Care Programs

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Kaiser Foundation Health plan of Georgia, Inc. Nine Piedmont Center 3495 Piedmont Road N.E. Atlanta, GA 30305-1736

Address Service Requested

Please Recycle. 60889516 01/18

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