PROVIDERNewsletter

GEorGIA | 2013 | ISSUE II�

Provider SatiSfaction Survey WellCare Health Plans, Inc. continues to focus efforts on the experiences of both our members and providers. In order to better understand and remain well informed about our valued provider network, we conducted the Provider Satisfaction Survey again in 2012. The survey concentrated on a variety of subjects including call center/member services, provider relations, continuity/coordination of care, provider network, utilization and quality management, finance issues, pharmacy and drug benefits, and overall satisfaction and loyalty.

As in 2011, extensive reviews of our 2012 survey results are under way to ensure that our focus is aligned with the needs of our providers. Current areas of focus include enhancing provider services at the local level, claim processing and issue resolution, enriching administrative tools/capabilities and a renewed emphasis on quality. The Provider Experience team is continuously engaged with several cross-functional teams working on these initiatives, and others that are aimed at better serving our providers. We anticipate incremental gains on several initiatives in 2013 and continued improvement beyond. Stay tuned as these efforts will be further communicated as the year progresses.

Very shortly, WellCare will again conduct a Provider Satisfaction Survey. This follow-up survey will be used to measure progress from last year’s effort to better evaluate how we can become more effective and productive business partners.

Your participation is encouraged – and appreciated – as together we strive to positively impact our members’ overall quality of care.

reminder… Cosmetic procedures are a covered benefit only when determined to be medically necessary. These services require clinical review to determine that they are being provided for the improvement and restoration of bodily function and not solely for the improvement of the patient’s appearance and/or self-esteem.

Provider reSourceS

Web reSourceS

Visit www.wellcare.com (Medicare) or georgia.wellcare.com (Medicaid) to access our Preventive and Clinical Practice Guidelines, Clinical Coverage Guidelines, Early and Periodic Screening, Diagnosis and Treatment (EPSDT) documents, Pharmacy Guidelines and other helpful resources. Providers may also request hard copies of any of the above documents by contacting their Provider relations representative. For additional information, please reference your Quick reference Guide at www.wellcare.com/ Provider/QuickReferenceGuides.

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remember to check messages regularly to receive new and updated information. Visit the secure area of www.wellcare. com (Medicare) or georgia.wellcare.com (Medicaid) to find copies of the latest correspondences. Use the area on the right labeled “Member/Provider Secure Sign-In,” then click on the Provider tab. You will see Messages from WellCare located in the right-hand column.

additional criteria available Please remember that all Clinical Coverage Guidelines, detailing medical necessity criteria for several medical procedures, devices and tests, are available via the provider resources link at www.wellcare.com/Provider/CCGs.

2012 Quality imProvement HigHligHtS The WellCare of Georgia, Inc. Quality Improvement (QI) program is an ongoing, comprehensive and integrated system that exists to actively initiate, monitor and evaluate standards of health care practice and infrastructures essential to the delivery of quality clinical care and service to enrolled members.

HigHligHtS from tHe 2012 Qi Program include: • Achieved Commendable NCQA status for Health Plan Accreditation

• Initiated local quality strategy that includes member-centric approach to improved health outcomes and member engagement in care

• Inventoried all initiatives related to HEDIS®

improvement action plans and focused on removing barriers to increase scores

• Visited and reminded providers of the importance of follow-up appointments for members receiving attention deficit-hyperactivity disorder (ADHD) medications

• Enhanced Appointment Timeliness initiative

• Achieved 98 percent compliance on 2012 External Quality review (EQr)

• Created new data sets that monitor the communication between behavioral and medical case management, thus enhancing the continuity and coordination of care

• Sustained provider compliance with Clinical Practice Guidelines for the last two years

• Enhanced Geographical Access reporting to communicate more comprehensive coverage within Georgia

• recorded statistically significant increased member satisfaction for:

– Ease of appointment setting with specialists

– Getting information/help from Customer Service

– Being treated with courtesy and respect by Customer Service staff

– rating of health plan

– Customer Service as a whole

• Improved coordination of care between hospitals and providers by advocating for enhanced discharge planning communication

• Completed face-to-face visits with providers to discuss their HEDIS rates

• Decreased the amount of balance-billing member complaints

• Sustained increase in Planning for Healthy Babies participation

our goalS for 2013 include: • Increase HEDIS scores to meet and then exceed

expectations set by the Department of Community Health (DCH)

• Continue to provide focused education for members and providers about EPSDT/Health Check, lead screening and immunizations

• Continue to focus our attention, through case and disease management, to those members who have been diagnosed with diabetes and asthma

• Continue to monitor compliance with preventive health and clinical practice guidelines through medical record review

• Increase efforts to work with community agencies to improve the care of our members

• Increase focus on sound data analysis, including identification of barriers and development of meaningful and effective interventions

• Investigate, analyze, and follow up on QI action planning for key composite areas found to be highly correlated with overall health plan satisfaction

• Develop specific plans and interventions to improve HEDIS outcomes

• Improve key member and provider satisfaction levels

• Increase enrollment in Planning for Healthy Babies Program (P4HB)

• Collaborate with external health plans to analyze issues surrounding emergency room utilization

• Show statistically significant improvement within performance improvement projects

• Aid in the transition of insourcing behavioral health care

• Plan onsite chart reviews to identify and educate providers on missed opportunities for compliance with HEDIS and EPSDT reporting

• Develop and enhance work plan template to be utilized in all applicable WellCare markets

• Continue to distribute provider incentives for HEDIS services

To receive a copy of our QI program description, please fax a request to the QI Department at 1-877-277-1810.

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eSPdt HealtH cHeck medical record revieW reSultS Q4 2012 The Georgia Department of Community Health (DCH) requires WellCare to perform Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Health Check Medical record reviews (Mrr). According to DCH specifications for the Mrr, medical records and providers audited under the Mrr are selected on a quarterly basis using a true random sample. WellCare must obtain a random sample of 120 EPSDT claims (visits coded as 9938x or 9939x with the EP modifier) from the previous quarter to be used as the basis for the current quarter’s charts and specific visit records for review. The selection of records is truly random, so high volume practices may expect a review more frequently.

The fourth quarter report was submitted December 30, 2012, to DCH and the results are as follows:

• of the 27 measures, only two (Standardized Developmental Screen at 75 percent and Standardized Autism Screen at 75 percent) did not meet the 80th percentile required for EPSDT measures.

• For the fourth reporting period in a row, WellCare and its providers have an overall compliance score of 95 percent or greater.

• Eighteen of the possible 27 measures scored at or above the 95th percentile and six measures scored 100 percent.

addreSSing deficiencieS In the past, individual providers were given Corrective Action Plans (CAPs) for indicators which did not meet the required 80th percentile. Now, the CAPs will be handled by WellCare as a whole.

Standardized develoPmental Screen Developmental screenings are required at ages 9 months, 18 months and 30 months. The documentation in the medical record must include all of the following: a note indicating the date on which the test was performed, the standardized tool used and evidence of a screening result or screening score. Per WellCare’s contract with DCH, this screening must be accomplished using one or more of the following recommended standardized developmental screening tools:

• Ages and Stages Questionnaire (ASQ) – 2 months to 5 years

• Ages and Stages Questionnaire – 3rd Edition (ASQ-3)

• Battelle Developmental Inventory Screening Tool (BDI-ST) – birth to 95 months

• Bayley Infant Neuro-developmental Screen (BINS) – 3 months to 2 years

• Brigance Screens-II (BS II) – birth to 90 months

• Child Development Inventory (CDI) – 18 months to 6 years

• Infant Development Inventory (IDI) – birth to 18 months

• Parents’ Evaluation of Developmental Status (PEDS) – birth to 8 years

• Parents’ Evaluation of Developmental Status – Developmental Milestones (PEDS-DM)

NoTE: It is important to note that standardized tools specifically focused on one domain of development [e.g. child’s socio-emotional development (ASQ-SE) or autism (M-CHAT)] are not included in the list. The screening is anchored to recommendations related to global developmental screening using tools that identify risk for developmental, behavioral and social delays.

Standardized autiSm Screen required at ages 18 months and 24 months or any time parents raise a concern. This screening is performed with an autism-specific screening tool. The M-CHAT is one such tool that is free and downloadable. Visit www.dbpeds.org for more information.

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Wellcare iS noW core PHaSe i and ii comPliant

WellCare Health Plans, Inc. is pleased to announce that as of January 1, 2013, we are Phase I and II compliant per the CAQH®

Committee on operating rules for Information Exchange® (CorE) guidelines.

The CorE objectives are designed to make it easier for physicians and hospitals to access patient insurance information before or at the point of care. CorE operating rules are streamlining eligibility, benefits and claims data by allowing providers to submit a request – using the electronic system of their choice – to obtain a variety of coverage information for any patient and from any participating health plan. Providers will receive more consistent and predictable data regardless of health plan.

CorE Phase I and II compliance enhancements include the ability to provide you with more detailed co-pay and coinsurance information for multiple services, including:

• Professional office visits

• Emergency services

• Hospital inpatient

• Hospital outpatient

To learn more about CAQH and the CorE initiative, please visit www.caqh.org.

diSeaSe management – imProving memberS’ HealtH Disease Management is a free, voluntary program that assists members with specific chronic conditions. Members are assigned a Disease Nurse Manager who can help the member with:

• Education and understanding of his/her specific condition

• Identification of adherence barriers and ways to overcome them

• Individualized life modification suggestions to improve daily life

• Self-management of his/her condition to improve health outcomes

• Motivational coaching for encouragement with the struggles along the way

• Improved communication with his/her primary care provider and health care team

Disease Management can assist your members with the following conditions:

• Asthma

• Chronic obstructive Pulmonary Disease (CoPD)

• Congestive Heart Failure (CHF)

• Coronary Artery Disease (CAD)

• Diabetes

• Hypertension

• obesity

• Smoking

For more information, or to refer a member to Disease Management, please refer to your Quick reference Guide at www.wellcare.com/Provider/ QuickReferenceGuides.

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cmS medicare Quality and Performance Star ratingS PhaRmaCy Quality measuRes CMS gauges plans’ performance via multiple quality and performance measures to allow beneficiaries to make informed decisions about their health care. We want to provide you with the specific list of quality measures that CMS evaluates and ask that you help us keep our members on track.

adHerence A member is adherent if the proportion of days covered (PDC) is greater than 80 percent for a particular class of medications.

This is defined by the member having continuous medication coverage (determined by pharmacy days’ supply claims) greater than 80 percent of the plan year starting from the first fill of the medication.

Adherence is reported as three separate measures:

• Diabetes medications:

– Biguanides, sulfonylureas, thiazolidinediones and DPP-IV inhibitors

• Hypertension medications:

– ACE inhibitors, ArBs, direct renin inhibitors

• Cholesterol medications:

– Statins

• Members are allowed to switch medications within a class and remain adherent

diabetic PatientS not on an ace/arb Diabetic patients (those identified as having a claim for a diabetes medication) not currently on an ACE inhibitor, ArB, or direct renin.

uSe of HigH-riSk medicationS Members 65 years or older with at least two fills for a high-risk medication. Most common high-risk medications include:

• Zolpidem/zaleplon

• Glyburide

• Cyclobenzaprine/carisoprodol

• Promethazine

• Hydroxyzine

• Amitriptyline

• Digoxin (doses > 125 ug)

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2013 Q2 Provider formulary uPdate Updates have been made to the Medicare Formulary. The most up-to-date complete formulary can be found at www.wellcare.com/medicare/medication_guide.

For more information regarding WellCare of Georgia’s pharmacy utilization management policy/procedures, please refer to the Medicare Provider Manual available at www.wellcare.com/provider/Providermanuals.

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HoW caSe management can HelP you Case Management helps members with special needs. It pairs a member with a case manager. The case manager is a nurse or licensed clinical social worker who can help the member with issues such as:

• Complex medical needs

• Solid organ and tissue transplants

• Chronic illnesses such as asthma, diabetes, hypertension and heart disease

• Children with special health care needs

• Lead poisoning

We’re here to help you! For more information about Case Management, or to refer a member to the program, please call us at 1-866-635-7045. This no-cost program gives access to a registered nurse (rN) or licensed clinical social worker (LCSW) Monday through Friday from 8 a.m. to 5 p.m.

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Wellcare Working WitH georgia PartnerSHiP for teleHealtH WellCare of Georgia, Inc. is proud to announce a new service that will enhance the ability of our members in rural communities to access the health care services they need.

WellCare is working with the Georgia Partnership for TeleHealth, Inc. (GPT), a charitable nonprofit corporation. GPT was formed to promote improvements in health care and health care facilities in rural and underserved communities throughout Georgia by establishing telemedicine programs.

Telemedicine makes it possible for members in remote locations to receive specialty services without traveling long distances. By leveraging technology, patients can connect with doctors using video technology at a site close to the member’s home.

WellCare’s partnership with GPT will provide our members access to one of the most comprehensive telemedicine networks in the nation, with over 200 specialists covering 40+ specialties throughout the state of Georgia. This will enable patients in remote locales to access care easier and earlier, thus reducing the instances – and associated physical and financial costs – of untreated health care problems.

GPT will give you another option when coordinating specialty care for your patients in remote areas. Members will be instructed to contact their physician to gain access to telemedicine services. To minimize the impact on you and your staff, WellCare does not require authorization for referrals to TeleHealth specialists. Physicians can refer their patients to a telemedicine specialist by completing the Intake Form located at georgia.wellcare.com/ provider/telemedicine. Forms should be submitted by fax to GPT at 1-912-285-0938.

For further information regarding GPT, including a list of participating providers and presenting sites, please visit the GPT website at www.gatelehealth.org or contact your Provider relations representative.

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Secure Provider Portal – benefitS of regiStering our secure online Provider Portal offers immediate access to an assortment of useful tools. Providers can create individual sub-accounts for staff member’s use, if needed.

All providers who create a login and password using their WellCare Provider Identification (Provider ID) number have access to the following features:

• Claims submission status and inquiry: Submit a new claim, check the status of an existing claim, and customize and download reports.

• member eligibility and co-payment information: Verify a member’s eligibility and look up specific co-payments.

• authorization requests: Submit authorization requests, attach clinical documentation and check authorization status. You can also print and/or save copies of authorization forms.�

• training: Take required training courses and complete attestations online.

• Reports: Access reports such as active members, authorization status, claims status, eligibility status and more.

• Provider news: View the latest important announcements and updates.

• Personal inbox: receive notices and key reports regarding your claims, eligibility inquiries and authorization requests.�

HoW to regiSter • Please visit www.wellcare.com/registration/provider to register. After registering, make sure to retain your login

and password information for future reference.

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2013 Q2 Provider formulary uPdate Updates have been made to the WellCare of Georgia Preferred Drug List. Please visit georgia.wellcare.com/ provider/pharmacyservices to view the current preferred drug list and pharmacy updates.

For more information regarding WellCare of Georgia’s pharmacy utilization management policy/procedures, please refer to the Medicaid Provider Handbook available at georgia.wellcare.com/provider/resources.

member medical record reQueStS WellCare of Georgia, Inc. would like to remind our provider network that contractual requirements state that a copy of the member’s medical record is made available, without charge, upon the written request of the member or authorized representative within 14 calendar days of the receipt of the written request. The medical records are to be furnished at no cost to a new PCP, out-of-network provider or other specialist, upon member’s request, no later than 14 calendar days following the written request.

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PSycHological teSting for medicaid memberS

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Thank you WellCare Medicaid behavioral health providers for your continued collaboration to provide health care to our members after the establishment of our own comprehensive behavioral health network on January 1, 2013. WellCare continues to educate providers on specific processes for the management of covered services as part of our integrated behavioral health program implementation. our recent webinar educated providers on WellCare’s authorization process for psychological and neuropsychological testing and reviewed the Clinical Coverage Guidelines for these services.

The psychological and neuropsychological testing form is required for the psychological testing authorization process. The form was revised January 2013 and is available at georgia.wellcare.com/formsanddocuments.

Key requirements on the form include:

• Complete all fields of the form with specific clinical information regarding diagnosis (both mental and physical health) and member/family health history

• List the dates of evaluation and treatment with any behavioral health provider

• record the dates of record review, rating scales and previous psychological testing

• List, in detail, the specific questions to be answered with testing that could not be answered with a comprehensive bio-psychosocial assessment, observation in therapy, or an assessment for level of care at a mental health or substance abuse facility; and

• Provide specific tests to be administered and the duration of each test.

For more information, please visit WellCare’s website to review the following helpful resources:

• Georgia Psychological Testing 2013 Provider Training Presentation (located on the secure Provider Portal)

• WellCare’s Clinical Coverage Guideline for Psychological and Neuropsychological Testing

• Guidelines for reviewing Psychological and Neuropsychological Testing.

If you have questions or feedback, please contact your Provider relations representative.

We’Re just a Phone Call oR CliCk aWay!

WellCare of Georgia, inc. medicare: 1-866-334-7730 | www.wellcare.com

medicaid: 1-866-231-1821 | georgia.wellcare.com

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GA021425_Pro_NEW_ENG State Approved 03152013 ©WellCare 2013 GA_02_13