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A Reflection on 2016 and a Look Forward to 2017
Now that we have almost a year of experience working with closely with Aspirus Arise to close gaps in care, improve patient outcomes, and serve our friends and neighbors, I spent time evaluating what we did well and how we can get better next year.
Over the last year we worked together with our insurance partners, Aspirus Arise, to expand our population health management capabilities to the commercial insurance market. As a result, Aspirus Care Coordinators and Health Resource Team members are now providing additional services to many of our patients who are in need of chronic condition management or are facing complex issues. As we continue to monitor these programs and I believe our joint efforts will continue to improve the health of our patients.
The development and deployment of these population health management programs were made possible by merging numerous sources of data in a way that allows us to offer additional health care resources to those who need it the most. While the technical task of bringing this data together is complete, we are learning more every day. As we learn more about the health of our patients and their patterns for utilizing health care, we will undoubtedly have data-driven action items to follow-through on next year.
Currently, the most important action-item item that we can do on a day-to-day basis is to work with Aspirus Arise members to ensure they receive as many services as possible from Aspirus clinicians. When an Aspirus Arise member receives care outside of Aspirus it causes delays or creates a substantial information gap about our patient's medical condition. Ultimately, these delays and gaps inhibit our efforts to target resources to those who need the most assistance in a timely fashion. Additionally, our patients with Aspirus Arise coverage will likely face negative financial consequences if they receive care elsewhere that we can provide here at Aspirus. In the next year, we will continue to work with Aspirus Arise to identify areas where our patients are utilizing care elsewhere in an effort to learn more about how we can improve the patient experience here at Aspirus.
We had a great first year working with Aspirus Arise! Moving forward our efforts will be focused on providing clinicians with data-driven solutions aimed at improving the care we provide to our friends and neighbors.
Sincerely,
Dr. Renee Smith
Renee Smith MD
Interim Executive Director and Chief Medical Officer
Aspirus Network Inc.
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Prescription Drug Program Updates Go Into Effect January 1, 2018
Information regarding our Prescription Drug Program can be found on our website under the
Aspirus Arise Drug Formulary
page. Specifically, you can access:
- Our Drug Program Policy, which includes how the formulary is developed and maintained, the prior authorization program, how to pursue an exception, and information on generic substitution and quantity limits
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The Drug Prior Authorization List, which identifies the applicable medications as well as who to contact to initiate the process. The current Drug Prior Authorization List can be found
here. Please note that prior authorization has been extended to all injectable chemotherapy (most chemo already requires prior authorization) and antiemetics such as Aloxi and Emend.
- Specialty drug approval policies
- Formulary/Preferred Drug List
FORMULARY/PREFERRED DRUG LIST CHANGES FOR JAN. 1, 2018
Preferred Drug List Additions*
Estring
Phoslyra
Velphoro
Preferred Drug List Exclusions with Alternatives
Drug names listed in CAPITALS are BRAND NAME DRUGS. Drug names listed in lowercase are generic drugs.
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Preferred Drug List Exclusion
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Preferred Alternatives
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ACIPHEX SPRINKLE
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esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole, NEXIUM Packets
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ACTOPLUS MET XR
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pioglitazone-metformin, metformin, pioglitazone
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AZASAN
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azathioprine
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BASAGLAR KWIKPEN
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LANTUS/SOLOSTAR, LEVEMIR/FLEXTOUCH, TOUJEO SOLOSTAR, TRESIBA FLEXTOUCH
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BUTRANS
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fentanyl patch
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CONDYLOX 0.5% GEL
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podofilox, imiquimod
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EPINEPHRINE AUTO-INJECTOR (by A-S Medications, Impax & Lineage)
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EPINEPHRINE AUTO-INJECTOR (by Mylan), EPIPEN, EPIPEN JR.
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FEMRING
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estradiol patches, estradiol tablets, yuvafem, ESTRACE Cream, ESTRING, PREMARIN Cream, PREMARIN Tablets
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FML S.O.P.
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dexamethasone sodium phosphate, fluorometholone, prednisolone sodium phosphate, LOTEMAX
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FORTEO
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alendronate sodium, ibandronate sodium, risedronate sodium, zoledronic acid, TYMLOS
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FOSRENOL
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sevelamer, PHOSLYRA, VELPHORO
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KALBITOR
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FIRAZYR
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LAZANDA
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fentanyl citrate lozenges
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NEUPOGEN
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GRANIX, ZARXIO
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NEVANAC
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bromfenac sodium, diclofenac sodium, ketorolac tromethamine, ILEVRO, PROLENSA
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OXYCODONE HCL ER
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hydromorphone er, morphine sulfate er, oxymorphone hcl er, HYSINGLA ER, NUCYNTA ER, OXYCONTIN
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PRADAXA
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ELIQUIS, XARELTO
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PRED MILD
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dexamethasone sodium phosphate, fluorometholone, prednisolone sodium phosphate, LOTEMAX
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PREVACID SOLUTAB
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esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole, NEXIUM Packets
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PRILOSEC SUSPENSION
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esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole, NEXIUM Packets
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PROCTOFOAM-HC
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hydrocortisone-pramoxine, pramcort
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PROTONIX SUSPENSION
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esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole, NEXIUM Packets
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RENAGEL
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sevelamer, PHOSLYRA, VELPHORO
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SANDOSTATIN LAR/ DEPOT
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SOMATULINE DEPOT
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SIGNIFOR LAR
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SOMATULINE DEPOT
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SUMAVEL DOSEPRO
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sumatriptan injection
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TEKAMLO
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amlodipine, amlodipine-valsartan, benazepril, lisinopril, losartan, telmisartan-amlodipine
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TIMOPTIC OCUDOSE
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timolol, betaxolol, levobunolol, ALPHAGAN P, COMBIGAN
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TREXALL
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methotrexate
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TRULANCE
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AMITIZA, LINZESS
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TUSSICAPS
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hydrocodone-chlorpheniramine, promethazine w/codeine
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ZORVOLEX
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diclofenac potassium, diclofenac sodium
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If you would like a copy of this information, please contact our Provider Contact Center at 888-711-1444.
*May be subject to prior authorization requirements.
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Viscosupplement Coverage Reminder
In our Summer 2017 issue, we shared the change in coverage for viscosupplementation. That has resulted in questions regarding prior authorization of the service. Because the service is
no longer covered, we don't advise providers to submit prior authorization. Prior authorization requests for the following will be returned as not approved:
Viscosupplement injections including, but not limited to:
- Hyaluronan or derivative
- Euflexxa
- Gel-one
- Gel-syn
- Genvisc 850
- Hyalgan
- Hymovisc
- Monvisc
- Orthovisc
- Synvisc
- Synvisc-One
- Supartz
Note: Although injections, aspirations and biopsy of large joints such as knee, hip, shoulder and other limb joints does not require prior authorizations, coverage of and the need for prior authorization of
the substance being injected should be verified.
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Provider Manual Revised for 2018
In the first quarter of 2018, please watch our website for our updated 2018 Provider Manual with new information you need to know. Our Provider Manual is designed and produced for our
preferred providers to promote a clear understanding of our policies and procedures, including provider services, prior authorizations, claims, and eligibility. Preferred providers are required
to participate, cooperate, and comply with the program as outlined in this Provider Manual.
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Coordination of Care is Crucial Among Behavioral Health and Primary Care Practitioners
Coordination of care among providers is a vital aspect of good treatment planning to ensure appropriate diagnosis, treatment, and referral. The importance of communicating with the customer's other health care practitioners cannot be overstated. This includes primary care practitioners (PCPs) and medical specialists, as well as behavioral health practitioners.
Coordination of care is especially important for customers with
complex medical care needs and those referred to a behavioral health specialist by another health care practitioner. All practitioners should obtain the appropriate permission from these customers to coordinate care among behavioral health and other health care practitioners at the time treatment begins.
We expect all health care practitioners to have a mechanism in place to:
- Discuss with the customer the importance of communicating with other treating practitioners
- Obtain a signed release from the customer and file a copy in the medical record
- Document in the medical record if the customer refuses to sign a release
- Document in the medical record if you request a consultation
- If you made a referral, transmit necessary information; and if you are furnishing a referral, report appropriate information back to the referring practitioner
- Document evidence of clinical feedback (i.e., consultation report) that includes, but is not limited to:
- Diagnosis
- Treatment plan
- Referrals
- Psychopharmacological medication (as applicable)
With this collaborative approach, we can achieve excellent coordination of care and help improve health outcomes.
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Radiology Benefit Management Updates
We continue to use NIA Magellan (National Imaging Associates Magellan), an accredited leader in the management of outpatient radiology benefits in the utilization management (UM) process. Updated NIA Radiology guidelines become effective in January 2018. Please be aware that ASO groups may have different prior authorization guidelines, which can be verified by calling Provider Services at 800-332-3297.
As of Dec. 4, 2017, providers can preview the complete set of the updated 2018 advanced imaging clinical guidelines through the RadMD portal prior to the implementation date of Jan. 2, 2018. You can continue to view all the current guidelines by accessing your RadMD account.
Highlights of the guideline changes to be implemented in January 2018 are as follows:
Global change to applicable guidelines
- A follow-up study may be needed to help evaluate a patient's progress after treatment, procedure, intervention, or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested. This was moved from the "Additional Information" section to be included as an approvable indication.
PET scan (oncology) guideline
- Clinical indications were added to cover an oncological Gallium 68 Dotatate PET/CT scan.
Cardiac guidelines (Heart (Cardiac) CT, Heart (Cardiac) MRI, Stress Echo, TTE, TEE)
- Clinical indications added to several of our cardiac guidelines to address valvular heart disease, supported by JU Doherty et al, ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2017 Appropriate Use Criteria for Multimodality Imaging in Valvular Heart Disease, JACC, 2017.
On Dec. 4, 2017, NIA will place a link on RadMD so that you can preview the complete set of the 2018 advanced imaging clinical guidelines prior to their implementation on Jan. 2, 2018; follow the instructions below. Meanwhile, you can continue to view all your current guidelines by accessing your RadMD account.
To access the link on RadMD, please follow these steps (sign in is not required):
- Go to the RadMD home page at radmd.com
- Click on the Solutions tab from the home page's main menu bar
- From the Solutions drop-down list, click on Advanced Imaging
- Click on the link for Preview of NIA's 2018 Standard Guidelines, listed under the Document section.
- The Table of Contents begins on page 3 of the PDF document
- Click once on the study to be viewed
- To return to the Table of Contents, click on "TOC" in the upper right-hand corner above the heading of each guideline
Remember, effective Jan. 2, 2018, NIA will replace the current clinical guidelines with the updated 2018 version.
Check your RadMD portal and our website for additional information, coming soon.
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Quarterly Medical Policy Updates
The Medical Policy Committee met this quarter and approved the medical policies due for annual review. The policy updates were emailed to providers Oct. 30, 2017, and we have included them in this issue for your convenience.
Please be sure all doctors, other clinical staff, and office staff are aware of these changes before submitting requests for coverage. We ask that you share these policy changes with providers who may be ordering or performing services and clinicians who may be referring patients for services.
The complete library of our medical policies can be found at
Medical Policy Updates
on our website; no password is required.
Specific questions or comments regarding development of policy content may be directed to the Medical Policy Editor
medical.policies@wpsic.com
or 800-333-5003, ext. 64133.
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Do You Know Your Practitioner Credentialing Rights?
Aspirus Arise requires credentialing of practitioners upon initial contracting and every three years thereafter to meet National Committee for Quality Assurance (NCQA) requirements. Credentialing of practitioners is performed by the Arise Health Plan Credentialing Department. Practitioners undergoing the credentialing process have the following rights:
- You have the right to review a summary of outside information obtained by the Credentialing Department for the purpose of evaluating your application.
- Requests to review a file shall be made to the Credentialing Manager. The review will take place on site during normal office hours.
- Providers shall not have access to references from other practitioners/health care facilities, recommendations, or peer-review protected information received as part of the credentialing process.
- Providers may receive a copy of only those documents provided by or addressed personally to the provider. A written summary of all other information shall be provided to the practitioner by the Medical Director or his/her designee.
- You will be promptly notified of information that varies significantly from the information you have provided and be given the opportunity to submit updated/additional documentation or corrections to the Credentialing Department. The correction of erroneous information must be done in writing within 10 days of being notified of the varying information. The Credentialing Department is not obligated to reveal the source of information if disclosure is prohibited by law.
- You have the right, upon request, to be informed of the status of your application at any time. Requests shall be directed to the Credentialing Manager. Credentialing Manager shall promptly provide applicant with information regarding date of application receipt, general category of items outstanding, and target approval date.
- You will be notified of the Credentialing Department's decision regarding your application via written letter within 60 calendar days of the department's credentialing or recredentialing decision.
If you have any questions regarding the credentialing process, please contact us at 715-972-8140 or
info@aspirusarise.com
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Our Promise:
Make our high-quality health care services cost-effective
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Integrate your health care so that your personal needs and preferences are considered.
Improve the communities we serve.
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