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In This Issue NEW!

HealthPlus Transition – What You Need to Know ........................................................................ 2

Provider Inquiry – New Hours ...................................................................................................... 3

NICU and Special Care Nursery Admissions-Update ................................................................... 3

Inpatient Hospital Readmissions-Update .................................................................................... 3

Admissions and Observation Stay Process Nurse Review Requirements – Update ..................... 4

Partnership with Change Healthcare ........................................................................................... 4

Equian to Handle HAP High-Dollar Inpatient Claims ................................................................... 5

Submitting Appeals to HAP via Mail and Fax ............................................................................... 6

Clinical Provider Appeals ............................................................................................................. 7

NDC Drug Code Billing Requirement for Outpatient Drugs-Update ............................................ 9

Additional Option for Obtaining Diabetic Testing Supplies ....................................................... 10

Online Health Care Available 24/7 with Telehealth .................................................................... 10

Tiered Networks ........................................................................................................................ 11

Verify Member Eligibility-Update .............................................................................................. 14

HAP Health Engagement Programs .......................................................................................... 15

Medicare Outpatient Observation Notice .................................................................................. 17

Medicare Prescriber Enrollment Requirement Delayed ............................................................. 17

ACA RADV Audit ....................................................................................................................... 17

Coordination of Care ................................................................................................................. 18

HEDIS Data Collection and Medical Record Reviews ................................................................. 19

SPECIAL FEATURES

Lab Services ............................................................................................................................... 20

Updating Demographic Information.......................................................................................... 21

REMINDERS

Billing & Claims ............................................................................................................... 22

Process for Claims Adjustments ................................................................................................ 22

Covered Medicare Preventive Exams......................................................................................... 23

Clarification on Replacement (xx7) Claims Process .................................................................... 24

Provider Refund Checks ............................................................................................................. 25

Cigna Claims Submissions Process Change Reminder ......................................................... 27

Disease Management ...................................................................................................... 28

Get to Know HAP Restore ......................................................................................................... 28

Utilization Management & Authorizations ........................................................................ 29

Prior Authorization Decision Timeframes .................................................................................. 29

Utilization Management Staff Availability ................................................................................. 30

Prior Authorization for In-Home and Facility-Based Sleep Studies Programs via eviCore ......... 30

Prior Authorizations from eviCore ............................................................................................. 31

Members ......................................................................................................................... 32

Helping Members Understand Their HAP Benefits and Programs ............................................. 32

Questions about HAP? ..................................................................................................... 33

Provider Monthly Update December 2016

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NEW!

HealthPlus Transition – What You Need to Know

If you are currently a HealthPlus provider, your HealthPlus contract has been converted to a HAP contract which allows you to see HAP patients. For example:

If you had an HMO contract with HealthPlus, you can see HAP HMO members.

If you had a PPO contract with HealthPlus, you can see HAP PPO members.

If you had a Medicare contract with HealthPlus, you can see HAP Medicare members. With the transition of HealthPlus members to HAP plans, there are key items to remember. Please see the information below.

Members All remaining HealthPlus members (including Medicare HMO) will be transitioned to HAP on Jan. 1, 2017.

Referrals Existing HealthPlus referrals will terminate on Dec. 31, 2016. Primary care physicians will need to

obtain new authorizations via CareAffiliate, HAP’s online authorization system.

On Dec. 20, 2016, primary care physicians can begin entering authorizations through CareAffiliate.

HAP will ensure there is no disruption to patient care.

CareAffiliate authorization application To enter prior authorizations, simply:

1. Log in at hap.org. 2. Select Authorizations. 3. Enter your information.

You can find training manuals and other helpful resources by Authorizations-CareAffiliate Help under Quick Links or the Help link in the CareAffiliate application.

Claims All HealthPlus claims for dates of service Dec. 31, 2016, and prior should be submitted to HealthPlus as timely as possible.

Websites The HealthPlus website (healthplus.org) is currently available for member eligibility, claims status,

referral status, Explanation of Payments, etc. In the future, most content will be transitioned to hap.org.

Access to hap.org should be requested as soon as possible to avoid delays in accessing important information.

If you don’t have access to HAP’s secure portal, you can:

Register online by visiting hap.org and selecting Register Now.

Contact Provider Services at (866) 766-4708.

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Provider Inquiry – New Hours

Provider Inquiry representatives are available to help you with claims and claims appeals status, Monday through Friday, 8 a.m. to noon and 1 p.m. to 5 p.m.

HAP Professional Fee Schedule 2017 Effective January 1, 2017, HAP will maintain its current professional fee schedule for all products (HMO, Alliance Health and Life Insurance Company and HPI (Rental Network).

Please note that the 2017 PCP reimbursement for specific E&M codes will remain at 110 percent of the HAP fee schedule.

NICU and Special Care Nursery Admissions-Update

On Oct. 1, 2016, HAP began its partnership with ProgenyHealth to manage the neonatal services we cover. ProgenyHealth specializes in neonatal care management throughout the first year of life. Under our agreement, ProgenyHealth’s neonatologists, pediatricians and neonatal nurse care managers work closely with HAP members – as well as attending physicians and nurses – to promote healthy outcomes for premature and medically complex newborns. As HAP’s liaison to our contracted hospitals, ProgenyHealth provides inpatient review services and assists with discharge planning to ensure a smooth transition to the home setting. Important! Please notify HAP immediately when a newborn is admitted to a NICU or special care nursery. HAP will notify ProgenyHealth of admissions and their neonatal nurses will contact your designated staff to conduct utilization management and discharge planning throughout the inpatient stay.

Inpatient Hospital Readmissions-Update

HAP is committed to ensuring the best quality of care for its members when hospitalization is required. As such, HAP will review hospital admissions and observation stay requests for readmission at the same hospital or within the same hospital system as follows:

Effective for dates of service January 1, 2016 forward, requests for hospital inpatient admissions for HAP members that were discharged within two (2) calendar days of a hospital admission

Effective for dates of service December 1, 2016 forward, requests for observation stays for HAP members that were discharged within two (2) calendar days of a hospital inpatient admission or observation.

If it is determined that the member requires a new inpatient admission or observation within the two (2) calendar days, the new request for admission/observation may be denied as a readmission. Decisions can be appealed by following our Provider Appeals policy.

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Admissions and Observation Stay Process Nurse Review Requirements – Update HAP uses HAP-specific UM criteria instead of standard InterQual® UM criteria to review requests for observation stays and inpatient admissions for the following set of diagnoses:

• Acute kidney injury • Abdominal pain • Anemia • Atrial Fibrillation • Cellulitis • COPD

• Deep vein thrombosis • DKA • Hyperglycemia • Hypertension • Infection • Nephrolithiasis

• Osteomyelitis • Sepsis and SIRS • Syncope • Vaginal bleeding

InterQual criteria are updated on a periodic basis. However, when HAP believes InterQual criteria can be modified to better align with available evidence, we adjust our criteria. McKesson invites feedback from users, and we will share our feedback for their consideration on future releases of InterQual criteria. You will find that HAP-specific UM criteria closely align with InterQual criteria. Details of the changes, including reference to the specific InterQual sections affected, can be found in the HAP Revised Interqual Guidelines – October 2015, which is posted in the Provider Newsroom. Please note: if a nurse documents that a case is not meeting InterQual or HAP-specific criteria, the nurse must refer the case to a HAP medical director for further review. Effective December 1, 2016, HAP will review all InterQual asterisk procedures for medical necessity for inpatient requests for commercial members. We are doing this because our expectation is that InterQual asterisk procedures will typically be performed in the outpatient setting for commercial members. Please allow 15 days for pre-certifying asterisk procedures as inpatient. There is no process change to Medicare members, as we follow the CMS inpatient procedure list. If you have any questions, please contact our Admissions and Transfers team at (313) 664-8833, option 3.

Partnership with Change Healthcare

HAP has contracted with Change Healthcare to review the use of Evaluation and Management codes for all providers as part of ongoing claim review activities. Change Healthcare analyzes claims for the purpose of identifying those providers who are billing high level codes significantly more often than other providers within the same specialty. The goal is to ensure that the appropriate code(s) is billed for the clinical services provided to HAP's members Change Healthcare will provide reports and may contact your practice to request medical records with the intention of identifying any inaccurate coding and to perform one-on-one coding education to ensure your practice’s understanding of coding guidelines.

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Equian to Handle HAP High-Dollar Inpatient Claims

HAP is partnering with Equian to review high-dollar inpatient claims. Equian uses condition-specific medical and financial expertise to review hospital bills for:

Clinical appropriateness

Billing errors

Variances from industry billing practices

Equian works with the provider and HAP to determine fair payment for services to HAP members. Below is Equian’s claims review process.

1. Before payment, HAP identifies high-dollar claims. 2. HAP sends the high-dollar claim to Equian. 3. The claim is denied pending Equian’s compliance claim review. 4. Equian requests and reviews the UB-04 billing claim form and an itemized bill from the provider. 5. Equian recommends payment on the claim’s compliant line items. 6. Noncompliant line items remain denied. Equian sends the provider a detailed explanation of the

denial. 7. If the provider disagrees with the denied portion of claim, the provider follows HAP’s appeals

process.

Example: HAP receives a $250,000 claim. The claim is denied. Equian reviews the UB-04 and the itemized bill. If $10,000 of the claim is noncompliant, $240,000 is paid.

Claims resolution and appeals process An Equian claims resolution manager is available to discuss Equian’s findings. Providers will have the opportunity to submit documentation to support claims submission. This can include medical records, physician orders, and billing policies. To formally appeal Equian’s findings, documentation can be submitted via mail or email.

Equian ClaimsAdmin@equian.com Attention: Reconsiderations 300 Union Blvd., Suite 200 Lakewood, CO 80228

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Submitting Appeals to HAP via Mail and Fax

To ensure timely and accurate review of appeals, please follow the process below when mailing or faxing appeals.

Provider Appeal Type Description Submit

Claims Claims denials for code editing, modifiers, paid amount, copays, and no prior authorization, units exceeded on an authorization, etc.

Mail (only) 2850 West Grand Blvd. Attn: Claims Adjustments 2850 West Grand Blvd. Detroit, MI 48202

Medical Services Post service appeals for medical services

Fax 313-664-5904 Mail HAP Attn: Provider Appeals 2850 West Grand Blvd. Detroit, MI 48202

Prescription Services

Appealing a denied claim for a medical drug

Fax (313) 664-5338 If denial is due to no authorization, please include:

A letter of appeal with explanation of why proper authorization was not obtained

The remittance advice showing the denial of the claim

A completed Medication Request Form (found on hap.org/mrf)

Clinical information to show medical necessity

Member Appeals Pre-service appeals where the provider is appealing services or prescriptions on behalf of the member

Fax (313) 664-5866 Mail HAP Attn: Member Appeals and Grievances 2850 West Grand Blvd. Detroit, MI 48202

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Clinical Provider Appeals

HAP supports high quality health care and encourages practitioners and providers to appeal when they feel a decision is contrary to the well-being of the member. Practitioners and providers may appeal adverse organization determinations—denials—if they present additional information to support their case. While determinations in standard appeal cases are expected to be less than 30 days, medically urgent cases are processed within 72 hours. The Provider Appeal Process applies to both medical and behavioral medicine providers. The following are examples of denials that may be appealed:

Referral/Pre-certifications: Failed medical appropriateness, retroactive requests, out-of-network service, non-covered benefit

Admissions: Failed medical appropriateness, late notification, no call-in Appeals are defined as:

Administrative: requests from providers to review an adverse determination of a decision involving contract or HAP rules.

Medical: requests from a provider to review an adverse determination of a decision involving medical necessity.

Submitting appeals

For an adverse organization determination decision made by HAP: Fax: (313) 664-5904

In writing: HAP Practitioner/Provider Appeals – Mail Code 010 2850 West Grand Blvd.

Detroit, Michigan 48202

For an adverse organization determination decision made by HAP for psychiatric or chemical-dependency related decisions:

Fax: (313) 664-5905

In writing: Medical Director for Behavioral Services (Level I) Coordinated Behavioral Health Management 2850 West Grand Blvd.

Detroit, Michigan 48202

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Level 1 Appeals The practitioner/provider has forty-five (45) calendar days from the date of the denial letter to appeal HAP issued denials. All cases that do not contain clinical information will be denied, reconsiderations require providers to file a Level 2 appeal. The table below outlines the appeal type and process to follow.

Appeal Type Process

Medical 1. The Medical Director, pharmacist or designated clinical staff review the appeal. Note:

The decision maker responsible for the initial adverse determination decision cannot review the appeal.

The decision maker may consult, as necessary, with board-certified licensed physicians or other clinical professionals from the appropriate specialty.

2. Decisions are based on medical necessity.

Administrative 1. HAP staff reviews the appeals using HAP business rules. Note:

The decision maker responsible for the initial determination will cannot review the appeal.

eviCore 1. eviCore processes commercial cases only. 2. Medicare claims must be submitted to HAP. 3. Appeals are processed using their contracted timeframe of 45-days.

Note: For networks with delegated utilization management agreements, Level 1 appeals should be directed to your managed care office.

Level 2 Appeals The provider has 45 days from receipt of the Level 1 appeal to submit a Level 2 appeal. All appeals will be processed within 45 days of receipt.

Appeal Type Process

Medical 1. HAP medical directors and clinical leadership review appeals. 2. Clinical information is presented, reviewed, and a determination is made.

Administrative 1. Utilization management leadership and Provider Services review administrative appeals.

2. Facts are presented and consideration is given for extenuating circumstances that may necessitate overriding HAP policy.

Decisions from this committee are final unless provider contract dictates specific actions.

EviCore HAP processes all level 2 appeals

All determinations will be communicated to practitioners by mail. For questions regarding the appeal process, contact HAP’s Provider Inquiry department at (866) 766-4661.

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NDC Drug Code Billing Requirement for Outpatient Drugs-Update

Effective for claims with dates of service November 1, 2015 forward, all outpatient, drug-related HCPCS codes and CPT codes must be billed with the following:

National Drug Code qualifier

NDC code

Unit of measure

Quantity

This information is required for CMS-1500 and UB-04 claim forms and Electronic Data Interface transactions.

This applies to all HAP products, excluding Medicare crossover claims and claims where HAP is not the primary payer. Any claim without a valid NDC code will be rejected. Please see attached list of affected codes. In the future, you can find this list under Procedure Reference Lists when you log in at hap.org as follows:

Codes That Require an NDC

Services that Require Prior Authorization List or the DME Services that Require Authorization List (NDC will be indicated in the Key column if it is required)

Format NDCs must contain a valid 11-digit number (no spaces, hyphens or extra characters) in a 5-4-2 format. The first five digits identify the manufacturer of the drug and are assigned by the Food and Drug Administration. The other digits, which are assigned by the manufacturer of the drug, identify the specific product and package size. If an NDC is less than 11 digits, add leading zeros to the appropriate segment to create the 5-4-2 configuration. Please see table below for format details.

NDC format on label Convert to 5-4-2 format

4-4-2: xxxx-xxxx-xx 0xxxxxxxxxx

5-3-2: xxxxx-xxx-xx Xxxxx0xxxxx

5-4-1: xxxxx-xxxx-x Xxxxxxxxx0x

Submitting the NDC

Claim How to Submit

Electronic claims Follow the 5010 837 X12 standard

CMS-1500 claim form

In box 24A-24G – in the shaded portion

Enter the NDC qualifier of N4

Followed by the NDC number (see format above)

Enter one space for separation

Enter appropriate unit of measure (F2, GR, ML or UN)

Enter the quantity

UB-04 claim form

In box 43

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Additional Option for Obtaining Diabetic Testing Supplies

This fall, members received a letter about an additional option for obtaining diabetic testing supplies. HAP’s Benefit Administration Manual was also updated to reflect this information. The Abbott Freestyle line of glucose test strips will be available at participating pharmacies. No other brands will be covered at the pharmacy.

How your HAP patients can obtain diabetic testing supplies at pharmacies You can send a new prescription to the patient’s pharmacy.

The pharmacist can help them obtain a new meter and test strips that will work with their specific meter.

There is no out-of-pocket cost for FreeStyle Precision Neo strips.

They can get a matching meter at zero out-of-pocket cost.

Lancets are covered at zero out-of-pocket cost.

Other Abbott brand test strips will be available at the patient’s Tier 1 generic copay as follows:

Quantity limits For test strips and lancets, there is a quantity limit of 100 per 90 days. If your patients are currently using insulin to manage their diabetes, a higher quantity limit of 300 per 90 days will apply. If larger quantities are required, you will need to submit an authorization. Note: this applies when diabetic supplies are obtained at the pharmacy.

Online Health Care Available 24/7 with Telehealth

HAP has partnered with American Well® to bring telehealth services to our members. Beginning in January 2017, doctors will be standing by 24/7 for live, online visits.

Here’s more information about telehealth services:

For nonemergency illnesses: HAP members can see doctors for conditions such as: colds, flu, headache, sprains and strains, rashes and sinus infections, pink eye and other minor conditions.

Certain medicines can be prescribed: Based on current regulations, if it’s medically necessary, doctors can prescribe certain prescriptions.

Online visits are secure: American Well, or Amwell as its known, is a private, secure tool that’s compliant with the Health Insurance Portability and Accountability Act, known as HIPAA. It’s built for HAP members to safely and confidentially consult with a doctor online. Patient privacy and security is extremely important.

Doctors are licensed, board-certified physicians: Members can review each profile in detail and pick out the doctor best suited for them.

Average wait time is two minutes: The average wait time to see a doctor is about two minutes.

Access on all devices: Members can easily connect with doctors on their smartphone, tablet and computer.

Abbott test strip Copay

FreeStyle Precision Neo $0

FreeStyle Freedom Lite Tier 1 (generic)

Freestyle InsuLinx Tier 1 (generic)

Precision Xtra Tier 1 (generic)

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Tiered Networks

Effective January 1, 2017, HAP will have new products with tiered networks for employer groups as well as a Medicare Advantage option. With tiered networks, cost sharing amounts vary based on the provider tier where member seeks care.

“Tier 1 Providers” are network providers in the highest benefit level or least amount of patient cost share.

"Tier 2 Providers” are the network doctors and other health care professionals, medical groups, hospitals, and other health care facilities in the lowest in-network benefit level or highest patient cost share.

Details of each plan is outlined in the table below.

Plan Name and Description Tier 1 Providers Tier 2 Providers

Allegiance Tiered Access (EPA)

Self-funded product for Allegiance employer group only

Allegiance Employed Physicians

Henry Ford Physician Network

Jackson Health Network Facilities:

Henry Ford Health System

Full HAP PPO Network

Allegiance Tiered Access (PPO)

Self-funded product for Allegiance employer group only

Allegiance Employed Physicians

Henry Ford Physician Network

Jackson Health Network

Facilities:

Henry Ford Health System

Full HAP PPO Network (including Cigna)

Genesys Tiered Access (POS)

Self-funded product for Genesys employer group only

Genesys Preferred Affiliated Providers

Full HAP HMO ASO Providers

Genesys Tiered Access (PPO)

Self-funded product for Genesys employer group only

Genesys Preferred Affiliated Providers

Full HAP PPO Network

HAP Senior Plus Henry Ford Tiered Access (HMO)

For Medicare Advantage members who reside in Macomb, Oakland, or Wayne counties

Henry Ford Health System

Greater Macomb PHO

Accountable Healthcare Alliance

Ancillaries (including Behavioral Health): MA HMO Network

Facilities:

Henry Ford Health System (excluding Henry Ford Allegiance)

Full HMO MA Network

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Member Eligibility Application The online Member Eligibility Application will be updated to reflect Tier 1 and Tier 2 benefit information.

270/271 file The 270/271 file will be updated to include Tier 1 and Tier 2 benefit information as outlined below.

HAP is initiating some new benefit offerings that include tiered levels of in-network member liabilities, effective Jan. 1, 2017.

To correctly reflect benefits, HAP’s 271 real-time eligibility response transaction has been modified to message tiered copay, coinsurance, deductible, and out-of-pocket data.

Beginning Jan. 1, members with these tiered benefits may have tiered in-network copay values transmitted on the 271, for service types including but not limited to:

­ Bariatric surgery ­ Durable medical equipment ­ ER ­ Glasses/frames ­ Facility room/board ­ Medical eye exam ­ Mental health ­ Office visits for specialists and primary care physicians ­ Physician/surgeon fees ­ Substance abuse ­ Skilled nursing facility ­ Urgent care

Tier-specific wording and message segments have been added to the 271 to allow recipients to clearly identify where tiered liabilities are applicable. For each applicable service type (black is old, red is new), format will appear as follows:

EB*B*IND*98**Office Visit Specialist Co-payment*27*45~ EB*B*IND*98**Office Visit Specialist Co-payment Tier 2 Network*27*35~ MSG*Applies to Tier 2 Providers Only~

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Sample ID cards Allegiance EPA

Allegiance PPO

Genesys POS

Genesys PPO

HAP Senior Plus Henry Ford Tiered Access (HMO)

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Verify Member Eligibility-Update

It is essential that you verify member eligibility. According to your HAP contract, you must verify the eligibility of your HAP patients at each visit before you deliver services. If you fail to obtain verification we may deny claims payment. You cannot balance-bill the member. It’s also important to always make a copy of the front and back of the patient’s ID card. The back contains important contact and claims submission information.

New information Soon, you will see an update to the Member Eligibility application that includes Tier1 and Tier2 benefit information as well as copay and deductible information.

How to verify eligibility and benefits There are two options for verifying a member’s eligibility. Both options are available 24 hours a day, 365 days a year. There is no limit on the number of members you can verify. You can:

Call the Provider Automated Service line at (800) 801-1766

or

Use the online application at hap.org ­ After you log in, select Member Eligibility ­ You can search for up to 10 members at a time ­ If you can’t find the member using his or her ID number, try searching by last name using the

magnifying glass icon

Note: If you are unable to retrieve the required benefit information and/ or have a discrepancy with the information provided, please send an email to: PI_benefitdiscrepancy@hap.org. (If you don’t receive an immediate acknowledgement, please confirm you have entered the correct email address).

Allow up to 24 hours (one business day) for a response

If the patient is in the office, please mark your email “URGENT”

An overview of the Member Eligibility application is included with this communication. You can also find it in the application under Help.

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HAP Health Engagement Programs

Aspire and Achieve Programs HAP’s Health Engagement Program rewards members for making healthy choices by saving them on their out-of-pocket costs. There are two separate programs under Health Engagement:

Aspire: participation-based and rewards employees who make attempts to improve their health

Achieve: outcomes-based and rewards employees who achieve specific health goals Members in either option must see a HAP-affiliated primary care physician or approved specialist (Cardiologist, Endocrinologist, OB/GYN, Geriatric Specialist only) to complete and submit their Member Qualification Form (MQF) that attests to their healthy lifestyle or efforts to achieve this status.

Health Engagement Reminders We cannot fail participants for not meeting a wellness target identified on their MQF. For example:

- If a member’s blood pressure was above the lifestyle target and they are taking medicine to help control it, they should receive points.

We must offer reasonable alternatives to participants if they are unable to meet a wellness target identified on their MQF which includes: - Allowing the participants to work with their physicians to develop their own alternatives - Contacting HAP’s Customer Service to discuss all programs that are available

There are no time restrictions for completing the treatment plan

Member Qualification Form Information about reasonable alternatives is on the form

Instructions for completing the form are on the back

Online form submissions will receive $30 reimbursement

Faxes are still acceptable but will not receive reimbursement

Use code 99080 when billing

Reward Your Health

To address market demand for programs that support wellness, promote behavior change and allow for a high level of administrative ease for insured members, providers and employers, HAP is offering a new health engagement program—Reward Your Health (RYH). This is a one-tier plan, designed to drive health behavior changes and biometric improvements through incentives and targeted wellness programs.

Overview of Reward Your Health Form is downloaded by or emailed to member upon registration for the program

Member visits their PCP for a preventive visit

PCP completes and faxes the Reward Your Health Results Form

Physicians will receive $15 reimbursement for faxed forms

Use CPT code 99199 when billing

Biometric data from the form is digitally imported into the member’s health assessment

Rewards/incentives are triggered by HAP for the member to receive based on employer funding preferences

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Reward Your Health Sample Form

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Medicare Outpatient Observation Notice Per the NOTICE Act, hospitals and Critical Access Hospitals must deliver the Medicare Outpatient Observation Notice to any beneficiary (including Medicare) who receives observation services as an outpatient for more than 24 hours. To see the final rule, please visit www.federalregister.gov.

Medicare Prescriber Enrollment Requirement Delayed

Any physician or other eligible professional who prescribes Part D drugs must either enroll in the Medicare program or opt out in order to prescribe drugs to their patients with Part D prescription drug benefit plans. CMS previously announced that enforcement of the prescriber enrollment requirement would begin on February 1, 2017. While CMS is committed to the implementation of the prescriber enrollment requirements, CMS also recognizes the need to minimize the impact on the beneficiary population and ensure beneficiaries have access to the care they need. To strike this balance, CMS will implement a multifaceted, phased approach that will align full enforcement of the Part D prescriber enrollment requirements with other ongoing CMS initiatives. Full enforcement of the Part D prescriber enrollment requirement will begin on January 1, 2019.

ACA RADV Audit

A requirement of the Affordable Care Act is Risk Adjustment Data Validation audits. The purpose of the audit is to verify the overall health conditions for each member that were used in determining the member’s eligible risk score. The member’s risk score was derived from health conditions documented in your medical records and reported on claims through diagnosis codes. In July, the Centers for Medicare and Medicaid Services sent a patient list to HAP. Based on this data, you may be selected to provide medical records for HAP patients identified on the sample list. HAP has contracted with CIOX Health to retrieve medical records. CIOX will contact provider offices to schedule the review and coordinate the medical record retrieval. As a HAP-contracted provider, you are required to allow HAP or its designee access to medical records. Watch for updates on the ACA RADV Audit in future monthly updates and in the Provider Newsroom when you log in at hap.org. We sincerely appreciate your cooperation and we will work with you to minimize disruption in patient care activities.

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Coordination of Care

A primary focus of our core values is to promote patient-centeredness as not only part of our quality initiatives, but because it’s the right thing to do. Each year, we participate in the Centers for Medicare & Medicaid Services Medicare member satisfaction survey—Medicare Advantage-Consumer Assessment of

Healthcare Providers and Systems also known as MA-CAHPS. The patient experience data collected from this survey can help enhance the services we provide and support our shared commitment to continuous process improvement.

Performance rating CMS uses MA-CAHPS results and data from several other sources, such as HEDIS® clinical measures, to evaluate plan performance and to assign Star ratings. Health plans receive a Star rating between one and five. Our goal is to achieve an overall 5-Star rating—the highest achievement. How members rate their physician and physician office experience in the following measures is critical to attaining a 5-Star rating:

Follow up on their test and X-ray results

Discussing all the prescription medications they are taking

Managing and coordinating their care and services among different providers You are already providing outstanding care to your HAP patients. The dialogue between physician and patient is critical to high patient satisfaction and CAHPS survey results. This impacts Medicare 5-Star ratings for the health plan.

Helpful reminders about the conversations to have with your Medicare patients When you are entering information into the patient’s EMR, let them know what you are doing and

why.

Does your patient exercise regularly or take part in physical exercise? Encourage them to start or improve.

Do they sometimes fall or have problems with balance or walking? If yes, suggest that they: – Use a cane or walker – Check their blood pressure while lying down or standing – Participate in an exercise or physical therapy program – Have a vision or hearing test

Emphasize that your patient has care coordination. Use this phrase if possible. Explain to them that you coordinate their care with specialists and hospitals through an electronic medical record, faxes and phone calls.

Ask if they use a computer and encourage them to subscribe to your system’s online medical records tool. This will help them view their test/lab results, send you a message, make appointments and more.

Ask them their preferred means of communication.

Confirm how you will follow up with them regarding test results.

Confirm if they are taking all of their prescribed medications as well as any supplements.

If they need help coordinating their care, offer your office’s assistance.

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HEDIS Data Collection and Medical Record Reviews

Quality improvement and performance assessment continue to be important expectations in today’s health care environment. Health plans, physicians, hospitals and other health facilities are all linked by activities designed to improve care outcomes and facilitate patient and consumer decisions.

Data collection More than 90 percent of health plans measure performance on various aspects of care and service using

the Healthcare Effectiveness Data and Information Set. HEDIS data collection and reporting are mandated by the federal Centers for Medicare & Medicaid Services. HEDIS incorporates standardized processes to capture medical record information combined with claims-based data elements.

Medical record review HAP has contracted Public Health Sciences to perform HEDIS medical record data abstraction in physician offices. The abstraction process will begin in early January 2017 and continue through early May 2017. Prior to the on-site review, PHS will contact your office to schedule a visit and distribute information to explain the data collection process. We may also ask your office to send copies of chart components via mail or fax for in-house review. The role of PHS is covered by HIPAA, which ensures that your patients’ protected health information will remain confidential and protected. If you have any questions regarding the medical record review process, please contact HAP’s Provider Services department at (866) 766-4708.

HEDIS 2016 Frequently Asked Questions

1. What is HEDIS? HEDIS is a standardized set of performance measurements developed by the National Committee for Quality Assurance to evaluate how well a health plan is performing in key areas: quality of care, access to care and member satisfaction with the health plan and providers.

2. Does HIPAA allow me to release records to HAP’s contracted medical record reviewer? Yes. As a HAP-contracted provider, you are permitted to disclose PHI to HAP’s medical record reviewer, Public Health Sciences. Under the HIPAA privacy rule, a signed consent from the member is not required for you to release the requested information.

3. Is my participation in HEDIS data collection mandatory? Yes. Participating providers are contractually required to provide medical record information so that we can fulfill our regulatory obligations.

4. Should I allow a record review for a member who is no longer with HAP or for a deceased member? Yes. Medical record reviews may require data collection on services obtained over multiple years.

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5. What is my office’s responsibility regarding HEDIS data collection? You and your office staff are responsible for responding in a timely manner to the PHS medical record reviewer’s request for medical record documentation. The reviewer will contact your office to establish a date for either on-site, fax or mail data collection. A patient list will be faxed to you so the requested medical records can be made available for the appointment or for submitting the documentation to PHS.

6. How should I provide the records to the PHS medical record reviewer? The reviewer will schedule an on-site review at your location, access the medical records via remote access to your electronic medical record system (preferred) or ask that you fax or mail the information to them. The methodology chosen will depend on the volume of records being requested from your office.

SPECIAL FEATURES

Lab Services

Specific lab tests can be performed in the physician’s office. Any lab tests not performed in the PCP or specialist’s office must be sent to a Joint Venture Hospital Laboratory (JVHL). Below are some important facts about JVHL:

The JVHL network is comprised of over 120 hospital-affiliated laboratories committed to providing managed care plan members and participating physicians with convenient, high quality and efficient laboratory services.

JVHL is the exclusive capitated HMO laboratory for HAP products.

JVHL participates in all of HAP’s product lines, including HAP, HAP Preferred, Inc., and Alliance Health and Life Insurance Company, along with HAP Medicare Advantage plans.

Capitation applies to Commercial HMO and POS products.

The capitation agreement includes outpatient and reference laboratory services.

JVHL does not participate in Professional pathology-Blood products/transfusion – RSD. The servicing provider must bill HAP directly.

JVHL coordinates BRCA testing for HAP HMO members (excluding members assigned to Genesys, Henry Ford Medical Group and U of M).

To find a list of approved in-office lab codes for PCPs and specialists, log in at hap.org and select Procedure Reference Lists under Quick Links and then Lab Services List. Providers are responsible to obtain prior authorization for certain lab services. Please check the Services that Require Prior Authorization list under Procedure Reference Lists. Failure to obtain prior authorization may result in claims denial. To locate a list of JVHL service centers, please visit www.jvhl.org or call (800) 445-4979.

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Updating Demographic Information

Make sure that members have access to up-to-date information in our online provider directories. Please notify HAP immediately if you have any changes in your practice or facility. To quickly verify your demographic information:

Visit hap.org; select Find a Doctor/Facility

Search for your name You can submit changes as follows:

To Change or Update Contact

Provider name

Address

Phone number and fax number

Email address

Practitioner area of practice and specialty changes

Practitioner leave of absence updates

NPI changes

Changes to “accepting new patients” status

Removal of a provider from the HAP provider directory

credentialing@hap.org

If you have changes in your W-9 name, W-9 billing address or Tax ID Number, you can

Email: IS_BCT_vendor@hap.org

Fax: (248) 443-7761

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REMINDERS

Billing & Claims

Process for Claims Adjustments

To eliminate duplication and ensure a more efficient, timely means of resolution, please use one of the options below when appealing claims. Important: Please do not fax claims appeals and do not submit medical records.

1. Call HAP’s Provider Inquiry department at (866) 766-4661

Available Monday through Friday from 8 a.m. to noon and 1 p.m. to 5 p.m.

Please have the following information available when calling: - Provider Name - Provider NPI - Provider Tax Identification Number (TIN) - Member’s Name - Date of Service - Total Amount Billed

2. Use HAP’s online claims application for claims adjustments. Simply:

Log in at hap.org

Select Claims

Search for the claim(s) that you wish to appeal

Select from one of three options:

Option Use when

Appeal- referral appeal

Claims and authorizations do not match

Payment Amount-Underpayment

You think HAP did not pay the appropriate amount for a claim based on your contracted rates

Payment Amount- Overpayment

You think HAP paid you too much for a claim per your contracted rates

Include the required information in the notes section:

Reason for submitting appeal/adjustment request

Contact name

Phone number

Email address (add this in the notes field)

Note:

For any appeals that do not fall into one of the options above, please select option 2—Payment Amount-Underpayment

If “Ineligible” displays in the column “Request Appeal,” contact Provider Inquiry at (866) 766-4661

We appreciate your cooperation in adhering to this process.

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Covered Medicare Preventive Exams

HAP covers the Medicare preventive exams identified below when billed with the appropriate code.

Covered Exam

Appropriate Code to Bill

Initial Preventive Physical Examination (IPPE). Also known as the “Welcome to Medicare” visit for new Medicare beneficiaries who are within the first 12 months of their Medicare Part B coverage. This is a one-time benefit.

G0402

Annual Wellness Visit. With a personalized prevention plan of service (PPS), initial visit G0438

Annual Wellness Visit. With a personalized prevention plan of service (PPS), subsequent visit

G0439

Note: Routine examinations (CPT codes 99391-99397) are not covered or reimbursed by Medicare or HAP.

For more information about the covered exams, see below. For more information about Medicare Preventive Services, visit www.cms.gov.

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Clarification on Replacement (xx7) Claims Process

Professional replacement billing should be used when there are data changes to a claim which would result in additional payment or corrections to the claim. To ensure proper payment, please follow the process outlined below.

Resubmit the entire claim

Include the original HAP claim number

Enter 7 in box 22 on the CMS-1500 or field 4 – Type of Bill on the UB-04 HAP will:

Deny the original claim

Make full payment on the new replacement claim Example:

Original Claim Replacement Claim

Lines and procedure Units Outcome Lines and procedure Units Outcome

1.99213 1 Paid* 1.99213 1 Paid

2.81000 1 Paid* 2.81000 1 Paid

3.81003 1 Paid* 3.81003 1 Paid

4.81005 1 Paid* 4.81005 1 Paid

5.72486 1 Paid* 5.72486 2 Paid

Important For reconsiderations on a claim outcome with no update or change in data, you can:

Contact HAP Provider Inquiry at (866) 766-4661 OR

Follow the online Claims Adjustment process (see process in this document)

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Provider Refund Checks

If you discover an overpayment, please contact the Provider Inquiry department at (866) 766-4661. If HAP has not already identified the recovery, you may either request that HAP initiate the recovery or remit payment to HAP using the attached spreadsheet. All refunds for HAP and Alliance Health and Life Insurance Company business can be sent to:

HAP Attn: Accounts Receivable 2850 W. Grand Blvd. Detroit, MI 48202

In the event of an overpayment, providers are expected to promptly refund HAP the amount overpaid or contact HAP to inquire if HAP has already identified the overpayment. By doing so, providers can avoid potential MSP demands, HAP initiated claim recoveries on future payments or other collection efforts. By law, providers are obligated to refund overpayments involving Medicare and other carriers. Please forward this information to your billing department and/or billing company. Note: For HAP Preferred business, please contact the TPA listed on your Explanation of Pricing.

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Patient

Name

Patient

HAP ID #

Date of

Service Claim #

Overpayment

Amount Reason for the Refund

Return form to:

HAP

Attn: Accounts Receivable

2850 West Grand Blvd.

Detroit, MI 48202

PROVIDER REFUND REPORT

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Cigna Claims Submissions Process Change Reminder

Cigna customers have access to the HAP Preferred network in 20 counties in Michigan. Effective January 1, 2016, please submit all claims for these patients directly to Cigna using Payor Code 62308. Any claims submitted directly to HAP will be rejected with error code 116 – Claims Submitted to Incorrect Payor. You will need to resubmit your claims to Cigna. Claims submitted to Cigna are subject to HAP and Cigna claim edits.

How to submit claims electronically to Cigna

Cigna strongly encourages you to submit claims electronically, including coordination of benefits (COB) claims. Using Cigna Payer ID 62308, there are two options to submit claims electronically:

1. Post-n-Track® - The Post-n-Track Web service is available at no cost to health care professionals that participate in the Cigna network. To enroll in this Web service, call (860) 257-2030, or visit Post-n-Track.com/Cigna.

2. Other EDI vendors - A list of electronic data interchange (EDI) vendors and transactions that Cigna supports are available at Cigna.com/EDIvendors. If you have questions about transactions submitted through your EDI vendor, please contact the vendor directly.

How to submit paper claims to Cigna

Although electronic filing is recommended, Cigna will maintain a process for submitting paper claims. You can find the appropriate address to submit claims on the back of the Cigna customer’s ID card. Please note that new ID cards for these Cigna customers will be issued in the coming months. Below is a sample copy of the new Cigna customer ID card.

We appreciate the care you provide to Cigna’s customers.

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Disease Management

Get to Know HAP Restore

HAP’s Restore program is designed to help our members with chronic conditions better manage their own health and make sure they’re getting the best care possible at all times. HAP Restore helps in more ways than one because it’s made up of three different, highly effective programs: CareTrack® Disease Management, Restore Case Management and Comfort & Palliative Care. Here is a quick look at each of these free programs.

Restore CareTrack Disease Management Restore CareTrack helps members manage their chronic conditions by providing resources that encourage smart choices. The purpose is to help them keep their prescribed treatment plans. To achieve that, a nurse health coach works closely with each member. The CareTrack program includes:

Telephone coaching to give encouragement and support

A three-month condition management teaching program

Medication monitoring

Monitoring for behavioral and emotional triggers relative to the treatment plan

Health reminders for screenings and tests

Members age 18 and older qualify for CareTrack if they are high risk with any of the following conditions:

Asthma (Members five years old and older with asthma are included)

COPD

Coronary Artery Disease (CAD)

Diabetes

Heart failure CareTrack also addresses the following as co-morbid conditions to the above:

Depression

Hypertension

Obesity

Restore Case Management This innovative program assists members requiring intensely focused care coordination due to complex conditions and those transitioning from one care setting to another. In order to minimize return visits to the hospital or emergency room, the program helps these members understand the requirements of their health status. It also helps reduce any barriers that might interfere with the services they need. An RN from HAP will work closely with each member’s health care provider to ensure the member is getting the right care when it’s needed, including:

Navigating through the local health care system

Scheduling tests, procedures and appointments

Addressing medical, therapeutic and polypharmacy issues

Secure home care, medical supplies and durable medical equipment when needed

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Restore Comfort & Palliative Care The Restore Comfort & Palliative Care program is a pre-hospice program for members with end-stage terminal conditions. It provides in-home health care services that combine both curative and palliative treatment options. Members have access to care 24 hours a day, seven days a week. The goal is to support the member through their terminal illness, while reducing the need for repeated emergency room visits and inpatient hospitalizations and to eventually transition care to hospice services when appropriate. Referring a member to any of the Restore programs is easier than ever. If you know of or are treating a HAP member who would benefit from additional assistance or for more information about any of HAP’s Restore programs, call (800) 288-2902 or email Restore@hap.org. To refer a member to the Comfort and Palliative Care program, call (313) 664-8324. Utilization Management & Authorizations

Prior Authorization Decision Timeframes

With the implementation of CareAffiliate, prior authorization decisions have not changed and will be provided as follows:

Non-urgent pre-service requests: A decision will be provided as quickly as the clinical condition warrants, not to exceed 15 calendar days, or 14 calendar days for Medicare Advantage members.

Urgent pre-service requests: A decision will be provided within 72 hours of receipt of the request.

Post-service decisions (retrospective review): A decision will be provided within 30 calendar days of the request.

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Utilization Management Staff Availability

For utilization management inquiries, HAP staff is available by telephone as follows:

For HAP Department Contact Information

Admissions

Transfers

Inpatient Review

Skilled Nursing Facility

Rehab

Admissions Team 24/7; 7 days per week

(313) 664-8833

Outpatient Authorizations and Services

DME

Homecare

Home Infusion

Hospice

Referral Management Team

Monday – Friday 8:00 a.m. – 4:30 p.m.

(313) 664-8950

Case management Case Management Monday – Friday 8 a.m. – 5 p.m.

(313) 664-8476

Pharmacy Services Pharmacy Monday – Friday 8:00 a.m. – 4:30 p.m.

(313) 664-8940

Behavioral Health Services Coordinated Behavioral Health Management (CBHM)

Monday – Friday 8 a.m. – 5 p.m.

(800) 444-5755

Prior Authorization for In-Home and Facility-Based Sleep Studies Programs via eviCore

Prior authorization is required for in-home and facility-based sleep studies for HAP HMO, HAP POS, Alliance Health and Life Insurance Company, and Medicare Advantage members. (Note: Genesys-assigned HAP HMO and POS members are excluded from this process).

Requesting a prior authorization

Both ordering physicians and rendering facilities can initiate a prior authorization request from eviCore. In-office procedures are not allowed. Ordering physicians may request studies to be performed only at HAP-contracted sleep study provider offices/facilities. There are three ways to request an authorization:

Fax: (888) 693-3210. Fax forms are available online or by calling the number below. Only MedSolutions fax forms are accepted.

Phone: (855) 736-6284 Monday through Friday, 8 a.m. to 9 p.m. (EST)

Online: medsolutionsonline.com Decisions on a routine prior authorization request will be processed within three (3) business days after receipt of the necessary information.

Resources and questions Criteria and request forms are available at evicore.com. If you have any questions or need additional information, please contact the eviCore Customer Service department at (855) 736-6284.

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Prior Authorizations from eviCore

Cardiac imaging, musculoskeletal procedures, radiation therapy and high-tech radiology services

The above procedures require clinical review and prior authorization from eviCore. Prior authorization is not required for:

Echocardiography, echo stress tests, radiation oncology and radiation therapy for HAP members who are under 18 years of age. Please see the Services that Require Prior Authorization List under Procedure Reference Lists when you log in at hap.org. A signifier of “AGE” will be next to the code.

Certain add-on codes found in the cardiology, musculoskeletal management and radiation therapy programs. For updates, see the Services that Require Prior Authorization List under Procedure Reference Lists when you log in at hap.org.

Requesting prior authorization

The most efficient way to obtain authorization from eviCore is at evicore.com. It’s important to have the patient’s chart available so that you can easily provide the following:

Insurance information

Member information (name, ID number, DOB)

Ordering physician information (name, address, TIN/NPI)

Servicing provider information (name, address where test is to be performed)

CPT and ICD-10 codes

Symptoms

Results of previous studies

Complete clinical information. This will minimize the need for further review by an eviCore clinical nurse or medical director.

You can also obtain prior authorization by phone at (888) 564-5487. Initial requests for authorization are no longer accepted by fax.

Notify HAP of the admission and discharge date

You need to notify HAP of the admission and discharge dates or your claim could be rejected. You can easily enter this information online. Log in at hap.org and select Authorizations and then Status. Following this process will help ensure efficient and timely processing of your prior authorization requests.

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Members

Helping Members Understand Their HAP Benefits and Programs

At HAP, it is our goal to continually educate our members about their health plans and to make them easy to use and understand. Since your patients frequently ask you questions about their benefits, we wanted to provide you with a guide that will help you help them. In addition to information on HAP’s website, new members receive a member kit when they enroll with us. The kit includes a member handbook, Notice of Privacy Practices, contact information for the member’s Personal Service Coordinator and more. Reliable information about your HAP patients’ health plans is always available at hap.org. When members register at hap.org, they have access to a wide variety of information. You can direct your HAP patients with questions to specific areas of the site, depending on their needs, as listed in the following chart:

hap.org Site Tab

Information Members Will Find

My Plan Authorizations for the last three years

Benefits coverage, deductible and out-of-pocket information

Claims and explanation of benefits (EOB) from the last three years

Contracts, benefit guides and riders

Coordination of Benefits information

My Health and Wellness

Health services and screenings that are overdue or due within the next two months

iStrive® for better health: Members can take a health risk assessment or participate in healthy lifestyle programs

Find a Doctor/Facility

Search for a doctor or facility

My Prescription Coverage

The member’s prescription history from the last 18 months

Copays, medication side effects and generic options

Members can also find information on:

Accessing care

The role of the personal care physician (PCP)

OB/GYN care

Member rights and responsibilities

Exclusive programs and services that focus on their health and well-being (i.e., weight management, smoking cessation, etc.)

Valuable discounts and extras on health and wellness-related activities through HAP Advantage

Downloadable forms, newsletters and educational brochures If your HAP patients have questions about their benefit coverage, you can refer them to this information on our website or to the Customer Service phone number on the back of their ID card.

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Questions about HAP?

You can always call us at (866) 766-4708 for more information. We also have the following information posted online at hap.org. If you prefer a hard copy, call the number listed above and we will mail it to you.

Affirmative statement about UM incentives

Clinical practice guidelines updates

Complex case management

Coordination of Care between Behavioral Health and Primary Care Providers

Covered and non-covered benefits

Credentialing information

Disease management services

Evaluation of medical technology

HAP’s policy for making an appropriate practitioner reviewer available to discuss any utilization management denial decision and how to contact a reviewer

Member rights and responsibilities

Network limits

Pharmacy procedures and formularies

Privacy and HIPAA information

Quality management program

Utilization management criteria