A publ icat ion for the Kaiser Permanente of Georg ia a ff i l ia ted communi ty network

Network NewsFALL 2008

KP Online-Affiliate is Here for YouT

hanks go out to all of you for your support in

our roll-out of KP Online-Affiliate.

Since this initiative is still in its early stages, we

want to take this opportunity to focus on referrals,

since they are an integral part of the KP Online-

Affiliate program. Below are some key points to

help you answer some frequently asked questions.

What You Need to Know About KP Online-Affiliate Claims and Specialty Referrals

For HMO Plan Members:

• HMO members have always had to have

referrals to see specialty providers.

• A referral in KP Online-Affiliate is required for

payment of all specialty office visits.

• Referrals are not required for Ob/Gyn, dermatology,

ophthalmology, optometry and behavioral health

providers.

• Kaiser Permanente has new referral guidelines:

Specialty referrals are now good for 270 days

(nine months) and default to six visits.

For Multi-Choice Plan Members:

• Multi-Choice members do not require a referral.

You do not need to generate referrals in

KP Online-Affiliate.

• Primary care physicians are encouraged to provide

guidance when members need specialty care. Their

out-of-pocket costs will be lower with Tier 1 specialists.

• Authorizations are required for procedures and

services on the Targeted Review List. These should

be requested via KP Online-Affiliate.

For Specialty-to-Specialty Referrals (HMO

Members):

• Members needing specialty care should be

referred by their primary care physician to the

appropriate specialist.

• In the coming months, we will be instituting a

new policy limiting specialty-to-specialty referrals.

We will contact you directly with clarifying details.

How Can Members Get Help With TheirReferrals?

• Members and physicians that need to request a

new referral or update ongoing referrals will need

to contact the member’s primary care physician.

• Primary care physicians can assist members in

updating specialty office visit referrals by entering

a referral into KP Online-Affiliate.

Questions about KP Online-Affiliate? We’ve got answers!Call the KP Online-Affiliate Telephone Help Line @ 1-877-240-1433

>> learn more on page 3

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Network News - Fall 2008 2

Clinical Guidelines Coming On-lineK

aiser Permanente updates each clinical guideline every

two years. These updates will be posted on KP Online-

Affiliate soon. We will be highlighting the most recent changes,

made quarterly, in hopes that you will review these to support

your practice.

The most recent updates will include those for ADHD, Chronic

Kidney Disease, Diabetes, Depression and the Pediatric

Immunization Schedule. Also, new to the national guidelines

are three clinical practice resources: Chronic Pain (long term

opoid therapy for adults), Chronic Pain (screening and

assessment) and Urology (standardizes hematuria evaluation).

To request a copy, please contact Kristen Berger by calling

404-364-4885.

Supporting Network Providers with the SMART® Registry

T

he SMART® Registry, a

Healthy Solutions tool to

help physicians better manage

chronic patients, was distrib-

uted in September 2008.

The Registry provides data

about patient demographics,

diagnoses and utilization; and

information on whether gaps

exist in recommended evi-

dence-based clinical care.

Chronic conditions identified

include diabetes, coronary

heart disease, heart failure,

asthma, chronic obstructive

pulmonary disease and co-

morbid hypertension. The

Registry identifies whether or

not patients are currently in

contact with a Healthy

Solutions Health Coach.

New to the Registry are med-

ication persistence rates,

which provide the percentage

of usage for dispensed med-

ications, specifically

ACEI/ARBs, lipid lowering

agents and beta blockers.

Physicians can use the

Registry to refer appropriate

patients to Healthy Solutions,

Kaiser Permanente’s health

coaching service.

For more information about

Healthy Solutions and the

SMART® Registry, please

contact Kristen Berger at

404-364-4885.

K

aiser Permanente’s Total Health Assessment

(THA) is a dynamic tool that includes a health

risk assessment (HRA); a completely confidential,

online survey designed to help members understand

the relationship between their behaviors and their

health. THA also links members to our free Healthy

Lifestyle tools.

Another valuable aspect of our THA is that Kaiser

Permanente members can choose to have their

HRA results integrated into their KP HealthConnect

electronic medical record and shared with their

primary care physician.

Make sure to let your patients who are Kaiser

Permanente members know about THA. They can

access THA by visiting www.kp.org and clicking on

the “My Health Manager” section.

It’s that easy!

Better Health is a Click Away!

K

aiser Permanente has a

closed formulary.

Providers should adhere to

the Kaiser Permanente

formulary.

The formulary can be accessed by

visiting the Provider Web site at

http://providers.kp.org/ga.

The non-formulary exception process is

explained in depth in your Provider

Manual, found online.

Kaiser PermanenteDrug Formulary

A

ll Kaiser Permanente medical

records departments are cen-

tralized in one convenient loca-

tion. You should send consultation

reports to the fax numbers listed

at the end of this article. Please

continue to use the specific fax

number given to you if your office

or facility was contacted directly.

When consultation reports are

received, they will be scanned

into the patients’ electronic med-

ical record (EMR). Please include

the member’s name, date of birth

and medical record number

(MRN) on all correspondence

sent to Health Information

Management Systems (HIMS).

The physicians in your office have

view-only access to members’

EMR via KP Online-Affiliate,

which contains medical record

information from visits to Kaiser

Permanente medical offices, as

well as consultation reports sent

to our HIMS department.

Network News - Fall 2008 3

O

n September 1, Kaiser Permanente launched

our self-funding program. You may have

already seen the new member ID cards (they are

green) carried by these members.

In addition, a link to the self-funded program Web

site is now live on the home page of the provider

Web site. You should go here first to check

eligibility and benefits for self-funded members and

view claim information for self-funded members.

You may also call 1-866-800-1486.

If you are unsure whether a member is self-fund-

ed, this can be determined in KP Online-Affiliate by

clicking on “Demographics/Eligibility” and then

“Benefits” to display the member’s plan.

Please send self-funded claims to the following

address:

PLEASE NOTE: Do not send claims for Kaiser Permanente

members that are not self-funded to this

address. Your claims will be returned if you

do so.

Self-Funding Program Update

Claims Information Now Available on KP Online-AffiliateC

laims information is now available in KP Online-

Affiliate. To access this feature, click on the

“Claims” tab on the left side toolbar. Only claims

received since August 15, 2008, will be viewable

through this system.

To search for claims for a particular physician, select

a date range, select the provider’s name from the

drop down box and click “Search by Provider.”

To search for claims for the entire group, select a

date range and click “Search by Vendor.” A list of

claims will display. You can view details by clicking

on the claim ID.

In order to search for claims pertaining to a specific

member, select that member using “Patient Search”

and then click on the “Claims” tab on the left side

toolbar.

You can always refine a search by selecting a specif-

ic date range and either search by provider, vendor

or member. Once the search is complete, to view

details on a specific claim, click on the claim ID. A

detailed report will display.

In the coming months, the Claims detail view will

change to provide additional information in an easier

to read format.

We hope you enjoy these additional features on KP

Online-Affiliate!

>> continued from page 1

KPIC, Self-Funded Plan Administrator

P.O. Box 30547

Salt Lake City, UT 84130-0547

EDI: Payor ID 94320

Centralized Address for Kaiser Permanente Medical RecordsSpecialty Fax Numbers:

Behavioral Health 1-866-480-8082

Cardiology 1-866-401-2508

Home Health/SNF 1-866-402-4315

Hospitals 1-866-401-2503

Nephrology 1-866-840-5816

Opthamology 1-866-840-5811

Orthopedics 1-866-840-5812

Radiology 1-866-401-2502

Urology 1-866-840-5815

Don’t see your specialty above?

Fax your documents to

1-866-840-5818 or call us at

770-496-3686.

T

he newly-introduced Cardiovascular Disease

(CVD) Management Program gives Kaiser

Permanente members with diabetes and certain

cardiovascular-related diseases: an interdisciplinary

team of clinicians to help members live with and

manage their chronic conditions.

Launched this summer, the program is available for

members meeting specific criteria relating to cardio-

vascular conditions and Type 2 diabetes (see crite-

ria below). It pairs qualifying participants with a

team of nurse practitioners, clinical pharmacists and

licensed practical nurses who work with members

to help them best manage their conditions.

Teams are based out of each of Kaiser

Permanente’s 15 medical centers in metro Atlanta

and offer a variety of appointment types, ranging

from one-on-one visits to group sessions. Team

members work closely with a member’s primary

care physician (PCP), updating on the member’s

progress.

In addition, team members help program partici-

pants navigate Kaiser Permanente’s existing

resources designed specifically for

diabetes and cardiac conditions.

This program replaces the Pharmacy

Cardiac Risk Service (PCRS) and

aspects of the previous Diabetes

Program. All of the diabetes classes

and access to nutritional services are

still available.

All Kaiser Permanente members

meeting the program’s specific

criteria will be contacted about this

program. There is no need for you

to refer patients into this program.

We look forward to working with our

contracted PCPs through the new

CVD Management Program!

Network News - Fall 2008 4

KP Introduces CVD Management Program

CVD Management Program Criteria

Members with Diabetes

• Newly diagnosed with diabetes (within 6 months), OR

• A1c between 7.0-9.0% on 2 or more medications and/or

including insulin, OR

• LDL>99 mg/dL and <130 mg/dL

Members with Coronary Artery Disease

(without diabetes)

• LDL>99 mg/dL

Members with Heart Failure

(not included in above diabetes & CAD criteria)

• Heart failure with a risk score between 5 and 10 on

Impact Pro

Standards for Medical Record DocumentationK

aiser Permanente’s NCQA sur-

vey is scheduled for 2010. To

continue our efforts for survey readi-

ness, we are introducing a more

defined medical record documenta-

tion review process.

This process is a result of several

months of diligent work, and the

2006-2007 medical record docu-

mentation audits, which revealed

many opportunities for improvement.

In order to meet standards (CMS,

NCQA and Kaiser Permanente),

our goal is to achieve 90 percent or

better in medical records documen-

tation review.

An updated copy of the medical

records standards will soon be avail-

able online via KP Online-Affiliate.

You may also contact Evon Smith,

RN, at 404-364-7387 to request a

copy.

Also, see your provider manual for

information regarding our policies

on the confidentiality, availability

and organization of members’

medical records.

Diagnosis Coding: Hierarchical Condition CategoriesY

ou should code chronic systemic illnesses at

every patient visit and revise the diagnoses as

often as necessary. Maximizing face-to-face encoun-

ters throughout the year will ensure that the medical

record is a true reflection of your patient’s clinical

picture.

When submitting claims or requesting referrals

via KP Online-Affiliate, you should include the

following:

• Accurate diagnosis code(s) should be included

on all referral requests

• Report all diagnoses during the visit when

submitting claims

• Old MI should be coded in addition to CAD if

there is a history of an acute MI

• The medical cause of the fracture should

be identified (osteoporosis, metastatic, etc.)

• History of cancer codes should be used if there

is no active treatment (including radiation,

chemotherapy, surgery)

• Diabetes diagnosis should be as specific as

possible: i.e., Type 1 or Type 2, Controlled or

Uncontrolled. Manifestations should also be

documented—renal, vascular, neurologic, etc.,

and supported with data in the note, labs,

procedures or symptoms.

I

n an effort to adhere to state and federal

regulatory guidelines, Kaiser Permanente has

standardized our method for reviewing

billing practices.

We perform audits on claims data to detect and

categorize potentially anomalous billing patterns.

You may be contacted so that we can perform a

medical records review.

The review process is intended to ensure that

medical record documentation is adequate and

code assignments (e.g. ICD-9, CPT and

HCPCS) are appended accurately according

to both federal and state regulations.

As we move forward with the medical record

review process, we ask that you and your staff

cooperate with any requests for medical record

documentation.

We at Kaiser Permanente rely on our partnership

with you to provide quality health care to our

members. We will continue working with you to

make sure we are serving our members and

community to the best of our ability. If you have

any questions, please e-mail Tyrone Whitted at

Martinez.T.Whitted@kp.org.

Review of Billing Practices

Diagnosis Coding Required on Radiologyand Lab OrdersEffective immediately, you are now required

to submit diagnosis code(s) when submitting

orders for radiology and lab services

performed at Kaiser Permanente medical

offices.

Reminder: Timely Filing LimitKaiser Permanente has a standard timely filing

limit of 90 days from the date of service. Claims

submitted after this limit will be denied. Per the

terms of your contract, you are not permitted to

seek reimbursement from members for charges

denied due to untimely filing.

NDC Coding ClarificationProviders filing claims on UB-04 claim forms do

not need to include NDC coding to accompany

specific drug-related HCPCS codes for drugs.

Our article in the Spring Network News still

applies to all other providers filing CMS - 1500

claims forms.

Corrected ClaimsYou can now submit corrected claims via EDI.

You must indicate the claim has been

corrected or it may be denied as a duplicate

claim. Contact your EDI vendor or our Claims

department for detailed instructions on

submitting corrected claims.

Network News - Fall 2008 5

Network News - Fall 2008 6

Persistence of Beta-blocker Treatment after a Heart AttackP

atients treated for acute

myocardial infarction (AMI)

usually receive care from multi-

ple physicians during their hospi-

tal stay. During the post-hospital

visit, it is the primary care physi-

cian’s (PCP) role to coordinate

ongoing care for these patients.

One important component to

address during this visit is the

benefits and the need for long

term beta-blocker use. These

benefits are well-established and

patient understanding can help

to improve medication compli-

ance.

To assist PCPs in providing evi-

dence-based quality care to their

patients following AMI, we will

send a letter to PCPs when their

patient(s) have been discharged

with a diagnosis of AMI. We

request that you consider—if not

already done at discharge—

initiating long-term beta-blocker

management. If there is a history

of a contraindication or intoler-

ance to a beta-blocker that pre-

vents initiation, please document

this in your chart.

Persistence of beta-blocker

treatment after a heart attack is

one of the HEDIS (Healthcare

Effectiveness Data and

Information Set) quality metrics

used by NCQA (National

Committee for Quality

Assurance) to measure and

rank the quality of medical care

provided by health plans. It is

also used by health plans to

measure and rank the quality of

care provided by physicians to

their patients.

Your continued support in

providing quality care to our

Kaiser Permanente members

is appreciated. Please contact

George Kawamura, MD, assis-

tant to the Chief of Ambulatory

Medicine, if you have any

questions or require additional

information. Dr. Kawamura can

be reached by calling 770-931-

6147 or sending an e-mail to

george.kawamura@kp.org.

RSV Therapy Available at Kaiser PermanenteR

espiratory Syncytial Virus (RSV)—the

leading cause of serious lower-respiratory

tract infection in children—season in Georgia

starts in November and ends in late March.

Kaiser Permanente offers RSV prophylaxis

with palivizumab (Synagis) during the peak RSV

season for infants and children who are at

high-risk of serious complications from RSV

disease. Prophylaxis begins one month prior to

the onset of

RSV season

and ends as

RSV dis-

ease activity

is waning.

Synagis is a

monoclonal

antibody

given to

high risk

infants and

children

under two

years of age

during the

RSV sea-

son.

The medication is given as an intramuscular

injection every four weeks.

Synagis is given to Kaiser Permanente

members at a single clinic site, which will be held

on alternate Saturdays at the Kaiser Permanente

Gwinnett Medical Office throughout the RSV

season. Clinics will be held beginning Saturday,

Sept. 27, and will run through Saturday, March

28. The only exception to receiving medication

at the clinic are children on home ventilators for

whom special arrangements may be made.

You may refer a patient for evaluation for

Synagis clinic by completing the Synagis clinic

referral form in KP Online-Affiliate or completing

a paper referral form, which can be found on the

Provider Web site (http://providers.kp.org/ga),

and faxing to 770-496-3405.

All referrals are reviewed by the medical

director of Kaiser Permanente Synagis clinic then

forwarded to clinic nursing staff. Your patient will

be contacted by the clinic staff for the initial

Synagis clinic appointment. If you have any

questions, call 770-496-3482. If your patients

have any concerns, they may contact the Kaiser

Permanente Synagis clinic staff at 770-677-6211.

Network News - Fall 2008 7

KP, Piedmont Healthcare Contract News

K

aiser Permanente’s contract with longtime community partner

Piedmont Healthcare has been expanded, effective July 1, 2008.

The contract allows most members to utilize services at Piedmont

Hospital, Piedmont Fayette Hospital and now Piedmont Mountainside

Hospital and Piedmont Newnan Hospital.

The expanded contract covers inpatient and outpatient services, and applies to members of Kaiser

Permanente’s commercial health benefit plans. Piedmont Healthcare is one of the state’s largest health-

care systems.

Grady Health System Receives $5 Million Gift from KP

K

aiser Permanente recently gave a $5 million gift to

Grady Health System to improve access to care

for the uninsured and to support its trauma services.

The gift will fund the care of 1,000 low-income unin-

sured patients with chronic illnesses; purchase a fleet

of 10 new “green” ambulances and equipment for

Grady’s Level I Trauma Center.

“As a non-profit health plan, Kaiser Permanente

understands and appreciates the important safety net

role Grady has in our community. Grady is the largest

safety net hospital in Metro Atlanta serving many of

those most in need. We at Kaiser Permanente want to

do our part to help it continue to serve as such a vital

resource,” said Peter Andruszkiewicz, president of

Kaiser Permanente of Georgia.

In addition to this Grady contribution, Kaiser

Permanente is donating $1.5 million to smaller safety

net organizations in metro Atlanta. The organization

also has a program that offers subsidized health insur-

ance for uninsured, income-eligible persons.

A portion of the $5 million gift to Grady Healthy System

will purchase a fleet of 10 “green” ambulances like the

one seen above.

Important News about Diabetes Eye Exams

D

iabetes is the leading cause of blindness in

the United States. High blood sugar can

damage blood vessels in the retina, and when

they are damaged, they can leak fluid or bleed,

causing the retina to swell and form deposits.

This is an early form of diabetic retinopathy called

background retinopathy.

Please remind your Kaiser Permanente patients

with diabetes that it is very important to see their

eye doctor at least once a year to have a dilated

retinal exam performed to detect signs of

retinopathy. The cost for this exam is a copay-

ment based on a member’s individual benefit

plan.

For a list of the Kaiser Permanente contracted

eye care providers, please have your Kaiser

Permanente patients visit kp.org or contact Kaiser

Permanente Customer Service at 404-261-2590.

Network News is a quarterly

publication for the Kaiser

Permanente of Georgia affiliated

community network.

Please send questions and comments

to ga.provider-relations@KP.org

Editorial Board/Contributors

Editor

Tatyana Kelly

Layout/Design

Billy Auer

Kaiser Foundation Health Plan of Georgia, Inc.

Nine Piedmont Center

3495 Piedmont Rd. N.E.

Atlanta, GA 30305-1736

Kim Barbero

Kristen Berger

Barbara Brown

Debra Carlton, MD

Juanita Cone, MD

Bethany Connor

Cheryl Earls

Donna Edwards

Linda Fox

Steve Giller

Henrietta King

Patricia Lewis

Earl Thurmond, MD

Anne Whitlock

Harold Wittcoff, MD

Kaiser Permanente Names New PresidentP

eter Andruszkiewicz has been named the president

of Kaiser Permanente of Georgia. After serving as

interim president since April, 2008, Andruszkiewicz has

worked collaboratively with the Health Plan leadership

team, the Southeast Permanente Medical Group, Inc.

and the Region’s board of directors in addressing a

number of key issues.

Selected after a national search, Andruszkiewicz has

more than 25 years of experience as a senior executive

in the health care industry. His breadth of experience

makes him an outstanding choice to continue in his role as regional president.

Andruszkiewicz joined Kaiser Permanente in 2005 and has served in a number

of executive capacities in national accounts. His work in the Regions Outside

California (ROC) include managing health plan operations and driving perform-

ance improvement in six ROC regions that serve more than 2.3 million mem-

bers. He had a key role in efforts to improve health plan capabilities and to

leverage technology investments. He also helped build a stronger relationship

between Marketing, Sales, Service and Administration and the regional presi-

dents and executive medical directors.

Before joining Kaiser Permanente, Andruszkiewicz spent 18 years with CIGNA

HealthCare, most recently as senior vice president of Middle Market Segment.

In addition, he served for four years as chief marketing officer at Blue Cross /

Blue Shield of the National Capitol Area, Washington, D.C.

Peter Andruszkiewicz

PRESORTED

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MARIETTA, GA

PERMIT NO.523