June 2013 - Gateway Health Plan

June 2013, Issue 13
Provider Update
PRODUCED FOR
GATEWAY HEALTH PLAN®
PROVIDERS AND
CLINICIANS
GatewayHealthPlan.com
O F F I C E S TA F F
IntroducIng the ProvIder
Pay-for-Performance Program
At Gateway HealthSM, we value the important role practitioners play in serving our members.
We support recognizing and
rewarding performance for those
practices committed to providing
quality healthcare that is accessible
and efficient. Therefore, working
collaboratively with the Department
of Public Welfare (DPW), Gateway
would like to welcome you to the
enhanced 2013 Gateway to
Practitioner Excellence ProgramSM.
This program supports Gateway’s
mission to deliver quality programs
that positively impact the personal
health of its members.
I
N
T
H
I
S
I
S
S
U
Thank you for your ongoing
commitment to providing accessible
and efficient quality care to your
patients with Gateway HealthSM. For
more information, please visit our web
site www.GatewayHealthPlan.com
and click on the providers link,
then on Gateway to Practitioner
ExcellenceSM located on the left hand
side of the web page, or contact your
provider relations representative.
E
CLINICAL
O F F I C E S TA F F
2 Pharmacy Department Help Line
2 How to Request that a Drug Be Added to
the Formulary
3 Gateway’s Interdisciplinary Care Team (ICT)
4 DIVA- Gateway’s Automated Telephonic
Referral and Eligibility Verification System
4 Appeals Corner
4 Fax Errors = Unnecessary Risk
5 Important Announcement Regarding Notification
of Provider Changes Sent to Gateway!
5 Important Credentialing Reminder
for all Physician Extenders
15 Advance Directives
6 2013 Practitioner and Provider
Satisfaction Surveys
18 Medical Necessity Determinations
6 Obstetrical Needs Assessment Form
18 Quality Improvement/Utilization
Management Program and Work Plan
7 What is the MOM Matters® Program?
19 Peer Review Information
12 Gateway Kick Starts Care4life Texting
Campaign Type 2 Diabetes
19 Affirmative Statement About Incentives
13 UM Criteria
14 Evidence-based Guidelines Available
On-line for Improving Health Outcomes
16 Model of Care Overview
8 Global Initiative for
Chronic Obstructive
Lung Disease (GOLD)
2013 Updates
9 Should I Change
this Patient’s HTN
Medication Regimen?
19 Hours of Operation
10 Medicare Part D
Opioid Over-utilization
Program
20 Care Transition Communication Between
Skilled Nursing Facilities and PCPs
11 Congratulations
Dr. Chaves-Gnecco
21 Managing Third Party Liability Claims
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Provider Update • June 2013 • Issue 13
O F F I C E S TA F F
the Pharmacy dePartment helP lIne
PatIent safety Is our #1 goal
Gateway’s Pharmacy Department is committed to providing a first-class customer
service experience for our providers.
In the spirit of these efforts,
Gateway’s Pharmacy Department has
designated staff to facilitate provider
questions related to the drug benefit
or other pharmacy processes.
If you are a provider or calling on
behalf of a provider, please call the
Pharmacy Technical Help Desk at
1-800-528-6738 (for Medicaid
questions) or 1-800-685-5215
(for Medicare Assured® questions).
A trained representative is ready to
help you with all of your questions
related to the drug benefit or other
pharmacy processes. A representative
can help you locate important
pharmacy forms (e.g. Drug Exception
Form, Medicaid Six Prescription
Benefit Limit Form, Prior
Authorization and Step Therapy
Forms), assist you in the pharmacy
prior authorization process, and
provide you with formulary
alternatives to non-formulary
medications. You can also find this
valuable information right on our
website under the Provider section at
http://www.gatewayhealthplan.com
/providers/pharmacy-tools.
O F F I C E S TA F F
how to request a drug
Be added to the formulary
Providers may request the addition
of a medication to the formulary.
Requests must include the drug
name, rationale for inclusion on the
formulary, role in therapy and the
formulary medications that may be
replaced by the addition. The Pharmacy
and Therapeutics (P&T) Committee
will review and take into consideration
these requests. All requests should be
forwarded in writing to:
Gateway HealthSM
Four Gateway Center
444 Liberty Avenue
Suite 2100
Pharmacy Department-P&T
Committee, Floor 19
Pittsburgh, PA 15222-1222
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O F F I C E S TA F F
gateway’s InterdIscIPlInary
care team (Ict)
lookIng for
assIstance wIth
managIng your
PractIce’s hIgh
rIsk Medicare
assured® PatIents?
Gateway’s Interdisciplinary Care
Team (ICT) would be delighted to
help! We at Gateway sincerely value
the insight of primary care physicians
who have been providing quality
care to our members, and strongly
support a co-management style when
addressing our members’ needs.
The ICT is dedicated to developing
a member driven care plan and to
coordinating all aspects of care
management tasks to identify, address
and minimize potential barriers to the
member’s care plan. This is achieved
by providing members with the
support, education and coordination
of community resources needed
to promote optimal member selfefficacy in the management of their
medical and psychosocial needs. It is
most successful when the ICT is
aware of what areas of support the
PCP may be in need of to achieve this
end. The ICT takes great pride in
maintaining compliance with the
requirements set forth by the Centers
for Medicare & Medicaid Services’
Model of Care and is comprised of
a network of board certified primary,
ancillary, behavioral health and
specialty care providers. The ICT
membership includes the identified
member, the member’s identified
caregiver, (when applicable), a
multidisciplinary staff including:
physicians and other licensed
practitioners, registered nurses,
master level and licensed social
workers, mental health practitioners,
pharmacists and related pharmacy
representatives, utilization
management, certified care
managers and various
community based
organizations, (that
may be assisting the
member), as well
as the ICT coordinator. The ICT
would be honored to partner
with you to implement positive
co- management strategies to foster
the empowerment of your Gateway
members, and to do so in a manner
that would have the lowest impact on
your, undoubtedly, busy schedule.
Please contact us at 1-800-685-5212
to discuss how your participation in
the ICT can help to achieve optimum
member outcomes.
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Provider Update • June 2013 • Issue 13
O F F I C E S TA F F
dIva- Gateway’s
Automated Telephonic
Referral and Eligibility
Verification System
Our DIVA Quick Reference Guide
is available at our website in the
forms and reference material
section. Instructions for referral
entry and retrieval are also printed
in our Gateway at a Glance.
Primary Care Practices
Does your practice have new staff
that is unfamiliar with DIVA? If so,
visit www.GatewayHealthPlan.com
to see a short instructional video on
how to enter a referral using DIVA.
O F F I C E S TA F F
aPPeals
corner
Providers play an important role in
the appeals process. After receiving
an appeal, Gateway will send a
letter to the appropriate providers
requesting all relevant documentation
supporting the service/item requested
for members. When Gateway
has the information needed, our
physicians can make better decisions
and possibly reduce the need for
further appeals.
O F F I C E S TA F F
fax errors =
unnecessary rIsk
Gateway has processes in place to help us research and respond to situations where
information has been sent or received in error. We recently noticed an increase in
the number of Obstetrical Needs Assessment Forms (ONAF’s) that are faxed to
Gateway, but are intended for other health plans. Providers are notified of these
errors on a case by case basis, but we also want to take this opportunity to remind
providers to check patients’ eligibility before sending information. Making sure
that your information is going to the right health plan helps keep your time
frames on target, and it helps protect your patients’ privacy!
As a Covered Entity of the HIPAA Privacy Rule and the ARRA/HITECH Breach
Notification Rule, Gateway has an obligation to notify other entities when we
receive Protected Health Information (PHI) that was not intended for us.
We wanted to let our providers know that they may have an increased risk of
potential ARRA Breaches when fax errors occur. If you have questions or
concerns, please feel free to contact Gateway’s Provider Service Department
at 1-800-392-1145 for Medicaid, or 1-800-685-5205 for Medicare Assured®.
Provider Update • June 2013 • Issue 13
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O F F I C E S TA F F
ImPortant announcement
regardIng notIfIcatIon
of ProvIder changes
sent to gateway!
Effective immediately, all practice changes
must be submitted in writing along with the
appropriate documentation using the Practice/
Provider Change Request Form or a formal letter.
Gateway HealthSM will no longer accept changes on
the recredentialing application or on the CAQH.
The practice/provider change request
Form can be found on our website
www.GatewayHealthPlan.com under the
forms and reference material section.
Provider notifications of changes should be
sent to the attention of the Provider Relations
Department located at our Pittsburgh corporate
office address. Please note we have a new
corporate address effective April 1, 2013:
This move did NOT affect our claims processing
offices. Please continue to send all claims and
referral forms for Gateway Medicaid to:
Gateway Health Plan®
P.O. Box 69360
Harrisburg, PA 17106-9360
Please continue to send Medicare Assured®
medical and behavioral health claims forms to:
Gateway Health Plan®
P.O. Box 69359
Harrisburg, PA 17106-9359
If you have any questions regarding this notice,
please contact provider services or your provider
relations representative directly.
Four Gateway Center
444 Liberty Avenue
Suite 2100
Pittsburgh, PA 15222-1222
O F F I C E S TA F F
ImPortant credentIalIng remInder for
all PhysIcIan extenders:
Please note that the collaborative agreement
needs to be specific and pertain to the physician
extender it covers. A DEA certificate could be
required to meet credentialing standards.
Additionally, if the extender is permitted to hold
a DEA certificate but does not prescribe,
the collaborative agreement should be
notated accordingly.
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Provider Update • June 2013 • Issue 13
O F F I C E S TA F F
2013 PractItIoner and ProvIder
satIsfactIon surveys
Gateway HealthSM will be conducting
both the Medicaid and Medicare
Assured® practitioner and provider
satisfaction surveys in June this year.
If you participate in both plans and
are chosen in the random sample, you
will receive and need to complete only
ONE survey. The survey will have a
column for Medicaid responses, and a
column for Medicare responses. This
will alleviate having to complete two
separate surveys.
If you participate in only Medicaid
or only Medicare Assured®, you will
receive a survey and only need to
complete the column for the product
in which you participate.
O F F I C E S TA F F
oBstetrIcal needs
assessment form
OB Providers play a very important role in the
MOM Matters® Program, particularly since early
identification of pregnant Gateway HealthSM
members is a key factor to the program. The
care managers at Gateway HealthSM have an
opportunity to contact your patients and help
them have a healthy pregnancy once we are
aware that they are pregnant. The care
managers can help your Gateway HealthSM
patients get the benefits and services they
need to have a safe and healthy pregnancy.
OB Providers are responsible to complete and fax
the Obstetrical Needs Assessment Form (OBNAF)
to Gateway HealthSM at 1-888-225-2360. The
form is designed to capture history and current
medical and psychosocial factors so that a
comprehensive assessment can be completed
and holistic interventions can be developed.
Completion of the form accurately and
completely is important. It is important to
submit the initial OBNAF after the member’s
first prenatal visit, after the 28 week prenatal
visit and after the member has delivered. The
OBNAF form can be found on our website at this
link. http://www.gatewayhealthplan.
com/ providers/forms-and-referencematerials/obstetrical-needsassessment-form-obnaf
The survey results help us identify
where we meet the needs of our
network and where we need to
improve. Your time to complete and
return the survey is greatly appreciated.
If you have any questions about the
2013 survey, call your provider
relations representative directly.
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O F F I C E S TA F F
what Is the mom matters® Program?
The MOM Matters® program
encourages pregnant women who are
members of Gateway HealthSM to
work with doctors, nurses, social
workers and other staff to get the best
care for them and their new baby.
•
Informational packets will be
mailed to your pregnant patients
once pregnany is confirmed.
•
Maternity care managers are nurses
or social workers who can talk
about questions or concerns that
your patients have with their
pregnancy or medical care and
assist them with some of the
following things:
– Talk with them during their
pregnancy and ask if they are
interested in additional
support and education.
– Schedule appointments.
– Referrals provided
to MATP for
transportation needs.
– Connect them
to community
resources to help
your patients
care for themselves
and their new baby.
– Arrange for a home visit from a
nurse during their pregnancy
and after their baby is born to
offer support and education.
in the community to prepare
them for their new baby.
•
An incentive for early prenatal
care and continuing prenatal care
is offered to them during their
pregnancy. If your pregnant
patients meet the criteria and
complete the program, they may
select a baby stroller, an infant/
toddler car seat or a Pack-N-Play
Kit to be mailed to their home.
•
If they would like to speak to a care
manager from the MOM Matters®
Program – please have them dial
1-800-642-3550 and select
Option 2.
– Discuss various classes your
member may want to take at
your OB/GYN office, clinic or
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Provider Update • June 2013 • Issue 13
CLINICAL
gloBal InItIatIve for chronIc
oBstructIve lung dIsease (gold)
2013 uPdates
gateway wants to help keep you up to date, so that you can optimize
the care of your coPd patients.
We’ve included a few highlights from
the 2013 Global Initiative for Chronic
Obstructive Lung Disease (GOLD).
The full report can be found at
http://www.goldcopd.org/
Guidelines/guidelines-resources.html
new sections:
•
You can also print the pocket guide
from this website!
•
Clinical COPD
questionnaire (CCQ).
•
Palliative care for patients
with advanced COPD.
Pharmacology updates:
•
Dual therapy of an inhaled
corticosteroid and a long acting
anticholinergic is no longer
recommended.
•
Inhaled corticosteroids should be
prescribed with a long acting beta 2
agonist and is only recommended
for high risk patients (group
C & D).
•
If a patient had one hospitalization
for a severe COPD exacerbation,
they are now considered to be
high risk.
•
GOLD cautions against the use of
inhaled corticosteroids when it is
not indicated because of the risk of
pneumonia and the potential for
increased fracture risk with long
term use.
End of life discussion -- This
section provides some information
to help the provider approach this
subject. GOLD notes that severe
COPD patients want to discuss end
of life issues, but this conversation
rarely occurs in clinical practice.
We welcome your referrals.
If you identify a patient
that may benefit from our
Gateway to Lifestyle
ManagementSM COPD
program,
you can make a referral by calling the
care management department.
•
Medicaid –
1-800-642-3550
•
Medicare Assured® –
1-800-685-5212
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CLINICAL
should I change thIs PatIent’s
htn medIcatIon regImen?
Hypertension is a modifiable risk factor
for cardiovascular and cerebrovascular
disease. According to a study presented
by Express Scripts to the American
Heart Association’s Quality of Care
and Outcomes Research (QCOR)
2012 Scientific Sessions showed that
“nonadherence to high blood pressure
medications was associated with an
increased risk of cardiovascular
hospitalizations or emergency room
visits and was more pronounced with
Medicare Part D Plan participants”.1
Previous studies have shown a link
in those less than 65 years of age.
Drug efficacy may not be the issue
for many patients who appear to be
non-responders. There is a probability
that non-compliance rather than
non-responding may be the issue.
This determination is difficult because
compliance is subjective however not
uncovering it can lead to unnecessary
intensification or changes of
antihypertensive therapies.
A frequent reason for non-compliance
is repeated periodic omissions of
medications or not adhering to a
schedule. Patients may not realize
that timing of blood pressure
medications matters. Although
most antihypertensives begin to work
within an hour, peak times can vary
from 4 hours to 15 hours or longer.
1
A case example worth highlighting
is a patient who was diagnosed with
“resistant hypertension” for several
decades despite numerous medication
and dose changes. Systolic pressure
could be in the 200 range; diastolic
in the 100 range, at times requiring
hospitalization. She religiously showed
her physician her medication card
listing meds exactly as ordered—but
she never achieved control. She never
shared, nor was she asked, about how
she was taking the medications! She
would take her blood pressure and if it
was in normal range she either skipped,
or cut her next dose of medication in
half. If her pressure increased her eyes
would water and she would develop
a slight headache. At that point,
pressures were pushing into the 200/
100 range or higher. She “corrected”
this by taking additional antihypertensive
medication. If her pressure didn’t come
down in about an hour-- out of fear of
a stroke-- she took another medication
or split a pill. She re-checked her
pressure a bit later and not surprisingly,
it would be low. She was thrilled at
the drop and would skip her next dose
or take a lesser amount. Her physicians
were driven nuts by the fluctuations
and continued to adjust meds… but
no one ever asked how she was
actually taking the medications.
One confounding factor—this patient
is a registered nurse!
Prior to altering medication changes
for hypertension, it may be worthwhile
to consider asking your patients
the following:
•
How many times a week do they
either miss taking their medications;
take it late or take it early?
•
Are you taking the dose prescribed—
cutting your pills or reducing the
number of times you take them
during the day? When a patient
determines that they do not need the
medication the number of times it’s
ordered, and reduce the times
themselves, they do NOT consider
this as “missing a dose”.
•
What time(s) of day are you taking
your blood pressure medications?
Some patients may be better served by
taking their antihypertensive at night
time. Others may just need instructed
on taking them at defined intervals.
By taking medications ad-hoc they
may be subjecting themselves to higher
pressures, unnecessary changes in
therapy and potential adverse outcomes.
Determining how someone is taking
their hypertensive medications may
equate to better outcomes and less cost
for your patients; less work for you,
your staff and the pharmacy!
http://lab.express-scripts.com/wp-content/uploads/2012/05/QCOR-AH-Adherence-Study-Clinical-BriefFINAL.pdf
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Provider Update • June 2013 • Issue 13
CLINICAL
medIcare Part d oPIoId
over-utIlIzatIon Program
In its 2013 Call Letter to Medicare Part
D sponsors, CMS acknowledged that
the opioid class of medication presents
many challenges for sponsors to ensure
beneficiary safety and to prevent fraud,
waste and abuse. As a result, CMS
provided guidance for a sponsordriven Opioid Over-utilization Review
Program and mandated that all Part D
plans shall develop and employ this
program in 2013. CMS has allowed
plans to determine their own
thresholds for overuse but has
suggested that any beneficiary who
consumes more than 120 morphine
equivalents (MED) daily for at least a
90 consecutive day period without a
cancer or palliative care diagnosis
may be considered for this initiative.
Gateway HealthSM, with approval
from its Pharmacy and Therapeutics
Committee, has decided to adopt this
threshold as its definition of opioid
overuse. Gateway is working with
delegated entity Care Management
Technologies (CMT) to identify high
risk beneficiaries, especially those
beneficiaries seeking opioid
prescriptions from multiple providers
and multiple pharmacies. CMT
has been assisting Gateway with
an ongoing opioid prescription
intervention initiative since 2011.
Once patients are identified for the
Opioid Overutilization Review
Program, CMS expects clinical staff
to communicate with all opioid
prescribers of the high-risk beneficiary
to determine medical necessity. If the
opioid utilization is determined to be
medically necessary, Gateway clinical
staff will document this and remove
the beneficiary from the program.
However, if an opioid prescriber
agrees that the beneficiary is on a
higher-than-necessary amount of an
opioid medication, the provider and
the Gateway staff will work together to
determine an appropriate amount, and
Gateway will be allowed to implement
a beneficiary-specific point of sale
(POS) edit to restrict the beneficiary
from exceeding this determined
amount. In addition, if there is lack
of response or no prescriber willing
to manage the patient’s opioid usage,
CMS allows Part D sponsors to
implement a POS edit that the plan
deems reasonable to prevent opioid
overutilization. Prior to any edit
implementation, a 30-day advance
written notice to the beneficiary and
opioid prescriber(s) will be sent.
While the POS edit is plan-specific,
CMS strongly encourages plans to
communicate such restrictions to
subsequent Part D sponsors if a
beneficiary transfers from one plan
to another.
Overall, the intent of the Opioid
Overutilization Review Program is to
encourage beneficiaries to streamline
their pharmacy and provider care,
improve patient safety and reduce
diversion. Gateway HealthSM highly
encourages its provider network to
participate in this program if you do
receive communication regarding
potential opioid overutilization of
one of your patients. Your assistance
is greatly appreciated as we strive
to provide our membership
with quality care.
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CLINICAL
congratulatIons dr. chaves-gnecco
Congratulations to Dr. Diego
Chaves-Gnecco on being named 2013
CDC Childhood Immunization
Champion for Pennsylvania. The CDC
Childhood Immunization Champion
Award, given jointly by the CDC
and the CDC Foundation, honors
individuals who are doing an
exemplary job or going above and
beyond to promote or foster childhood
immunizations in their communities.
Pennsylvania
Diego Chaves-Gnecco,
MD, MPH, FAAP
Founder and Program Director,
Salud Para Niños
(Health for Children)
Pittsburgh, PA and Gateway
HealthSM Practitioner
Dr. Diego Chaves-Gnecco’s work
with immunizations stems from a
time when he met an unvaccinated
seven-month old Latino infant in a
Pennsylvania clinic. A bad experience
with doctors who did not speak their
language had left the family wary of
trusting the healthcare system.
Dr. Chaves-Gnecco had seen the
consequences of vaccine-preventable
diseases while studying medicine in
Colombia. His empathy for the family’s
situation and ability to provide clear
information convinced them to get
their baby immunized. After learning
that many other U.S. Latino children—
particularly in Southwestern
Pennsylvania—were in similar
situations, Dr. Chaves-Gnecco
founded Salud Para Niños in 2002.
Salud Para Niños at Children’s Hospital
of Pittsburgh is a free, bilingual,
culturally competent clinic that aims
to increase childhood immunization
rates in the local Hispanic/Latino
community. Using resources such as
the Vaccines for Children program to
obtain vaccines, and the Pennsylvania
Statewide Immunization Information
System to monitor immunization
records, Dr.
Chaves-Gnecco
helps keep
children in this
historically
underserved
community
up-to-date on
life-saving vaccinations. He is also a
tireless advocate, visiting churches and
using Spanish-language media to
encourage immunization, and teaching
medical students and residents how to
reach vulnerable communities.
Dr. Chaves-Gnecco has enrolled more
than 950 children at Salud Para Niños.
Their immunization rates are now
similar to other children in the region,
and better than rates in many other
Hispanic/Latino communities. His
successful influenza and pertussis
immunization campaigns have
increased vaccination rates against
both diseases.
For improving the health of Hispanic/
Latino children and families, Dr.
Chaves-Gnecco is Pennsylvania’s CDC
Childhood Immunization Champion.
We are lucky to have
Dr. Chaves-Gnecco on
Gateway Health’s team!
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Provider Update • June 2013 • Issue 13
O F F I C E S TA F F
gateway kIck starts care4lIfe
textIng camPaIgn to make It easIer
for memBers to get suPPort for
tyPe 2 dIaBetes
Numerous studies have demonstrated the effectiveness of
text-based programs toward improving health outcomes.
Today, nearly 80 percent of the
Managed Care population texts.1
Because of this, Gateway
HealthSM is now enrolling
members in the care4life diabetes
texting campaign. Letters went
out to 12,000 diabetic members;
half to Medicare Assured® and
half to Medicaid.
How did we finally get here?
After more than a year of research
and development, Gateway is
collaborating with Voxiva,
a public health company
endorsed by the
American Diabetes
Association,
nationally
renowned
hospitals and health insurance
companies to promote their highly
successful diabetes texting program,
care4life. The SMS text messages
are both HIPAA-compliant and
user friendly.
Gateway care managers and
member service representatives are
trained on how to use the texting
campaign so they can direct
diabetic members to the care4life
program. As an added bonus, the
text messages are free to end user for
those with Tracfone and Safelink
accounts. Standard texting rates will
apply to other carriers and members
will be notified at the end of each text
that they can opt out at any time.
Continued
Source* Cole-Lewis H. Kershaw T. Text Messaging
as a Tool for Behavior Change in Disease Prevention
and Mgmt. Epidemiologic Reviews Vol. 32 (2010)
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O F F I C E S TA F F
um
crIterIa
How can members sign up?
There are 2 ways:
1) Go to
https://www. care4life.com and
click the “Sign Up Now” button.
The bottom of the form asks for
an activation code. The member
should enter: mhealth
2) Text the word JOIN to the
number 300400. Members will
need to reply to the welcome
message with the sign-up code:
mhealth and then reply to the
next text with their first name.
Participants then complete a short
health profile, which places users in
appropriate messaging protocols and
personalizes their experience based
on current ADA recommendations.
Information can be shared with care
managers so they can track and
review members’ progress as well as
identify potential care gaps.
Moving forward, Gateway is exploring
other texting platforms such as
text4baby (maternity care),
text4health (general wellness) and
text2quit (smoking cessation).
These programs have demonstrated
ability to improve and keep
appointments, medication adherence
and immunization schedules.
Members will also be notified of
texting campaign via Televox and
future newsletters. If the soft launch
of this three-month texting campaign
goes well, the program will expand
into other patient populations.
Gateway Utilization
Management criteria
information is available to
participating practitioners/
providers via a telephone
request to Gateway’s medical
director. Criteria information
may also be requested via the
telephone from the utilization
care management nurse
during the authorization
request process, at orientation
sessions and/or by written
request to the Medical
Management Department.
Information about how to
request criteria is also included
on all denial notices. As a
reminder, the Utilization
Management telephone
number for all practitioners and
providers is 1-800-392-1146.
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Provider Update • June 2013 • Issue 13
O F F I C E S TA F F
evIdence-Based guIdelInes avaIlaBle
on-lIne for ImProvIng health outcomes
Gateway HealthSM has developed,
approved and adopted clinical practice
and preventive health care guidelines
based on current national guidelines.
These evidence-based guidelines are
promoted in an effort to improve
health care quality and reduce
unnecessary variations in care.
These guidelines are reviewed and
approved annually by a committee of
peer reviewers and network practicing
physicians. A few of the key changes
for 2013 include:
•
Clarification of the acceptable
methods of colorectal cancer
screening,
•
Addition of clinical breast
examination for women every
1-3 years (age 21-39) and
annually 40+ years,
•
Clarification of the hereditary/
metabolic screenings for infants
at selected intervals,
•
•
Added dental home screening
by age 1 and every 6 months
after, and
Adoption of a new clinical practice
guideline for major depressive
disorder in adults in primary care.
These guidelines are from nationally
recognized sources (such as the
American Diabetes Association(ADA),
U.S. Preventive Services Task Force
(USPSTF), etc.) and can be viewed at
www.GatewayHealthPlan.com.
The guidelines adopted for Gateway
Health for 2013 include the following:
•
Adults with HIV
•
Adult Preventive Care
•
Asthma
•
Cardiac Medical Management
•
Childhood Preventive Care
•
COPD
•
Diabetes
•
Hypertension
•
Routine and High Risk
Prenatal Care
•
Lead Screening (Medicaid only)
•
Major Depression in Adults
in Primary Care
•
Bipolar Disorder (Medicare only)
•
Schizophrenia (Medicare only)
To view these guidelines select “Forms
and Reference Materials” under the
“I am a healthcare provider” section,
then select “Quality Improvement”
on the left hand side.
To request a hard copy of an item,
please feel free to contact the Quality
Improvement Department at
412-255-7277.
Provider Update • June 2013 • Issue 13
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O F F I C E S TA F F
advance dIrectIves
The Omnibus Budget Reconciliation
Act (OBRA) of 1990 included
substantive new law that has come
to be known as the Patient SelfDetermination Act and which largely
became effective on Dec 1, 1991.
The Patient Self-Determination Act
applies to hospitals, nursing facilities,
providers of home healthcare or
personal care services, hospice
programs and health maintenance
organizations that receive Medicare
or Medicaid funds. The primary
purpose of the act is to assure that the
beneficiaries of such care are made
aware of advance directives and are
given the opportunity to execute
them if they so desire. It is also to
prevent discrimination in care if the
member chooses not to execute
advance directives. As a participating
provider within Gateway’s network,
you are responsible for determining if
the member has executed an advance
directive and for providing education
when it is requested.
Gateway’s Medical Record Review
Standards state that providers ask
members age 21 and older whether
they have executed advance directives
and will document the response.
Providers who have members
age 65 and older need a notation
of annual review of members
advance directive.
You can also request a copy of a
“Living Will” form from the Quality
Improvement Department by
calling 412- 255-7277. There is no
government mandated form. A copy
of the “Living Will” form should be
maintained in the medical record.
Providers will receive educational
material regarding member’s rights
to advance directives upon entering
the Gateway practitioner network
as well. Advance directive forms
are made available through
www.GatewayHealthPlan.com.
To access these forms go to Providers
and then the "Forms and Reference
Materials" section.
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Provider Update • June 2013 • Issue 13
O F F I C E S TA F F
model of care overvIew
Gateway HealthSM currently offers four Special Needs Plans (SNPs).
Medicare Assured® covers those who
have Medicare, Parts A & B and full
Medical Assistance (Medicaid) or
Qualified Medicare Beneficiary
(QMB/QME Plus) or SLMB Plus.
These individuals are referred to as
“dual-eligibles”. Medicare Assured®3
covers those who have both Medicare
Parts A & B and assistance from the
State or are SLMB, QDWI or QI.
Medicare Assured® Select and Medicare
Assured® Select Plus covers those who
have both Medicare Part A & B and
at least one of the following chronic
conditions: diabetes, cardiovascular
disorder or chronic heart failure.
There are no income requirements
for the chronic condition Special
Needs Plans.
As a SNP, Gateway is required by the
Centers for Medicare and Medicaid
Services (CMS) to administer a Model
of Care Plan. The SNP Model of
Care Plan is the architecture for care
management policy, procedures, and
operational systems.
•
Administrative Roles – These roles
involve the day-to-day operations
of the plan such as processing
enrollments, paying claims, and
handling appeals and grievances.
•
Service Delivery Roles – These
roles involve providing care to the
beneficiary, including such things
as advocating, informing and
educating beneficiaries, identifying
and facilitating access to community
resources, and ensuring that the
member receives the care he/
she needs.
•
Oversight Roles – These include
oversight of both administrative
and clinical functions. Some
examples include monitoring
model of care compliance,
assuring statutory and regulatory
compliance, and evaluating the
model of care effectiveness;
monitoring the Interdisciplinary
Care Team (see below); assuring
timely and appropriate delivery
of services; assuring seamless
transitions; and timely follow-up to
care, and conducting chart reviews.
snP model of care elements
1. Staff structure and care
management roles
— There are three essential care
management roles within
Gateway’s Model of Care:
2. Provider Network having
specialized expertise and use of
clinical guidelines - Gateway
contracts with a network of
providers with the clinical expertise
pertinent to the Medicare Assured®
population. The providers go
through appropriate credentialing
processes and are expected to use
appropriate clinical guidelines in
the care of Gateway’s members.
3. Health Risk Assessment (HRA) Health risk assessments are a set
of questions designed to provide
Gateway with an overview of a
member’s health status and risks.
Shortly after enrolling, each
member is asked to complete a
health risk assessment, either by
paper or over the phone.
Reassessments are performed
at least annually thereafter.
4. Interdisciplinary Care Team
(ICT) - EACH member of
Medicare Assured® is assigned to
an Interdisciplinary Care Team
based upon his/her level of need as
indicated by the assessment of the
HRA. The composition of the
team varies based on the needs
of the member. Under most
circumstances, the member’s
primary care physician (PCP)
is included on the ICT. Whenever
possible, the member or member’s
caregiver is included as part of
the team.
5. Individualized Care Plan (ICP) An individualized care plan
contains goals, objectives and plan
of care for the member. The ICP
is developed by the ICT based
on needs identified by the health
risk assessment.
Continued
Provider Update • June 2013 • Issue 13
6. Communication Network Gateway has a communication
network to facilitate communication
between the Plan, the member,
providers, and when necessary the
ICT. Communication is primarily
handled via printed materials/
reports, faxes, and telephone calls.
9. Model of Care Training - Model
of care training is provided to
Gateway Medicare Assured®
employees, sub-contractors,
and providers at time of hire /
contract, and annually thereafter.
7. Performance and health outcomes - Performance and health
outcomes are measured in a variety
of ways within Gateway. Some of
these include the Medicare Health
Outcomes Survey (HOS), the
Consumer Assessment of
Healthcare Providers and Systems
(CAHPS) survey, the Healthcare
Effectiveness Data and Information
Set (HEDIS) measures, various
member surveys, and analysis of
encounter data.
•
how the model of care works
for a member
•
8. Measurable Goals - Using
CMS guidelines, Gateway has
established model of care goals
that measure, and attempt to
improve outcomes for things such
as access to medical, mental health,
and social services; access to
preventable health services; and
cost-effective service delivery.
•
•
Shortly after a member enrolls with
any of the Medicare Assured®, plans,
the member is given a health risk
assessment. The assessment is
mailed to the member as part of
the member’s new member packet.
The member is asked to complete
and return the form. If the form
is not returned within a specified
period of time, care management
outreaches to that member
by telephone.
The ICP is communicated to the
member, the member’s primary
care physician (PCP), and other
ICT members as appropriate;
normally by mail.
PA G E
17
•
The member receives care as
indicated on his/her ICP.
•
At least annually, the member
receives another health assessment
to determine if the needs of the
member have changed.
other Important Information
about gateway’s model of care
•
Gateway recognizes that member’s
care needs are varied and are
subject to change. Policies and
procedures have been put in place
to allow members to receive the
level of care management needed
for their particular circumstance.
•
Members may be referred for care
management in a variety of ways:
o Providers may call
1-800-685-5212, option 1
The completed health risk
assessment is reviewed, and based
on that review; the member is
assigned to an Interdisciplinary
Care Team (ICT).
The ICT develops the member’s
Individualized Care Plan (ICP).
Input is gathered from the primary
care physician (PCP) whenever
applicable.
|
o Members may self-refer by
calling 1-800-685-5212,
option 1.
o Gateway employee via
an internal process.
•
Oversight of the model of care
plan is handled by the Medicare
Compliance and Regulatory
Department. Specific questions
with regard to the model of care
plan should be addressed with your
Gateway provider representative.
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Provider Update • June 2013 • Issue 13
O F F I C E S TA F F
medIcal necessIty determInatIons
The authorization process for medical necessity determinations
at Gateway is accomplished through the application of the
Department of Public Welfare’s definition of medical
necessity. Satisfaction of any one of the following standards
will result in authorization of the service:
•
The service or benefit will, or is reasonably expected to,
prevent onset of an illness, condition, or disability.
•
The service or benefit will, or is reasonably expected
to, reduce or ameliorate the physical, mental, or
developmental effects of an illness, condition, injury,
or disability.
•
The service or benefit will assist the individual to achieve
or maintain maximum functional capacity in performing
daily activities, taking into account both the functional
capacity of the individual and those functional capacities
that are appropriate for individuals of the same age.
Medical necessity determinations must be made by qualified
and trained providers.
The utilization care manager refers cases to the Gateway
medical director and/or physician advisor for a medical
necessity determination.
O F F I C E S TA F F
qualIty ImProvement/utIlIzatIon
management Program and work Plan
Gateway’s QI/UM Committee recently approved the 2013
QI and UM programs and work plan. These documents
outline activities for Medicaid and Medicare Assured®. The
evaluations of the 2012 programs have also been finalized.
If you would like a written summary of any of these
documents, please call the QI department at 412-255-7277.
Provider Update • Jume 2013 • Issue 13
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affIrmatIve
statement aBout
IncentIves
O F F I C E S TA F F
Peer revIew InformatIon
Gateway’s UM decisions are based only on
the appropriateness of care and services
and existence of coverage. Gateway does
not specifically reward practitioners or
other individuals for issuing denials of
coverage or service. Financial incentives
for UM decision makers do not encourage
decisions that result in under-utilization.
Gateway monitors for both over and
under- utilization of care to prevent
inappropriate decision making, identify
causes and corrective action, and to
indicate inadequate coordination of
care or inappropriate use of services.
Gateway is particularly concerned about
underutilization and monitors utilization
activities to assure members receive all
appropriate and necessary care.
Gateway offers providers the opportunity for peer
reviews whenever a medical necessity decision is made
to deny or reduce a service.
The utilization management nurse phones the ordering or attending physician’s
office to review the details of the request and the physician’s decision. The nurse
will provide the Gateway physician name and a phone number so that you have
the opportunity to discuss the decision, including the reason that you believe the
service is medically necessary. When calling the Gateway physician, please have
the following information readily available to ensure a timely discussion with
the appropriate physician:
•
Name of the Gateway physician to whom you were directed to speak
•
Member information, including the Gateway identification number and/or
authorization number
hours of
oPeratIon
Please remember – Gateway HealthSM
has a requirement that our Provider’s
hours of operation for their Medicaid
patients are expected to be no less than
what your practice offers to commercial
members. Please reference your Provider
contract and Gateway’s Provider Office
Policy and Procedure Manual located at
www.GatewayHealthPlan.com
regarding provider availability
and accessibility.
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Provider Update • June 2013 • Issue 13
O F F I C E S TA F F
care transItIon communIcatIon
Between skIlled nursIng
facIlItIes and PcPs
Since Medicare patients are especially
vulnerable to receiving fragmented
and unsafe care as a result of poorly
coordinated care transitions,
Gateway’s Medicare Assured® SNP
plans make special efforts to help
providers to manage the care
transition process. Planned and
unplanned care transitions occur
when patients’ healthcare needs
change from one setting to any other
setting, including when a patient’s
care is discharged from a skilled
facility to home as the patient’s care
is transitioning back to the member’s
Primary Care Physician (PCP).
When patients are experiencing a
planned or an unplanned care
transition, the sending setting must
provide a patient care plan to the
receiving setting within one business
day of the transition notification.
For planned transitions from an
inpatient skilled facility to home, the
member care plan should be sent to
the treating practitioner, which is
the member’s PCP. Sharing a
comprehensive care plan increases
continuity and coordination of care
across the settings and helps prevent
patient risks. A patient care plan
includes patient-specific information
that is relevant to the member’s
clinical condition and health status,
such as a current problem list,
allergies/sensitivities, medication
regimen, baseline physical and
cognitive functioning and advance
directives. The patient care plan
is often referred to as: transfer
summary, discharge summary or
patient instructions.
At least annually, Gateway measures
provider effectiveness in sending
patient care plans to the receiving
setting care within the one business
day timeframe. One of the ways that
this is accomplished is through an
annual provider satisfaction survey.
Results from the 2012 PCP
satisfaction survey identified that
PCPs are not receiving adequate
transition documentation from
skilled nursing facilities regarding
Gateway patients.
Gateway collaborates with members,
PCPs, and participating skilled
nursing facilities to improve transition
communication. One of the ways
that Gateway helps to facilitate safe
care transition is by mailing an
inpatient approval letter to the
member. This letter helps to educate
members about care transitions and
Continued
Provider Update • Jume 2013 • Issue 13
informs members of how to reach
Gateway for help with transition
needs. In an effort to encourage
that care transition communications
are being issued to the member’s
PCP, the inpatient approval letter also
identifies the member’s PCP name,
address and phone number.
Communication to PCPs regarding
inpatient acute and skilled admissions
was enhanced in 2012 with the
implementation of a weekly fax
process. The weekly fax advises the
PCP of any acute or skilled admission
occurring for any Gateway member
on the PCP’s patient panel.
Effective May 21, 2013, skilled
nursing facility providers are being
advised of the need to communicate
care transition information to the
patient’s PCP and offered the PCP
contact information during the
prior authorization process.
If you have questions or
suggestions regarding care transition
management, please contact care
management at 412-255-4272.
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managIng thIrd
Party lIaBIlIty claIms
Providers/Vendors are reminded that:
1. All refund checks relating to workers compensation claims should be sent to
Gateway HealthSM, Attn: Finance
2.
All refund checks relating to Medicare auto claims should be sent to Gateway
HealthSM, Attn: Finance
3. All refund checks relating to Pennsylvania Medicaid auto claims must be sent
directly to the Department of Public Welfare (DPW).
MOST IMPORTANTLY….DPW never retracts payments. Providers/Vendors MUST issue a check and
make it payable to the “DEPARTMENT OF PUBLIC WELFARE” and send the check to:
Commonwealth of Pennsylvania
Department of Public Welfare
Third Party Liability Section
P.O. Box 8486
Harrisburg, PA 17105-8486
Your cover letter should include the patient’s recipient or case number, if not available, use the
social security number along with the accident date.
More current information may be included on
Gateway’s website, www.GatewayHealthPlan.com, which is available 24/7.
Four Gateway Center; 444 Liberty Avenue; Suite 2100; Pittsburgh, PA 15222 | www.GatewayHealthPlan.com
PROVIDER SERVICES
MEMBER ELIGIBILITY/DIVA VERIFICATION LINE
PHARMACY
Medicaid 1-800-392-1145
Medicare 1-800-685-5205
Medicaid and Medicare 1-800-642-3515
Medicaid 1-800-528-6738
Medicare 1-800-685-5215
MEDICAL MANAGEMENT
Medicaid 1-800-642-3550, Option 4
Medicaid 1-800-392-1146
Medicare 1-800-685-5207
GATEWAY TO LIFESTYLE MANAGEMENTSM
EPSDT
Medicaid 1-800-642-3550
Medicare 1-800-685-5212
MEDICAID ONLY
ICON KEY
MEDICAID & MEDICARE
MEDICARE ONLY