Provider News November 2019

Security Health Plan distributes Provider News digitally. Information in this newsletter is important for care providers, clinic managers, patient assistance, coding and other clinic staff. Please share with your colleagues. If you wish to receive this monthly newsletter, please create a Provider Portal account by contacting your practice's organization administrator. If you don't have an organization administrator, click here to set one up.

Proud of it

Security Health Plan’s Wilhelm named to Wisconsin task force on reducing prescription drug prices Sue Wilhelm, pharmacy services director and interim clinical officer at Security Health Plan of Wisconsin, Inc., has been named by Wisconsin Gov. Tony Evers to serve on the Governor’s Task Force on Reducing Prescription Drug Prices. The 21-member task force includes six state agency officials, three Wisconsin legislators and representatives from a dozen medical, pharmacy and health advocacy organizations throughout Wisconsin. Read more

Security Health Plan supports Chippewa County training event to prepare public officials for suicide response “I will never be able to explain what it feels like to hold your child the day they come into this world; and to hold them the day they leave,” Debra Judnick told participants at the recent “Postvention: Train the Trainer” in Chippewa County. Judnick lost her 15-year old daughter to suicide in 2016. She spoke at the training in hopes of helping better prepare those involved in the aftermath of a suicide. Read more

Coding corner

Don’t let the past come back to haunt you; sorting active diagnoses from past medical history  By BRENDA ANDERSON, Revenue Management Educator Clinically, a patient’s past and present diagnoses should be accessible to any provider caring for that patient. In the coding world, “past medical history” and “history of” refer to conditions that a patient had in the past but no longer exist.   Read more to avoid coding errors related to the timeframe of diagnoses.

Policy review

Security Health Plan's November policy meeting did not occur prior to publication. Please make sure to check the December Provider Newsbrief for new, changed and retired policies.

Provider expertise requested for medical policies and criteria As Security Health Plan reviews and develops clinical criteria on Medical and Interpretation Policies, we ask providers with particular professional knowledge or clinical expertise on certain subjects for their input and opinions. Requests from providers must be documented on the Provider Input Form . Please download the form from www.securityhealth.org/medicalpolicies. Then, email the completed form to [email protected]. We appreciate your input. To receive payment, providers must meet all policy criteria outlined for the specific service provided. Please review the current month’s medical policy updates and/or changes at www.securityhealth.org/medicalpolicies.

Security Health Plan updates

Security Health Plan initiates nutritious benefit for members with congestive heart failure after hospital/SNF stay By SHERRI WINER, Health Services Nurse Manager Beginning Jan. 1, 2020, Security Health Plan's Medicare Advantage HMO-POS and Ally Rx D-SNP members who have a diagnosis of congestive heart failure (CHF) will receive a nutritious benefit to assist in their recovery. Security has arranged for members to receive two weeks of free meals after they are discharged to home from an inpatient hospital stay or a Medicare-approved stay for recovery following illness or injury in a Medicare-certified skilled nursing facility. Read more

Payment methodology changes for home health under new CMS Patient-Driven Groupings Model By JENNIFER DENNEE, Government Policy and Reimbursement Specialist Effective Jan. 1, 2020, the Centers for Medicare and Medicaid Services (CMS) will be implementing a new Home Health Patient-Driven Groupings Model (PDGM). The PDGM is a new payment model for the Home Health Prospective Payment System (HH PPS). The PDGM relies more heavily on clinical characteristics and other patient information to place home health periods of care into meaningful payment categories and eliminates the use of therapy service thresholds. Read more

Security Health Plan asks providers to help promote bone mineral density screening By MARGIE STRAKA, Quality Improvement Nurse Security Health Plan is committed to helping health care providers and patients in the effort to prevent fractures. It is vitally important that all providers’ offices continue to emphasize the importance of bone mineral density (BMD) screening for osteoporosis with patients at appointments. Security Health Plan will help promote bone health by reinforcing information patients obtain from their providers and by providing community support and information. Read more

Contact eviCore claim response team for questions on radiation oncology, outpatient therapy claim denials eviCore has established a claim response team to address provider questions specifically related to claim denials for radiation oncology or outpatient therapy claims. Examples of questions eviCore’s team can answer: claims denied for no authorization, claims denied as units exceeding authorized services and services denied at the time authorization was requested. The eviCore Claim Response Team can be contacted at 866-221-8787, Option 2. This number should be utilized only for claim questions, but not to initiate an authorization. Claim denial questions for high-end imaging, cardiac services, sleep studies, outpatient pain, outpatient and inpatient total joint replacements or back surgeries will continue to be answered by Security Health Plan’s provider assistance team. Call 800-548-1224 (TTY: 711).

CMS Offers New Resources to Help Clinics Improve Physical Access for People with Disabilities In recognition of the Americans with Disabilities Act, the Centers for Medicare and Medicaid Services Office of Minority Health (CMS OMH) offers several new resources to help improve physical accessibility for people with disabilities. The CMS memo describes resources available for providers as well as patients. Click here to view the memo and access links to important resources to help you make your practice more accessible.

Wisconsin DHS offers new HealthCheck resources for BadgerCare patients and providers The Wisconsin Department of Health Services (DHS) has created a new “ Supporting Your Child’s Health ” HealthCheck brochure and other resources for BadgerCare Plus patients and providers. HealthCheck covers annual exams and specialized services to make sure children on BadgerCare Plus get continuous quality health care. HealthCheck exams and services are designed to meet a child’s health and developmental needs through age 20. Click here to view the DHS HealthCheck web page. A new brief HealthCheck informational video and other resources for health professionals can be found on this HealthCheck provider resources web page .

Reminders

Use Provider Portal to verify claims information Claim status, eligibility, benefits and prior authorization requirements can be verified on the Security Health Plan Provider Portal. Click here for information on Provider Portal access and other ways to get the information you need by email, phone and fax.

Verify benefits and eligibility through frequent ID card scanning, checking Security Heath Plan portal By SARA FOEMMEL, Director of Operations Security Health Plan and Security Administration Services member identification (ID) cards are a useful tool for both providers and patients to easily identify a patient’s type of coverage. Security recommends that the current member ID card be requested at each visit. Some members change coverage each year, and therefore it is especially important to make a copy of each patient’s ID card when receiving services for the first time each year. This will assist with timely claim submission and payment. The fastest way to determine eligibility and benefits is by using the Security Health Plan portal. Providers should ensure that your office staff are verifying benefits and eligibility at every patient visit, prior to rendering service. If your office is not currently signed up for the SHP provider portal, please create a provider portal account by contacting your practice’s organization administrator. If you don’t have an organization administrator, click here to set one up.

Telehealth service coverage expands in 2020 for Medicare Advantage plans  By JENNIFER DENNEE, Government Policy and Reimbursement Specialist Effective January 1, 2020, the Centers for Medicare & Medicaid Services (CMS) is eliminating standard fee-for-service restrictions on telehealth access for Medicare Advantage plans (not including our Secure Saver MSA plan). In an effort to increase virtual care choices and benefits, Security Health Plan Medicare Advantage members will have additional telehealth and virtual care benefits beyond Original Medicare. This includes greater access to telehealth services in both rural and urban areas, even in their own home. Read more

Important online information is a click away You can find important information on services, standards and processes when you visit our Provider and Facility Manuals at www.securityhealth.org/providermanual . Read more

Prior authorization updates

Medical services prior authorization updates for 2020; clarification of Vagus Nerve Stimulator prior authorization By KAREN BORGEMOEN, Nurse Navigator / Medical Policy Nurse Security Health Plan requires prior authorization for certain medical services, care or equipment in order to ensure coverage and payment for those services. A number of requirements have been added for 2020 as we work to make sure all care, services and treatments are medically necessary. Read more for a clarification of prior authorization requirements regarding the Vagus Nerve Stimulator.

eviCore authorization letter will note limitations on outpatient therapy visits and units Please note when requesting prior authorization from eviCore for outpatient therapies that there are several types of limitations to review on the authorization letter.  Read more

Update on Provenge®: January 2020 updates to prior authorizations and post service claim edits By AMANDA SIEGLER, Clinical Pharmacy Specialist Security Health Plan requires prior authorization (PA) and post service claim edits (PSCE) on medications in order to ensure coverage and payment for those services. A number of requirements have been added for 2020 as we work to make sure all care, services and treatments are medically necessary. Read more for information on PA requests for Provenge ® (sipuleucel-T).

Pharmacy prior authorization tips for success By AMANDA SIEGLER, Clinical Pharmacy Specialist Prior authorization (PA) is a key part of utilization management to ensure medications are being prescribed and utilized according to clinical guidelines and in the most cost-efficient manner. It is important to complete PA request forms as accurately as possible in order to avoid delays with drug approvals. This ensures patients can start their drug therapy in a timely manner. Filling out the form correctly the first time also decreases the risk of the request needing to go through the appeals process.  Read more for some tips on filling out PA requests timely and efficiently.

Help patients find you Has your practice moved? Have you changed the name or ownership of your practice? Do all of your providers accept new patients? Is anyone seeing patients in a new or different location? Has anyone left your practice or been replaced in the last year?

Help patients find you by keeping information about your practice current with Security Health Plan. Security Health Plan’s online provider directory is the primary provider search tool we offer our members. Members use the “Find a Doctor” directory to search for providers who can fill their specific care needs, whether they’re looking for a primary care provider who sees children, a specialist with privileges at a specific hospital, or an affiliated nursing home near their aging parents.

To help patients find you, visit www.securityhealth.org/directory . Whether you’re a provider, a practice or a facility, please review the directory information for accuracy. Be sure to contact us right away with any needed updates: You can report a change to Provider Relations staff. Call us at 715-221-9640 (TTY: 711), fax changes to us at 715-221-9699 or email us at [email protected] .

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