2015–2016 INFLUENZA SEASON

(1)

PROVIDER

Newsletter

FLORIDA | 2015 | ISSUE IV

IN THIS ISSUE

2015–2016 Influenza Season...Page 1 Medicaid Content Included in WellCare

Editing Tools ...Page 2 Florida Medicaid Provider

Manual Updated ...Page 2 Special Needs Model of Care ...Page 3 Medicare Open Enrollment Period (OEP)

for 2016 ...Page 3 New WellCare Pharmacy

Benefit Manager ...Page 3 Healthy Behaviors Program ...Page 4-5 Balance Billing Guidelines ...Page 6 Q4 2015 Provider Formulary Update ...Page 6 Updated CPGS ...Page 7 Appointment Access and

Availability Audits ...Page 7 2015 Medicare Enhanced Physician

Payment for Key Quality Codes ...Page 7 New Provider Services Technology ...Page 8 Provider Resources ...Page 8

2015–2016 INFLUENZA SEASON

By now, your practice should be prepared for the 2015–2016 influenza season. It is important to develop an influenza vaccine purchasing plan that allows you to meet the needs of your patients. Influenza seasons are unpredictable and can begin earlier or last longer than expected, so plan ahead in order to protect your patients and employees. You should regularly review your influenza vaccine purchasing options and reassess the needs of your organization. For assistance, please call one of the Provider Services phone numbers at the end of this newsletter.

FOR THE IMMUNIZATION-RESISTANT

Misinformation about vaccine safety has existed since the dawn of vaccines and its dissemination is permitted by the freedom to express opinions, no matter how incorrect. Nurses, physician assistants and other office staff play a key role in establishing and maintaining a practice-wide commitment to communicating effectively about vaccines and maintaining high vaccination rates – from providing educational materials, to being available to answer questions, to ensuring that families who may opt for extra visits for vaccines schedule and keep vaccine appointments.

Confused parents may delay or refuse immunizations for their child due to misperceptions of disease risk and vaccine safety.

A successful discussion about vaccines involves a two-way conversation, with both parties sharing information and asking questions. These communication principles can help you connect with patients and their caretakers by encouraging open, honest and productive dialogue.

Please see page 7 for flu shot incentives.

(2)

MEDICAID CONTENT INCLUDED IN WELLCARE EDITING TOOLS

Medicaid content will be included in the editing tools currently used by Wellcare. Medicaid experts continually monitor CMS for quarterly and special regulatory updates to national rules; updates are delivered on a quarterly basis to the editing tool.

This content will include both national and state-specific editing guidelines.

NATIONAL MEDICAID RULES

National Medicaid editing rules are based on CMS guidelines and are applicable to all Medicaid claims.

Examples of these national rules include:

• Medicaid National Correct Coding Initiative (NCCI)

• Medically Unlikely Edits (MUE)

• National physician fee schedule

• Medicaid national policies and guidelines issued by CMS

• Validation edits

STATE-LEVEL MEDICAID RULES

State Medicaid editing rules are based on guidelines published by each state or territory (jurisdiction). Each state defines how guidelines are organized, communicated and published.

STATE-LEVEL MEDICAID RULES ARE BASED ON:

• State-specific policies

and guidelines • State-specific fee schedule • State-specific code sets Edit examples may include:

• Immunizations

• Family planning

• Laboratory services

• Durable Medical Equipment (DME) edits

• Prescription referrals

• Validation edits

• Modifier requirements

FLORIDA MEDICAID PROVIDER MANUAL UPDATED

There have been recent changes to the Florida Medicaid Provider Manual effective October 1, 2015. The updated manual can be viewed online (and/or printed) at our website at wellcare.com/Florida/Providers/Medicaid.

This update provides information regarding these and other topics including:

• Florida Healthy Kids Program

• Claims

• Appeals and grievances

• Quality Improvement

• Pharmacy

If you have any questions or would like a printed copy of the Provider Manual, please contact your Provider Relations representative or call one of the Provider Services phone numbers at the end of this newsletter.

NEW WELLCARE PHARMACY BENEFIT MANAGER

WellCare will have a new Pharmacy Benefit Manager (PBM) in 2016.

Members will receive new ID cards with updated processing information.

Please remind patients who have a prescription benefit through WellCare to bring their new card to the

pharmacy beginning January 1, 2016.

Please also refer to www.wellcare.

com/Florida/Providers/Medicaid/

Pharmacy for 2016 formulary and pharmacy network changes.

(3)

SPECIAL NEEDS PLANS MODEL OF CARE

An integrated Dual Eligible Special Needs Plan (D-SNP) combines Medicare and Medicaid benefits. WellCare members may qualify for a D-SNP plan if they are 18 or older, live in a geographic area where a D-SNP plan is offered, and are eligible for both Medicare and Medicaid benefits. As part of the D-SNP plan, WellCare has developed a Model of Care that ensures members are receiving needed care. Quality is our most important goal.

EXAMPLES OF 2014 QUALITY IMPROVEMENT PROGRAM GOALS WE ACCOMPLISHED INCLUDE:

• Completed assessments for members who are part of the WellCare D-SNP population

• Completed individualized care plans for D-SNP members

• Conducted inter-disciplinary care teams with providers and a health plan case manager to ensure that quality care is provided

• Reviewed data on quality outcomes for diabetes, congestive heart failure, chronic obstructive pulmonary disease and mental health diagnoses to ensure members receive high quality-care

• HEDIS® Practice Advisors were deployed to assist provider practices in improving their health care outcome rates IN 2015, OUR GOALS ARE TO CONTINUE:

Improving the WellCare D-SNP Model of Care program to assist with members receiving the right care at the right time in the right setting

• Reviewing and measuring the quality of care and services that our members receive

• Working with providers as a team to help meet members’ health care needs

• Working with providers as a team to organize care so that together we can coordinate our members’ health care and improve the quality of service

• Focusing on contracting with and maintaining High Performance Provider Networks

• Reviewing and updating our guidelines to ensure that a safe and healthy environment for care is maintained We look forward to continuing to partner with our providers to ensure members get the best care. To receive a copy of our Quality Improvement Annual Evaluation and/or the D-SNP Model of Care Evaluation, please call Customer Service.

MEDICARE OPEN ENROLLMENT PERIOD (OEP) FOR 2016

It is that time of year again! The Open Enrollment Period or OEP.

This is the most exciting and busiest time of the year. OEP is our greatest enrollment period and the time you will see the most growth in your practice. During this time, providers have an opportunity to engage with our highly trained Benefit Consultants to partner together and educate your members and prospective new members for your practice. WellCare can provide an opportunity to showcase your practice at our corporate seminars, joint newspaper advertisements and at large senior events.

OEP begins October 15 and ends December 7.

The time is NOW – if you are interested in participating with WellCare during this fruitful time of year, please feel free to contact your local Benefit Consultant or Sales Director.

Julio Atenza, Director, WFL Sales, 813-928-0262 Joey Anselmo, Director, EFL Sales, 407-267-0269

(4)

HEALTHY BEHAVIORS PROGRAM

The Healthy Behaviors Program rewards members for taking small steps that will help them live healthy lives. For simple tasks like completing primary care provider (PCP) visits, prenatal visits, and certain health checkups, (see the table below) members can earn rewards which are placed on reloadable Visa® cards. Members can use these cards at a variety of locations to purchase items including milk, bread, diapers and over-the-counter (OTC) items from a pharmacy. The more services members complete, the more they can earn.

Healthy Behaviors

Program Reward Type Reward Amount Reward Criteria

Medically approved smoking cessation

program

Healthy Rewards discount card

Reward varies based on member usage; target 5-20% discount on select

healthy lifestyle items.

Attendance and completion of a smoking cessation program

Medically directed

weight loss program Healthy Rewards discount card

Enrollment with a Health Coach

Medically approved alcohol or substance abuse recovery program

Healthy Rewards discount card

Self-identification, provider identification, or HRA responses indicating need, and agreeing to receive educational materials

New Member Healthy Behavior

Health Risk Assessment Completion

Reloadable restricted Visa

card $10 Health Risk Assessment Completion

within the first 90 days of enrollment

Initial PCP Visit Reloadable restricted Visa

card $10 Initial PCP Visit within 90 days of

enrollment

Completion of either Healthy Rewards discount card

Completion of HRA or PCP Visit = Healthy Rewards discount card

Children’s Healthy Behavior

Well-Child Visit:

0-15 months

card $10 0-15 Months: Well-child visit per

periodicity schedule (reward for each visit, up to 6 visits)

Child Health Checkup:

3-6 years

card $10 3-6 years: Child health checkup visit

(EPSDT) (reward for each visit) Adolescent Checkup:

7-21 years

card $20 7-21 years: Adolescent checkup visit

(reward for each visit)

(5)

Healthy Pregnancy Behaviors

Prenatal visits

Reloadable restricted Visa card plus stroller

or portable playpen

$20 plus a stroller or

portable playpen 6 prenatal visits before the birth of baby

Postpartum visit Reloadable restricted Visa

card $10 1 postpartum visit 21-56 days after

the birth of baby

Completion of both Reloadable restricted Visa

card

Members who complete both receive $30 incentive

plus a stroller or portable playpen

Completion of prenatal + postpartum visits = total incentive

Well-Woman Healthy Behaviors

Screening mammogram Reloadable restricted Visa

card $20 Completion of Screening

mammogram (ages 40-65)

Dental Healthy Behaviors

Preventive dental visits Reloadable restricted Visa

card $10 1-20 years: any dental care visit with

a dentist

Diabetes Healthy Behavior Program

Eye exam Reloadable

restricted Visa

card $10 Complete eye exam (enrollees with

diabetes ages 18-75)

HgbA1C control Reloadable restricted Visa

card $10 Goal achievement for HgbA1C (8)

LDL control Reloadable restricted Visa

card $10 Goal achievement for LDL level (100)

*Rewards card cannot be used for the following: Gambling, alcohol, tobacco or drugs (except for over-the- counter drugs). The value of the card cannot exceed a $50 amount.

Providers can encourage their patients to participate in the Healthy Behaviors Program by signing and including their provider ID on applicable activity reports.

For more information on WellCare’s Healthy Behaviors Program, please contact your Provider Relations representative or call one of the Provider Services phone numbers at the end of this newsletter.

(6)

BALANCE BILLING GUIDELINES

Participating providers are required to accept payment directly from WellCare. WellCare’s payment is payment in full, with the exception of applicable co-payments, deductibles, coinsurance and any other amounts listed as member’s responsibility on your Remittance Advice. Any bill generated to a member to collect for cost sharing other than those outlined above is prohibited. Balance billing of “zero cost-share” dual eligible members is prohibited, including co-payments, etc., as listed above.

Please consider the following scenarios that may unintentionally create a balance billing problem:

• You have a billing/practice management system that automatically generates a bill to a member if you have not received a Remittance Advice from the plan within a certain time frame or if the expected amount received (in some cases zero, for denials) is less than the remitted amount.

• You have sent a lab test or other services out of network without proper authorization, creating a situation where our member may be inappropriately billed

• You have not confirmed eligibility with WellCare, resulting in the incorrect classification of a member as self- pay, which in turn generates a bill to the WellCare member for services rendered. You can avoid this scenario by requiring all patients to present their ID cards at the time of their visit.

The generation of a balance bill to a Medicare Advantage and Medicaid Managed Care member is not only against WellCare’s policy, but is also strictly prohibited by CMS guidelines.

If you have any questions or concerns regarding claims, please call one of the Provider Services phone numbers at the end of this newsletter or your Provider Relations representative.

Note: A provider may charge a member for services not covered by WellCare only when both parties have agreed prior to the service being rendered that the member is being seen as private pay. The provider must obtain the member’s written consent that he or she will be financially responsible for the non-covered service, and that consent must be signed and dated on or before the date of service.

Q4 2015 PROVIDER FORMULARY UPDATE

MEDICAID:

The Staywell Preferred Drug List (PDL) has been updated. Visit ahca.myflorida.com/Medicaid/Prescribed_Drug/

pharm_thera/fmpdl.shtml to view the current Staywell PDL and pharmacy updates.

Visit www.wellcare.com/Florida/Providers/Medicaid/Pharmacy for the Healthy Kids PDL and pharmacy updates.

You can also refer to the Provider Manual available at www.wellcare.com/Florida/Providers/Medicaid to view more information regarding WellCare’s pharmacy Utilization Management (UM) policies and procedures.

MEDICARE:

There have been updates to the Medicare formulary. Find the most up-to-date complete formulary at www.

wellcare.com/Florida/Providers/Medicare/Pharmacy.

You can also refer to the Provider Manual available at www.wellcare.com/Florida/Providers/Medicare view more information regarding WellCare’s pharmacy UM policies and procedures.

(7)

APPOINTMENT ACCESS AND AVAILABILITY AUDITS

WellCare is required by CMS and state regulations to administer appointment access and availability audits.

The audits are conducted by a third party vendor, SPH Analytics, and keep us compliant with NCQA and other accreditation entities. Auditors identify themselves when calling provider’ offices, and provide appointment examples for existing members.

If an audit of your office reveals areas for

improvement, you will receive a notification letter and an outline of the appointment types and standards.

You will be provided an opportunity to respond, and will be re-audited in 90 days.

For more information on appointment access and availability audits, please contact your Provider Relations representative or call one of the Provider Services phone numbers at the end of this newsletter.

UPDATED CPGS

ADHD and Bipolar Disorder Clinical Practice Guidelines (CPGs) have been reviewed and posted to www.wellcare.com/Florida/

Providers/Clinical-Guidelines/CPGs.

Updates have been made to the following chronic and preventive CPGs: Asthma, Cholesterol Management, Congestive Heart Failure, COPD, Coronary Artery Disease, Diabetes in Adults and Children, Hypertension, Sickle Cell Disease, and Smoking Cessation.

In addition, new CPGs are available:

Behavioral Health Conditions in High Risk Pregnancy, Motivational Interviewing and Health Behavior Change, Palliative Care, Persons with Serious Mental Illness and Medical Co-Morbidities, and Substance Use Disorders in Pregnancy.

2015 MEDICARE ENHANCED PHYSICIAN PAYMENT FOR KEY QUALITY CODES

WellCare of Florida is offering additional reimbursement to our Medicare providers who submit detailed claims related to the following measures:

STAR MEASURE STANDARD ELIGIBLE CODES

Annual Flu Vaccine The percentage of members who received an influenza vaccination between July 1 of the measurement year and the date when the CAHPS 5.0H survey was completed.

CPT: 90653–90657, 90660–90662, 90672, 90673, 90685–90688, HCPCS: Q2034–Q2039 Care of Older Adult –

Functional Status Assessment Percentage of adults age 66 years and older who had a functional status assessment during the measurement year.

CPT: 1170F

Osteoporosis Treatment for Women

The percentage of women 67–85 years of age who suffered a fracture and who had either a bone mineral density (BMD) test or prescription for a drug to treat osteoporosis in the six months after the fracture.

BMD Test: CPT: 76977, 77078, 77080, 77081, 77082

• Enhanced Payment of $20 per code for select codes with dates of service between October 1, 2015, and December 31, 2015

• Only physicians who submit on a CMS-1500 (paper form) or an electronic 837P form are eligible for this Enhanced Payment

• Claims must be received by January 31, 2016, to be eligible

• Encounters submissions are also eligible, but may require longer payment cycle

• Payments will be “in addition to” other WellCare incentive programs

• Payments will be made on a monthly basis starting in late November 2015, with a final payment in late February 2016 for claims received by January 31, 2016

(8)

FL031312_PRO_NEW_ENG FL5PRONEW70043E_0815 ⁷⁰

043

PROVIDER RESOURCES

WEB RESOURCES

Visit www.wellcare.com/Florida to access our Preventive and Clinical Practice Guidelines, Clinical Coverage Guidelines, Pharmacy Guidelines, key forms and other helpful resources. You may also request hard copies of any of the above documents by contacting your Provider Relations representative. For additional information, please refer to your Quick Reference Guide at www.wellcare.com/Florida/Providers/Medicaid or www.wellcare.com/Florida/Providers/Medicare.

PROVIDER NEWS

Remember to check messages regularly to receive new and updated information. Visit the secure area of

www.wellcare.com/Florida to find copies of the latest correspondence. Access the secure portal using the “Provider Secure Sign-In” area in the Provider drop-down menu on the top of the page. You will see Messages from WellCare located in the right-hand column.

ADDITIONAL CRITERIA AVAILABLE

Please remember that all Clinical Coverage Guidelines detailing medical necessity criteria for several medical

procedures, devices and tests are available on our website at www.wellcare.com/Florida/Providers/Clinical-Guidelines.

NEW PROVIDER SERVICES TECHNOLOGY

WellCare is excited to announce some major technology improvements within our call centers, making it easier for providers to do business with us. You will see a difference in the speed and quality of service that you get when you call us.

One component of this multimillion dollar technology investment is a new Interactive Voice Response (IVR) system, designed to enhance WellCare’s communication channels and provide a better customer experience.

This new IVR system will provide the following enhanced features and functionality:

• New technology to expedite provider verification and authentication within the IVR

• Provider/member account information is sent directly to the agent desktop from the IVR validation process so you don’t have to repeat yourself – saving you time

• Full speech capability, allowing you to speak your information and inquires or use your touch-tone keypad

• Ability to receive member benefit information through the self-service IVR

• Receive claims information on full or partial payment claims and multiples lines of claims denials

• Rejected claims information is now available through the IVR

Future improvements include virtual hold and callback, allowing you to hang up yet stay in queue and receive a callback when the next agent is available; plus multimedia queuing for Web chat, email and text.

To prepare for these changes, we want to remind you to have the following information available with each call:

• Your WellCare provider ID number

• NPI or Tax ID number for validation, if you do not have your WellCare provider ID number

• For claims inquiries – the member’s ID number, date of birth, date of service and dollar amount

• For authorization and eligibility inquiries – the member’s ID number and date of birth

We look forward to better serving our provider partners with these technology improvements.

WE’RE JUST A PHONE CALL OR CLICK AWAY!

MEDICARE:

1-888-888-9355

Or visit www.wellcare.com

MEDICAID:

Staywell 1-866-334-7927 wellcare.com/Florida

CHIP:

Staywell Kids 1-866-698-5437 wellcare.com/Florida