A publication for AultCare & PrimeTime Health Plan...

Provider NewsDecember 2015

The

A publication for AultCare & PrimeTime Health Plan providers

2 > Medicare Advantage Plan

3 > Part D Prescriber Enrollment Requirement

> Part D Pharmacy Information

4 > Fraud, Waste & Abuse > Hours of Operation > Credentialing Reminders > Accurate Member Information

5 > Utilization, Case & Disease Management Services

6 > Contact List > Genetic/Molecular Testing

7 -10 > Practice Guidelines

11 > Information Accessible To You on our Website

12 > Medication Reconciliation Post-Discharge

13 > Home Safety

14 > An Update on: Access & Office Site Standards

15 > National Provider Identifier (NPI) Communication

> Novolog & Apidra Step Therapy > Silver&Fit

16 > 835 Electronic ERA/EFT

I N S I D E T H I S I S S U E :

COMINGIN2016...

12/15

AUTOMATED AUTHORIZATIONS & COVERAGE DECISIONS IN REAL TIME

Please look for mailings, emails and informational materials on our website regarding the continued communication of Clear Coverage!

BEGINNING JANUARY 1, 2016 The Centers for Medicare and Medicaid (CMS) is requiring all Medicare Advantage Organizations (MAO) to verify their provider network is adequate and the provider directory is up-to-date. The guidance from CMS requires all MAO plans to correspond with contracted providers a minimum of one time per quarter to verify provider information. This requirement provides us the opportunity to ensure the information communicated to our enrollees (your patients) is accurate.

You will begin receiving quarterly emails from AultCare beginning January 2016.

The email communication will give you all the details needed to communicate any changes. If you prefer not to provide verification and/or changes to your information via the email, we will require you to correspond in writing.

Please contact AultCare Credentialing at 330-363-1400 with any questions: Monday thru Friday 8:00 AM to 4:30PM or by email at [email protected]

If you are not currently corresponding with AultCare via email, please use the Provider Information Form located on the AultCare website www.aultcare.com under the Provider Tab to communicate your email information.

Please be sure to supply the email addresses for your credentialing contact, practice administrator and your provider, i.e. physician, physician extender, etc.

PROVIDER INFORMATIONVERIFICATION REQUIREMENTS

AULTCARE PROVIDER PORTAL

The Provider Portal located on the AultCare website www.

aultcare.com offers a variety of information to our providers.

Once you’ve logged in to the secure area, you can obtain

eligibility, claim status, prior authorization forms, etc.

As we continue to expand services on the Provider Portal,

it is more important than ever for your practice to utilize the

services offered on the secure area of the Provider Portal.

If you don’t already have an established username and

password, we strongly encourage you to go to the AultCare

website and establish a username and password.

Have you forgotten your username and password; please

use the website to retrieve your login credentials.

InterQual and Clear Coverage are trademarks of McKesson Corporation and/or one of its subsidiaries. © 2015 McKesson Corporation. All Rights Reserved.

Clear Coverage™ is a cloud-based application and platform assisting providers and payers to collaborate on coverage decisions in real time through automated authorizations.

The goal of Clear Coverage™ is to streamline the prior authorization process.

Clear Coverage™ incorporates InterQual® and AultCare’s criteria into a fully automated, interactive workflow. Clear Coverage™ assists with the medical review process as well as eligibility verification. Making clinical and coverage guidelines transparent to providers in real time, frees up your medical management staff and allows them the timeto address other tasks.

Clear Coverage™:• Reduces administrative costs and provider challenges with authorization requests

3 Available 24 hours a day, seven days a week, 365 days a year• Streamlines eligibility verification• Provides consistency• Provides feedback with accurate documentation

The Provider News 2

PTHP 2015 AEP Provider 8.5x11 sheet approved.indd 1 10/29/2015 11:19:01 AM

H3664_AEPPN2016 Accepted 12152015

The Provider News 3

Be enrolled in Medicare in an approved status OR Be validly opted out of the Medicare program.

The Centers for Medicare and Medicaid Services (CMS) is strongly recommending all prescribers to enroll by January 1, 2016 to allow time for processing applications and to ensure prescriptions are not denied. Please visit the following website to get more information about this requirement and to enroll electronically. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Prescriber-Enrollment-Information.html. Enrollment is free of charge and takes little time to complete.

COVERAGE DETERMINATIONSn PRESCRIBER SUPPORTING

STATEMENT CMS requires us to reach out to the

member’s prescriber to get supporting documentation on why the member needs to have a drug that is a high risk medication or that requires a quantity limit or for any drug with an edit that you the physician would like waived.

n INCLUDE AS MUCH INFORMATION AS POSSIBLE

In order to process the request we need as much information as possible to provide to our clinical team to review and make a decision on coverage.

n STEPS FOR EASY SUBMISSION: There is a standard coverage

determination form (which is on the website); however, it is not required. The criteria we need may also be faxed to you and you may use that as well when submitting additional information.3 Fax: 330-580-6764 3 Verbally by phone: 330-363-74073 E-mail: pthppharmacy@aultcare.

com

n EXPEDITED VS. STANDARD TIMEFRAMES

Please keep these timeframes in mind when requests are submitted to PrimeTime Health Plan. If we do not receive the supporting documentation within the timeframes listed below, the request may be denied.

If you would like more detailed information regarding the Coverage Determination process, it is available on our website under the member’s specific plan.

Part D Pharmacy InformationThe following table contains specific instructions on how to obtain detailed resources regarding the 2016 PrimeTime Health Plan formulary.

The documents can be found on our website at www.primetimehealthplan.com.

Subject Description

Clinical Prior Authorizations

Location

Criteria and list of medications

Step Therapy On the website, select “Forms” at the top, under “Prescription Drug Information (Part D)” choose “ Criteria-2016 Step Therapy.”

Step Therapy criteria and list of medications

Quantity Limits On the website, select “Forms” at the top, under “Prescription Drug Information (Part D)” choose “Criteria-2016 Quantity Limits.”

Quantity Limits for each medication

Tier 2016 Comprehensive Formulary (for an abridged version to print, choose the “2016 Abridged Formulary”)

On the website, select “Forms” at the top, under “Prescription Drug Information (Part D)” choose “2016 Comprehensive Formulary.”

On the website, select “Forms” at the top, under “Prescription Drug Information (Part D)” choose “Criteria-2016 Prior Authorization.”

Expedited = 24 hours3 An expedited coverage

determination must be completed by our team in 24 hours – this means the members health could be seriously jeopardized if the determination is not done in 24 hours. If you check the box that states expedited or write “urgent” on the request, we are assuming that the member’s health is at severe risk.

Standard = 72 hours3 For standard requests, PrimeTime

Health Plan has 72 hours to provide a determination.

PRESCRIBER ENROLLMENT REQUIREMENT

Part D Beginning June 1, 2016, in order for PrimeTime Health Plan member’s prescriptions to be covered under Part D, physicians and other eligible professionals who write prescriptions for Part D drugs MUST either:

FURTHER INFORMATION WILL BE COMMUNICATED AS IT BECOMES AVAILABLE.

HOME SAFETYCredentialing Reminders:Please complete the Request for Provider Information Form

or Request for Facility Information Form in order to communicate any of the below changes/additions

in your practice to AultCare:

The Request for Provider Information Form and Request for Facility Information Form can be located on the AultCare Website under the Provider Tab at www.aultcare.com. You may also call the Provider Credentialing Department at 330-363-1400 Monday thru Friday 8:00am – 4:30pm or email [email protected]

Once the appropriate form(s) have been received, the request will be submitted to the AultCare Membership Services Committee for consideration. Approval of new locations and/or services is dependent upon various criteria which could include location and type of service.

The credentialing process for a new provider can take up to 60-90 days. The process for a change in status can take up to 45-60 days. Providers who intend to treat AultCare members for non-approved services at a non-approved location will be considered non-panel.

Please be sure to keep your CAQH information up to date in order to expedite the credentialing process.

n New provider

n Provider retirement

n Practice affiliation change

n Leave of absence

n Practice name change

n Practice location change

n Tax identification number

change

n Billing information change

n Location closing

n New location

n Accepting new patients

The Provider News 4

Accurate MemberI N F O R M A T I O Nn When submitting claims please ensure member

information is reflective of the ID card

n For example; abbreviations, middle initials, Jr/Sr, nicknames, etc.

n Discrepancies may cause claim processing delays or denials

Fraud, Waste & AbusePrimetime Health Plan and AultCare encourage anyone with knowledge of suspected instances of non-compliance and/or fraud, waste or abuse (FWA) to report this information. Please know, this information can be reported anonymously and without fear of retaliation. Every effort is made to maintain confidentiality.

To report FWA contact our Compliance/FWA hotline toll free at: 1-866-307-3528 or https://aultcarepthp.alertline.com

AULTCARE SERVICE CENTERHOURS OF OPERATION:

Monday through Friday - 7:30am to 5:00pmPhone: 330-363-6360

Long Distance: 1-800-344-8858TTY-330-363-2393 or 1-866-633-4752

www.aultcare.com – Contact Us – Choose Provider from the drop down list

TIMKEN SERVICE UNIT330-363-6282

1-800-505-2858

PRIMETIME HEALTH PLANHOURS OF OPERATION:

Monday through Friday - 8:00am to 4:30pm Local Provider line - 330-363-3123

Long Distance Provider line - 1-855-281-7561TTY Local 330-363-7460

TTY Long Distance 1-800-617-7446www.primetimehealthplan.com

The Provider News 5

We have combined the traditional services of Utilization Management, Case Management and Disease Management into one service, provided by a Care Coordinator, who will help the member navigate through the health care system. Our team of registered nurses, licensed practical nurses and licensed social workers are available by phone to help your patients take control of their health and well-being.

Services available, but not limited to, include: n Assistance with the referral process to out-of-network specialistsn Help with transitioning patients care to panel providers, if

appropriaten Care coordination to help your patients coordinate their plan

benefits while maintaining quality, cost-effective treatmentn Community resource information to provide assistance with

prescriptions, utilities and transportation if your patients are having financial difficulties

n Phone calls with a nurse who specializes in managing care for health conditions

n Educational materialsn Informative mailings and handouts about your patient’s

conditionsn Disease Management programs such as Cardiocom® and

GlucoCom® to help your patient manage CHF and diabetes from the convenience of their home

n Staff to guide you and your patient in the right direction and help you work with your doctors to improve your health

n Reliable referrals to service agencies in the communityn Educating the community with Aultman Health Talk Speaker

Series for accurate health information. For information visit http://www.aultman.org and click on the Health and Wellness link or call 330-363-8255 (TALK).

Members may benefit from our Care Coordination services if they:

n Have questions about their health status or health caren Are in need of a organ transplant

n Have been newly diagnosed with cancern Are experiencing complex medical issuesn Are receiving specialty care outside of the networkn Have questions or concerns regarding chronic conditions

Utilization Management Decisions Based on Medical Necessity

n Utilization Management decisions are based on the appropriateness of care and services as well as eligibility and coverage of requested services.

n AultCare & PrimeTime Health Plan do not reward practitioners or other individuals for issuing denials of coverage or service of care. There are no financial incentives for Utilization Management decision makers that result in underutilization.

n The specific criteria used in decisions are available to you at no cost by contacting the Utilization Management department at the phone numbers listed on page 6.

n A physician, nurse, or pharmacist reviewer is available to discuss Utilization Management denial decisions.

Utilization Management Staff Availability

n Care Coordination staff members are available from 8:00AM until 4:30PM Monday through Friday for inbound calls regarding Utilization Management issues and questions regarding the Utilization Management process.

n Care Coordination staff members can receive inbound communication regarding Utilization Management issues after normal business hours via voicemail or fax.

n Care Coordination staff can send outbound communication regarding Utilization Management inquiries during normal business hours.

n Care Coordination staff members will identify themselves by name, title, & organization when initiating or returning calls regarding Utilization Management issues.

n TTY/Hearing impaired and language assistance is available for members who require these services (see page 6 for contact information).

> AultCare and PrimeTime Health Plan offer a Care Coordination program to help your patients get the care, information and community services they need.

Utilization, Case & Disease Management Services

The Provider News 6

Genetic/Molecular TestingAULTCARE PRIOR AUTHORIZATION FOR

Contact List:

TOO BUSY TO CALL US? You may also email us 24 hours a day 7 days a week at www.aultcare.com or www.primetimehealthplan.com by clicking on the “Contact Us” link at the top of the website homepages. You will receive a response within 1 business day of your inquiry.

*We understand that some of your patients have special communication needs. We will provide a translator or hearing impaired services (TTY) to those members who are in need. If you have a patient who requires these services, please contact our service center at the numbers provided and we will gladly assist them.

DEPARTMENT HOURS LOCAL / TOLL-FREE NUMBERS TYPES OF INQUIRIES / CONCERNS

• Any questions or concerns unrelated to those noted above

AultCare Customer Service

Monday - Friday7:30 am - 5:00 pm

• 330-363-6360• 1-800-344-8858• (TTY 330-363-2393)*

• Claim Status• Benefits• Eligibility• Status of referrals, precertifications, prior authorizations

PrimeTime Customer Service


• 330-363-3123• 1-855-281-7561• (TTY 330-363-7460)*

Utilization Management Monday - Friday8:00 am - 4:30 pm

• 330-363-6360• 1-800-344-8858

• To request referrals, prior authorizations, precertifications

Case/Disease Management


• 330-363-6360• 1-800-344-8858

• Referrals to Case or Disease Management programs

Network Analysis,Credentialing & Contracting

• 330-363-1400• Fax: 330-363-6421• [email protected]

Provider Relations Monday - Friday

• Update your provider information• Request to become a provider


• 330-363-1160• Fax: 330-363-1155

EFFECTIVE - JULY 1, 2015:• AultCare requires prior authorization by the ordering physician for genetic/

molecular testing. Claims that are received without a prior authorization will be denied, as AultCare would not have the opportunity to review the request and render a coverage determination regarding: medical necessity, analytical

or clinical validity, or clinical utility of the test.• AultCare will require transparency from providers and laboratories billing

genetic/molecular testing.

3 This requires a disclosure of each test/procedure, by CPT Code and test name to be billed, as not all tests have been assigned their own unique CPT code.

3 Bundles or panels of tests, without clarification of each test that is to be performed, will no longer be considered for payment, and will be denied.

3 Only those tests deemed medically necessary to establish a diagnosis or directly impact the treatment or management of the member will be approved for coverage.

Your failure to prior authorize a test places your patient in a position that he/she may become responsible for the billed charges on the claim.

Reminder to AultCare providers regarding the requirements for prior authorization and the coverage determination process for genetic/molecular testing:

WHAT THIS MEANS:1. You, the ordering physician, must prior authorize all

genetic/molecular testing. Prior authorization requests will no longer be accepted directly from the labs.

2. You must provide clinical information to support the request when you prior authorize the test.

3. You must provide the CPT Codes for the tests that the lab will be performing; this suggests that you work with a laboratory that ensures transparency.

A prior authorization form specific to Genetic/Molecular Testing will be available on the AultCare Website at www.aultcare.com after July 1, 2015.

Please note: Prior authorization is not required for Cytopa-thology or Cytogenetic studies

Questions can be directed to the AultCare Service Center at 330-363-6360 between 7:30 am - 5:00 pm Monday - Friday.

continued on page 8

RATIONALES FOR GUIDELINES: The following guidelines are based on reviews of current medical literature. They are designed to assist providers in managing the care of their patients and to achieve more uniform quality standards for clinical care of AultCare members. The guidelines are not intended to replace the clinical judgment of the provider or to establish a standard of care. The decision to follow any particular guideline should be made by the provider after considering the circumstances presented by the individual member. Outcomes expected: To encourage uniform quality standards for the clinical care of Ault-Care members.

ASTHMANational Institute of Health: National Heart, Lung, Blood Institute; Guidelines for the Diagnosis and Management of Asthma, current edition

http://www.nhlbi.nih.gov/health-pro/guidelines

ATRIAL FIBRILLATION: American Heart Association, American College of Cardiology, and the Heart Rhythm Society; Guideline for the Management of Patients With Atrial Fibrillation, current edition

http://content.onlinejacc.org/guidelines.aspx

ATTENTION-DEFICIT/HYPERACTIVITY DISORDER American Academy of PediatricsADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disor-der in Children and Adolescents, current edition

http://pediatrics.aappublications.org/content/136/5?current-issue=y

BIPOLAR DISORDERAmerican Psychiatric Association; Treatment of Patients with Bipolar Disorder, current edition

http://psychiatryonline.org/guidelines.aspx

CARDIOVASCULAR RISK PREVENTION American Heart Association, American College of Cardiology; Guideline on Lifestyle Management to Reduce Cardiovascular Risk, current edition


The Provider News 7

PRACTICE GUIDELINES

The Provider News 8

P R A C T I C E

continued on page 9

CHILDHOOD AND ADOLESCENT OBESITYAmerican Academy of Pediatrics Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: current edition; AAP Pediatric Obesity: Practical Applications and Strategies From Primary to Tertiary Care, current edition

http://pediatrics.aappublications.org/content/136/5?current

CHOLESTEROLAmerican College of Cardiology, American Heart Association; Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults, current edition

http://my.americanheart.org/professional/StatementsGuidelines/ByTopic/TopicsA-C/ACCAHA-Joint-Guidelines_UCM_321694_Article.jsp#.VkOwjW7h-PG

COPDNational Institute of Health: National Heart, Lung, Blood Institute; Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, current edition

http://www.goldcopd.org/Guidelines/guidelines-resources.html

Spirometry for Health Care Providers, current edition

http://www.goldcopd.org/Guidelines/guidelines-resources.html

DEPRESSIONAmerican Psychiatric Association; Treatment of Patients with Major Depressive Disorder, current edition

http://psychiatryonline.org/guidelines.aspx

Encompasses: two HEDIS measures: 1. Antidepressant Medication Management which includes

members 18 years of age and older who were diagnosed with a new episode of major depression, treated with antidepressant medication, and who remained on an antidepressant medication treatment. Two phases of treatment included are as follows:

a. Effective Acute Phase Treatment. Newly diagnosed and treated members who remained on an antidepressant medication for at least 84 days.

b. Effective Continuation Phase Treatment. Newly diag-nosed and treated members who remained on an antide-pressant medication for at least 180 days

CANCER DETECTION, PREVENTION, AND RISK REDUCTIONThe National Cancer Institute of the Department of Health and Human Services, National Institute of Health, provides screening/testing guidelines for the following types of cancer, current editions:

• Breast Cancer Risk Reduction

• Breast Cancer Screening and Diagnosis

• Breast Cancer and Ovarian Cancer: Genetic/Familial High-Risk Assessment

• Cervical Cancer Screening

• Colorectal Cancer Screening

• Colorectal: Genetic/Familial High-Risk Assessment

• Lung Cancer Screening

• Prostate Cancer Early Detection

http://www.cancer.govhttp://www.nccn.org/professionals/physician_gls/f_guidelines.asp

> HEDIS® is a registered trademark of the National Committee for Quality Assurance

G U I D E L I N E S2. Follow-up After Hospitalization of a Mental Illness includes

discharges for members 6 years of age and older who were hospitalized for treatment of selected mental health disorders and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. Two areas for follow-up include:

a. Members who received follow-up within 7 days of discharge

b. Members who received follow-up within 30 days of discharge

DIABETESAmerican Diabetes Association; Clinical Practice Recommendations and Position Statements; Standards of Medical Care in Diabetes, current edition

http://care.diabetesjournals.org HEART FAILUREAmerican College of Cardiology, American Heart Association; ACCF/AHA Guideline for the Management of Heart Failure, current edition


HIV/AIDSThe U.S. Department of Health and Human Services 1. Antiretroviral Treatment

• Adult and Adolescent Guidelines, current edition• Pediatric Guidelines, current edition

2. Maternal-Child Transmission, current edition

3. Perinatal Guidelines, current edition

4. Post-Exposure Prophylaxis• Health-Care Worker Exposure Guidelines, current edition• Nonoccupational Exposure Considerations, current edition

5. Preexposure Prophylaxis for the Prevention of HIV Infection in the United States, current edition

6. Management of HIV Complications, current edition

7. Tuberculosis Guidelines, current edition

8. Opportunistic Infections Guidelines, current edition

9. Revised Guidelines for Counseling, Testing, and Referral, current edition

http://www.aidsinfo.nih.gov/Guidelines/Default.aspx?Menu-Item=Guidelines HYPERTENSIONThe American Heart Association, the American College of Cardiology, and the Centers for Disease Control and Prevention; An Effective Approach to High Blood Pressure Control: A Science Advisory From the American Heart Association, the American College of Cardiology, and the Centers for Disease Control and Prevention, current edition


IMMUNIZATIONS - ADULTS AND CHILDRENCenter for Disease Control National and Prevention; Advisory Committee on Immunization Practices (ACIP) Recommendations and Immunization Schedules, current edition

http://www.cdc.gov/vaccines/acip/index.html

PREGNANCYAmerican College of Obstetricians and Gynecologists; Guidelines for Perinatal Care, current edition

http://www.acog.org

The Provider News 9

P R A C T I C E

continued on page 10

The Provider News 10

OSTEOPOROSIS National Osteoporosis Foundation; Clinician’s Guide to Prevention and Treatment of Osteoporosis, current edition

http://nof.org/hcp/practice

OBESITYAmerican College of Cardiology, the American Heart Association, and the American Obesity Society; Guideline for the Management of Overweight and Obesity in Adults, current edition


SCHIZOPHRENIAAmerican Psychiatric Association; Treatment of Patients with Schizophrenia, current edition

http://psychiatryonline.org/guidelines.aspx STROKEAmerican Heart Association, American Stroke Association; Guidelines for the Primary Prevention of Stroke, current edition


> HEDIS® is a registered trademark of the National Committee for Quality Assurance

PRACTICE GUIDELINES continued

The complete listing of practice guidelines is also in the provider manual, which is located on the web. If you would like to request a paper copy or have any questions, call the Customer Service phone line at 330-363-6360 or toll free at 1-866-633-4752. TTY / TDD Line: 330-363-7460 or 1-800-617-7446.


> If you have questions, you may be able to find the answers to your questions at www.aultcare.com and www.primetimehealthplan.com. We continue to enhance

the information available on our websites.

Here’s a list of some of information and services you’ll find on our websites:

• Provider Directory: Our searchable provider directories include information about our network healthcare professionals. You can search by network, by specialty, name, hospital affiliation, languages spoken, gender, zip code, county, and whether or not they are accepting new patients

• Health & Wellness Tools: Access to the Health Talks calendar (AultCare website only), interactive self-management tools, and information about the Emmi® Education programs

• Care Coordination Services: Information regarding our Utilization, Case, and Disease Management programs

• Pharmacy Information: Access to the pharmacy directory, formularies, recall information, and prior authorization/step therapy/quantity limit information

• Health Care Reform: AultCare answers your questions about Health Care Reform

• Claims Submission Information: Electronic claims procedures and electronic claims submission enrollment forms

• Provider Credentialing Information: Request for application forms, CAQH information, Status change forms, OSHA information, HIPAA information

• Quality Management programs, evaluations, & outcomes: Including HEDIS® and CAHPS® outcomes, and Quality Management Program Evaluation

• Eligibility, Benefit Verification, & Claims Payment Information (requires log-in)

To You on our WebsiteI N F O R M A T I O N A C C E S S I B L E

If you do not have internet access and would like a written copy of any of the information listed above, please call Provider Relations at 330-363-1160 and a representative will be happy to assist you.

> HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

PROVIDER MANUALS (REQUIRES LOG-IN): Includes information such as:

• Member Rights & Responsibilities• Grievance & Appeals• Provider Credentialing• Pharmacy Management Procedures• Practice Guidelines• Medical Record Guidelines• Claim Submission Procedures• Utilization Management Procedures• Evaluation of New Technology• Disease & Case Management Programs• Appointment Availability Guidelines• Notice of Privacy Practices

Medication Reconciliation Post-Discharge

M e d i c a l R e c o r d S t a n d a r d S p o t l i g h t :

The Quality department will be adding

a new measure to our list of medical

record review measures for the 2016

HEDIS® season. This measure assesses

the percentage of discharges from January

1-December 1 of the measurement year

(2015) for Medicare beneficiaries 18 years

of age and older for whom medications

were reconciled on the date of discharge

through 30 days after discharge

(for a total of 31 days).

NUMERATORMedication reconciliation conducted by a

prescribing practitioner, clinical pharmacist

or RN, as documented through either

administrative data or medical record review

the date of discharge through 30 days after

discharge (31 days total).

* Documentation in the

medical record must include

evidence of medication

reconciliation and the date

when it was performed.

ANY OF THE FOLLOWING

MEETS CRITERIA:

• Documentation that the

provider reconciled the

current and discharge

medications

• Documentation of the current medication

with a notation that references the

discharge medications

(e.g., no changes in medications since discharge, same medications at discharge, discontinue all discharge medications).

• Documentation of the member’s current

medication with a notation that the

discharge medications were reviewed.

• Documentation of a current medication

list, a discharge medication list and

notation that both lists were reviewed on

the same date of service.

• Notation that no medications were

prescribed or ordered upon discharge.

* Only documentation in the outpatient chart

meets the intent of the measure, but an

outpatient visit is not required.

CPT CODES:

99495, 99496, 1111F


> HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

HOME SAFETY

If you are aware of an enrollee

that could benefit from these

services, please contact

AultCare or PrimeTime Health

Plan at the numbers provided

on page 6 and ask to speak

to a Case Manager.

Statistics from the Home Safety Council show that 1/3 of all injuries that occur in the United States happen in the home.

The home is also the second most common location of unintentional fatal injuries in the United States.

With the goal of reducing Emergency Room visits and hospitalizations related to injuries in the home, AultCare and PrimeTime Health Plan have partnered with Aultman Home

Safety Services to provide free in-home safety assessments to our enrollees who are at risk.

AultCare and PrimeTime Health Plan are committed to improving the mental and physical health of our members as well as decreasing their risk for falls.

Please review the safety suggestions below:

Utilizing canes, walkers and other assistive devices • Shower seats •

Avoid throw rugs on hard surfaced floors •Use of hearing aids and glasses •

Good lighting •Medical Alert systems when needed •

Assessment of medications •

With advanced age, typically comes an

increased risk for member falls, which can

cause devastating results on a member’s physical

and mental health. As a provider, we ask that you address fall

prevention with members.



AultCarePrescriptionD R U G U P D A T E

• Mupirocin (the generic for Bactroban) has been available for years generically in both ointment and cream formulations. Recently, the cream formulation has had a three fold price increase. AultCare will be instituting a step therapy requirement for failure of the ointment formulation before the cream formulation. Prescribing the generic for Bactroban ointment will provide the patient the most cost effective therapy.

• Combination drug formulations often provide benefits for both prescriber and patient when indicated. Typically, the combination products do not come at increase cost to the health care system. Recently, AultCare has identified some combination drug therapies that have a significantly higher cost associated with their prescribed use as compared to each entity being separately prescribed. Examples for which AultCare has instituted utilization management tools are:

a. Amlodipine/Atorvastatin (generic for Caduet)

b. Pioglitazone/Metformin (generic for Actoplus)

We encourage prescribers to utilize each agent

separately for the above products as it will provide the

patient the most cost effective outcome.

> Consumers value timely accessibility of medical care and providers. AultCare and PrimeTime Health Plan monitor primary care and behavioral health practitioner appointment and after hours accessibility annually against AultCare standards. Our accessibility standards are measured with physician surveys and providers are notified if particular trends are identified. Accessibility is also measured by member surveys, complaints, and grievances and providers are also notified if particular trends are identified and could result in an on-site visit.

Appointment Accessibility Standards (Internists, Family Practitioners, General Practitioners, Pediatricians, Obstetricians):• Routine appointments are available within 2 weeks involving non-acute symptoms or follow-up care• Preventive care appointments are available within 8 weeks• Urgent appointments are available within 24-48 hours depending upon severity of the

condition at the time of the initial call• Emergent life-threatening symptoms offer an immediate appointment or direct patient to the Emergency Department• Less than 30 minutes average wait time in office• Practice facilities must be wheelchair accessible, easy entry and exit from the building• AultCare to maintain a provider network that has at least 85% of practices accepting new

patients

Appointment Accessibility Standards for Behavioral Health (BH):• Routine BH appointments within 10 business days• Urgent appointments within 48 hours• Non-life threatening emergent appointments within 6 hours (to be compliant members with non-life-threatening emergencies can also directed to the ER if necessary)• Follow-up care following hospitalization for mental illness within 7 days of discharge

After Hours Accessibility Standards• 24 hours a day/7 days a week on-call coverage mechanisms directing members to access care outside practice hours; this can be accomplished with 24/7 triage services or a voicemail message directing members to the Emergency Room or to call 911 in case of an emergency after-hours AND directing members on how to access urgently needed care after-hours

Office Site Quality StandardsHere is a summary of our standards for quality of office site criteria:• Physical Accessibility and appearance including handicapped accessible• Well-lit waiting rooms• Adequate seating• Posted office hours• Adequate examination room space.

For more information on the Access & Office Site Standards, please access your provider manual on our website at www.aultcare.com. If you do not have internet access and

would like a paper copy, please contact Provider Relations at 330-363-1160 or Credentialing at 330-363-1400.

Access & Office Site StandardsA N U P D A T E O N :


National Provider Identifier (NPI) Communication• The National Provider Identifier

(NPI) is a Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard

• The NPI is a unique identification number for covered healthcare providers

• Covered healthcare providers, health plans and healthcare clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA

• Claims must be submitted based upon the information you have attested to on the National Plan & Provider Enumeration System (NPPES)

3 If there have been changes to your practice (addition of a physician, physician has left the practice, multiple locations, billing location or there has been a change to your group practice) please be sure you have updated your information on the NPPES system

3 Also, contact your vendor/clearinghouse to ensure they are using the most up to date information

• Submitting claims with NPI information that does not accurately reflect the information submitted on the NPPES system, could cause claim denials

• Please take time to review your claim submissions in regard to NPIs

AultCare wants to make you aware of some formulary changes that will go into effect 01/01/2016.

AultCare approved a formulary change for the medication Novolog Insulin . Currently, Novolog is a Brand Preferred (2nd tier) medication and it will be moved to a Brand Non-Preferred (4th tier) medication, effective January 1, 2016. It will also require a Step therapy process with no history look back.

Depending on your patients medical condition and your evaluation, you may want to consider the medication below, which is in the same class as Novolog and is a Brand Preferred (2nd tier) medication on our formulary.

• Humalog Insulin

Apidra Insulin is currently Non Preferred and will remain Non Preferred (4th tier) medication but will also require a Step Therapy Process with no history look back.

Your patients have access to Disease Management programs to help control certain aspects of their health. AultCare’s GlucoCom® program helps members manage their diabetes by monitoring their daily blood glucose readings with in-home tele-monitoring equipment. This program is free for your AultCare patients to participate in. If interested, please call 330-363-2421 to speak with a Disease Management nurse about the program.

If you have questions, please call Customer Service at 330-363-6360 or 1-800-344-8858. A customer service representative is available to assist you Monday through Friday

from 7:30 a.m. to 5:00 p.m.

Novolog® & Apidra® Step Therapy

The Silver & Fit Exercise and Healthy Aging program offers opportunities for everyone at any level of mobility. The program offers access to participating fitness clubs or exercise centers, the option to work out at home using up to 2 Home Fitness Kits per year, Healthy Aging materials (online or DVD), and other web tools like health articles, challenges and more.

If you have a member that is interested in the Silver & Fit Exercise and Healthy Aging program, please call the Prime Time Health Plan Customer Service number on page 4 of this newsletter.

We want to take the opportunity to tell you about an exciting program offered to our members

at no additional cost.

H E R E A T P R I M E T I M E H E A L T H P L A N

HEDIS® 2016: Benefit of Remote AccessIf you haven’t considered doing your HEDIS audit via remote access, here are some benefits:

Contact our Quality Specialist, Kathi Yoder at 330-363-3912 for more information on remote access for the HEDIS 2016 abstraction audit.

• Easy scheduling• No office interruptions to your daily patient care• No need for AultCare staff in your offices• No use of office laptop, copier or fax machine• Secure and confidential for PHI

> HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Provider NewsThe A publication for AultCare & PrimeTime Health Plan providers

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PERMIT #1005

A publication for AultCare & PrimeTime Health Plan providers

If you do not have an existing account, click on the button to “register for new account” then click on my dashboard and then important forms.

Prior to completing the on line enrollment, please contact your vendor/clearinghouse to discuss your interest in the 835 Electronic ERA/EFT. You may have separate enrollment requirements with them.

835 Electronic ERA/EFTO N L I N E E N R O L L M E N T I N S T R U C T I O N S

If your practice is interested in establishing electronic ERA/EFT with AultCare, please visit our website at www.aultcare.com and log in to your account.

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