California
Provider
Newsletter
2019
•Issue III
Quality
How Care Management Can Help You
Care Management helps members with special needs by pairing a member with a care manager. The care manager is a Registered Nurse (RN) or Licensed Clinical Social Worker (LCSW) who can help the member:
• Complex medical needs
• Solid organ and tissue transplant coordination
• Special health care needs
• Housing and placement needs
We’re here to help you!
For more information about Care Management, or to refer a member to the program, please call us at 1-866-635-7045. This no-cost program gives access to an RN or LCSW Monday–Friday from 8 a.m. to 8 p.m.
In This Issue
Quality
How Care Management Can Help You ...1 Easy Choice Rebrands to WellCare ...2 Medication Adherence and RxEffect™ ...2 WellCare of California Earns NCQA
Accreditation Status ...3 Disease Management –
Improving Members Health! ...3 Health Outcomes Survey (HOS)
for Medicare Members ... 4 Is Your Clinical Laboratory Improvement Amendment (CLIA) Compliant? ... 5 Earn a Medicare Peak Performance Bonus .... 6 Operational
REMINDER of Current Policy ... 5 Electronic Funds Transfer (EFT)
through PaySpan® ...7 Provider Formulary Updates ...7
...
Updating Provider
Directory Information 8
Provider Resources ... 8
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Join our digital and social communities for up-to-date information on how we’re working with you and others to help our members live better, healthier lives.
Quality
Quality
Easy Choice Rebrands to WellCare
We are excited to share that Easy Choice Health Plan changed its name and updated the brand to WellCare, effective June 6, 2019. Transitioning to the WellCare brand aligns the market with WellCare’s national Medicare strategy.
Today, WellCare has the honor of caring for more than 5.5 million members. We are excited to continue working with you to provide our members with the quality coverage and services they deserve. WellCare will continue to offer our members comprehensive benefits and preventive care, including dental, vision, hearing, transportation and more.
Our goal is to make the brand transition to WellCare seamless. No action is required on your part. There will be no changes to member coverage or to your points of contact. There will be no interruption of benefits or payments related to the rebranding. In the coming months, you will begin to receive materials with the new logo. In the meantime, member ID cards with the old logo are still valid through Dec. 31, 2019.
If you have any questions, please call Provider Services at 1-866-999-3945 Monday-Friday from 8 a.m. to 8 p.m. Thank you for your patience as we make this exciting transition.
Medication Adherence and RxEffect™
To help with medication adherence, WellCare engages our members with refill reminder phone calls, off-therapy (missed dose) phone calls and letters as well as utilizing our network pharmacies to help counsel our members.
However, there is nothing as powerful as a reminder from the member’s primary care provider about the importance of medication adherence.
RxEffect™ is an online platform available to WellCare Medicare provider groups to help improve members’
medication use and compliance.
Talk to your WellCare associate today to get users from your office access to the RxEffect™ portal.
This web portal:
Is sponsored by WellCare – so there is no cost to our provider partners Uses predictive modeling to target
the patients who need it most Uses real-time monitoring of
pharmacy claims and is updated daily Includes opportunity flags for 30-day
conversions, diabetic patients not on statins, Appointment Agendas and high-risk medications
Quality Quality
WellCare of California Earns NCQA Accreditation Status
The National Committee for Quality Assurance (NCQA) has awarded WellCare of California (formerly known as Easy Choice Health Plan) with accreditation status for its Medicare Advantage plan in California.
NCQA is a private, nonprofit organization dedicated to improving healthcare quality. NCQA accreditation evaluates the quality of healthcare that health plans provide to their members and is a nationally recognized evaluation consumers can use to assess their plans. To earn accreditation, NCQA evaluates how well a health plan manages all parts of its delivery system, which covers physicians, hospitals, other providers and administrative services.
“We’re committed to ensuring our members have access to high-quality care and services,” said Karen M. Johnson, regional president, Medicare west division, WellCare. “This achievement was made possible through the hard work and dedication of our associates, our providers and our partners who, day in and day out, help our members live better, healthier lives.”
Disease Management – Improving Members Health!
Disease Management is a free, voluntary program that helps members with specific chronic conditions.
Members are assigned a Disease Nurse Manager who can help the member with:
Education and understanding of their specific condition
Identification of adherence barriers and ways to overcome them Individualized life modification suggestions to improve daily life Self-management of their condition to improve their health outcomes Motivational coaching for encouragement with the struggles along the way Improved communication with their Primary Care Provider and healthcare team
Disease Management can assist your members with the following conditions:
• Asthma
• Diabetes
• Obesity
• Congestive Heart Failure (CHF)
• Hypertension
• Smoking
• Coronary Artery Disease (CAD)
• Heart Disease
For more information, or to refer a member to Disease Management, please call us at 1-877-393-3090, (TTY 1-877-247-6272) Monday–Friday, 8 a.m. to 6 p.m.
Quality
Health Outcomes Survey (HOS) for Medicare Members
Thank you for your continued commitment to your patients. Your daily dedication is a key to keeping patients healthier, happier and more engaged in improving their health outcomes. In planning for your patients’ annual wellness visits, here are some topics to consider that impact HOS measures and scores:
Balance problems, falls, difficulty walking and other risk factors for falls.
• Suggest the use of a cane or a walker
• Check blood pressure with patient standing, sitting and reclining�
• Suggest an exercise or physical therapy program
• Suggest a vision or hearing test
• Perform a bone density screening, especially for high-risk members�
• Screen for UTIs and review medications for interactions that increase fall risk�
The need for physical activity and ways to increase physical activity.
• Talk to the patient about the importance of exercise and physical activity
• Discuss with the patient how to start, increase or maintain activity�
Bladder control and treatments for issues that may arise as the patient ages.
• Ask the patient if bladder control is a problem
• If so, ask if it interferes with sleep or daily activities
• Talk to the patient about treatment options
Physical and mental health.
• Ask the patient about physical and mental health compared to two years ago
• Discuss ways to improve status of both mental and physical health
• Suggest patient begins exercise programs or physical therapy, if warranted�
These topics also can be discussed by your office or nursing staff while patients are waiting to be seen.�
Is Your Clinical Laboratory Improvement Amendment (CLIA) Compliant?
We would like to remind our Medicare providers that WellCare will continue to uphold the Federal guidelines (Section 353; Public Health Services Act, 42 United States Code §263a – Certification of laboratories and Centers for Medicare
& Medicaid Services Title 42 CFR Part 493) where it outlines that any facility or individual provider that performs laboratory services and wants to receive payments under Medicare and Medicaid programs must have a valid and active CLIA certificate for the type of tests being performed for each location.
To further assist with your claims processing, please submit your CLIA number on the claim as follows:
Electronic Claim: Loop 2300, REF01 = X4, REF02
Quality
Paper Claim (CMS 1500): Field 23
If there are multiple items in Box 23, the provider should include a hyphen (-) or semicolon (;) between the items
If you’re uncertain whether you meet the requirements, please see our flyer for more information and links to other resources: https://www.wellcare.com/~/media/PDFs/NA/Provider/Medicare/2019/NA_CARE_PROV_CLIA_
Claims_Flyer_ENG_1_2019_R.ashx?la=en
Operational
REMINDER of Current Policy
We value your partnership and work to ensure that every WellCare member receives quality healthcare.
Admission Notifications and Prior Authorizations
Notification when a WellCare member is admitted to a facility:
As a reminder, WellCare requires notification by the next day when a member is admitted to a facility. This includes all admissions. Notifications necessary for WellCare to obtain clinical information to perform case management and ensure coordination of services. Failure to notify WellCare of admissions may result in denial of the claim.
Prior authorization for outpatient services:
WellCare has enhanced and standardized the provider portal authorization look-up took with respect to place of service and clinical appropriateness. To reflect industry best practices and reduce the administration burden on providers, the number of procedures requiring prior authorization has been reduced. Please remember to consult the authorization look-up tool on the provider portal and obtain appropriate prior authorization. Failure to obtain prior authorization where required may result in denial of the claim.
Quality
Earn a Medicare Peak Performance Bonus
To ensure our Medicare members receive important medical services by the end of 2019, WellCare is offering a bonus to providers who deliver and appropriately document quality care to our members.
The Peak Performance Program is part of WellCare’s initiative to recognize providers who improve the overall health outcomes of our members.
Providers in California can potentially earn a $75 bonus by scheduling appointments with members to address the following target measures:
• Anti-Rheumatic Drug Therapy
• Care of Older Adult – Functional Status Assessment (DSNP members only)
• Care of Older Adult – Pain Screening (DSNP members only)
• Colorectal Cancer Screen
• Diabetes HbA1c ≤ 9
• Mammogram
• Statin Therapy for Patients with Cardiovascular Disease
Peak Performance Bonus Details:
• Bonuses for the Peak Performance Program are
triggered through the normal Provider/Plan submission of claims/encounters
• Bonuses are in addition to the compensation you may receive under the Partnership for Quality (P4Q) Program
• The measurement period is Sept. 1, 2019 to Dec. 31, 2019
• All claims/encounters must be submitted by Jan. 31, 2020
• Payment will be made in summer 2020.
Peak Performance Bonus Instructions:
1 2
Schedule and conduct an exam with the member by Dec. 31, 2019 to address the target measure(s).
Upon completion of the examination, document care and diagnosis in the patient’s medical record and submit the claim/encounter containing all relevant documentation including ICD 10, CPT and/or CPT II codes by Jan. 31, 2020.
If you have questions about the Peak Performance Program, please contact your Provider Relations Representative, Quality Practice Advisor, or call Provider Services at 1-866-999-3945 (TTY 711). You can reach us Monday–Friday from 8 a.m. to 6 p.m.
Operational
Electronic Funds Transfer (EFT) through PaySpan®
Five reasons to sign up today for EFT:
You control your banking information.
No waiting in line at the bank.
No lost, stolen, or stale-dated checks.
Immediate availability of funds – no bank holds!
No interrupting your busy schedule to deposit a check.
Setup is easy and takes about five minutes to complete. Please visit www.payspanhealth.com/nps or call your Provider Relations representative or PaySpan at 1-877-331-7154 with any questions.
NOTE: We will only deposit into your account, not take payments out.
Provider Formulary Updates
Find the complete Formulary at
https://www.wellcare.com/California/
Providers/Medicare/Pharmacy.
You can also refer to the Provider Manual to view more information regarding WellCare’s pharmacy Utilization Management (UM) policies and procedures. To find the Provider Manual, visit https://www.wellcare.com/
California/Providers/Medicare.
Operational
Updating Provider Directory Information
We rely on our providers and IPA/Medical Group partners to advise us of demographic changes so we can keep our information current. To ensure our members and WellCare staff have up-to-date provider information, please give us advance notice of changes you make to your office phone number, office address or panel status (open/closed). Thirty-day advance notice is recommended.
Please send updates via the following methods:
Providers participating through an IPA/Medical Group partner shall send update notifications directly to your contracted IPA(s) and/or Medical Group in accordance with your contract. If you need additional information on where to submit your demographic changes, please contact your affiliated IPA(s) or Medical Group.
Providers contracted directly with WellCare:
Email:
Mail:
WellCare
Attn: Network Management 10803 Hope Street, Suite B Cypress, CA 90630
Thank you for helping us maintain up-to-date directory information for your practice.
We’re Just a Phone Call or Click Away
WellCare: 1-866-999-3945 https://www.wellcare.com/medicare
Provider Resources
Provider News – Provider Portal
Remember to check messages regularly to receive new and updated information.
Visit https://provider.wellcare.com/ and click on the Providers tab.
Resources and Tools
Visit https://provider.wellcare.com/ to find guidelines, key forms and other helpful resources. You may also request hard copies of documents by contacting your Provider Relations representative.
Refer to our Quick Reference Guide, for detailed information on many areas including Claims, Appeals and Pharmacy.
These are at www.wellcare.com/medicare, click on Resources under your state.
Please remember that all Clinical Guidelines detailing medical necessity criteria for several medical procedures, devices and tests are also available on our website, click on Clinical Guidelines under Tools.
