PROVIDER
Newsletter
SOUTH CAROLINA | 2015 | ISSUE I
IN THIS ISSUE
Coming Soon! New Provider
Services Technology ...Page 1
Provider Satisfaction Survey ...Page 2
Appointment Access and
Availability Audits ...Page 3
HEDIS Tips...Page 3
Availability of Review Criteria ...Page 4
Access to Utilization
Management Staff ...Page 4
Q1 2014 Provider
Formulary Update ...Page 4
Clinical Practice Guidelines ...Page 5
2014 CAHPS Survey Results ...Page 6
Provider Resources ...Page 8
COMING SOON!
NEW PROVIDER SERVICES TECHNOLOGY
WellCare is excited to unveil some major technology improvements in early 2015. You will see a difference in the speed and quality of service that you get when you call us.
• Are you tired of spending additional time with Customer Service to identify yourself?
• Are you tired of internal transfers?
• Are you tired of spending time to validate member information?
• Would you prefer to complete some of these standard inquiries via self-service?
We listened to your feedback, and soon you will be able to provide your information, as well as your member’s, within our Interactive Voice Response system. This will greatly reduce the time you spend on the phone when calling us.
In preparation for these changes, we want to provide some quick tips to help you navigate this new process. Have the following information available with each call:
1. WellCare provider ID number
2. NPI or Tax ID number for validation if you do not have your WellCare provider ID number
3. For claims inquiries – the member’s ID number, date of birth, date of service and dollar amount
4. For authorization and eligibility inquiries – the member’s ID number and date of birth
Some additional features will soon be available, including improved call menus and enhanced self-service capabilities. You will also be able to select between speaking your commands or using your touch-tone keypad to enter selections. All of these changes are being implemented to make it easier to do business with us. Thank you for your support and all that you do for our members.
PROVIDER SATISFACTION SURVEY
WellCare continues to focus efforts on the experiences of both our members and providers. In order to better understand and remain well-informed about our valued provider network, we conducted a Provider Satisfaction Survey in 2013, and again in 2014. The survey concentrated on a variety of subjects, including call center/member services, provider relations, continuity/coordination of care, provider network, utilization and quality
management, finance issues, pharmacy and drug benefits, and overall satisfaction and loyalty.
Extensive reviews of our 2014 survey results are underway to ensure that our focus aligns with the needs of our providers. Current areas of focus include enhancing provider services at the local level, claim processing and issue resolution, enriching administrative tools/capabilities, and continued emphasis on quality. WellCare is
continuously engaged with several cross-functional teams working on these initiatives, and others that are aimed at better serving our providers. We anticipate incremental gains on several initiatives in 2015 and continued improvement beyond. These efforts will be further communicated as the year progresses.
Shortly, WellCare will again conduct a Provider Satisfaction Survey. This follow-up survey will be used to measure progress from last year’s effort to better evaluate how we can become more effective and productive business partners.
Your participation is encouraged – and appreciated – as together we strive to improve our members’ overall quality of care.
HEDIS TIPS
The start of a new calendar year also marks the start of a new HEDIS® year! We thank you for the care you and your staff provide to your patients — our members. As you know, our goal is to ensure that every member receives the care they need to stay healthy. It is also our goal to make every effort to ensure all of our providers receive the credit that is deserved for caring for our members.
The following tip may be helpful to receive deserved credit during the current HEDIS year:
If you use EHR (electronic health records), please be sure that the software captures health education/
anticipatory guidance (CPT 99381-99397), BMI (body mass index) percentile plotted on an age-growth chart (V85.1-V85.54), counseling for nutrition (V65.3), and counseling for physical activity (V65.41). If these components are not being captured and/or submitted in the claims information, your office probably is not receiving appropriate credit. Consider contacting your software vendor for assistance to capture these measures.
If you need to fax the Quality Improvement (QI) Department HEDIS/CareGap information, please use the following number: 1-866-291-4158.
Please notify your PR rep if you have any questions.
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, The Myers Group, and keep us compliant with NCQA and other accreditation entities.
Auditors identify themselves when calling providers’ 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 given an opportunity to respond, and will be re-audited in 90 days.
For more information on appointment access and availability audits, please contact your PR rep.
3
ACCESS TO UTILIZATION MANAGEMENT STAFF
The Utilization Management (UM) section of your Provider Manual contains detailed information related to the UM program. Your patient, our member, can request translation services and materials in a different format including other languages, large print and audio tapes. There is no charge for this service.
If you have questions about the UM program, please call Provider Services at the number listed on your Quick Reference Guide located at www.wellcare.com/South- Carolina/Providers/Medicaid
AVAILABILITY OF REVIEW CRITERIA
The determination of medical necessity review criteria and guidelines are available to providers upon request.
You may request a copy of the criteria used for specific determination of medical necessity by calling Provider Services at the number listed on your Quick Reference Guide at www.wellcare.com/South- Carolina/Providers/Medicaid.
Also, please remember that all Clinical Coverage Guidelines, detailing medical necessity criteria for certain medical procedures, devices and tests, are available on our website at www.wellcare.com/
South-Carolina/Providers/Clinical-Guidelines.
Q1 2014 PROVIDER FORMULARY UPDATE
The WellCare of South Carolina Preferred Drug List (PDL) has been updated. Visitwww.wellcare.com/South-Carolina/
Providers/Medicaid/Pharmacy to view the current PDL and pharmacy updates.
You can also refer to the Provider Manual available at www.wellcare.com/South-Carolina/Providers/Medicaid to view more information regarding WellCare of South Carolina’s pharmacy Utilization Management policies/procedures.
CLINICAL PRACTICE GUIDELINES
Clinical Practice Guidelines (CPGs) are best practice recommendations based on available clinical outcomes and scientific evidence. WellCare CPGs reference evidence-based standards to ensure that the guidelines contain the highest level of research and scientific content. CPGs are also used to guide efforts to improve the quality of care in our membership. The CPGs listed below are available on our Provider website atwww.wellcare.com/
South-Carolina/Providers/Clinical-Guidelines/CPGs.
GENERAL CLINICAL PRACTICE GUIDELINES
• Asthma
• Cholesterol management
• Chronic heart failure
• Chronic kidney disease
• COPD
• Coronary artery disease
• Diabetes in adults
• Diabetes in children
• HIV antiretroviral treatment in adults
• HIV screening
• Hypertension
• Imaging for low back pain
• Lead exposure
• Obesity in adults
• Obesity in children
• Osteoporosis
• Pharyngitis
• Rheumatoid Arthritis
PREVENTIVE HEALTH GUIDELINES
• Adult preventive health
• Postpartum guidelines
• Preconception and interpregnancy
• Pregnancy
• Preventive health pediatric
BEHAVIORAL HEALTH CPGs
• ADHD
• Depressive disorders in adults
• Depressive disorders in children
• Schizophrenia
• Substance use disorders
• Suicidal behaviors
5
2014 CAHPS SURVEY RESULTS
WellCare of South Carolina values our members (your patients). It is our goal to partner with providers in improving members’ health. We want members to have a positive experience when seeking health care. One way we do this is by collaborating with The Myers Group (TMG), an NCQA certified HEDIS® survey vendor, to administer an annual Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey. The CAHPS survey helps us determine and address any problems or concerns members may be having in receiving health care. The graphs below show a part of the results from the 2014 survey.
WELLCARE OF SOUTH CAROLINA Medicaid Adult CAHPS
100%
80%
60%
40%
20%
0% 2014
Your Plan
2013 2012
Benchmark Summary Rate Comparisons (8-10*) Rating of Health Care (Q13)
65% 71% 71% 71% 70% 70%
NA NA NA
Quality Compass All Plans Benchmark TMG Benchmark
100%
80%
60%
40%
20%
0% 2014
Your Plan
2013 2012
Benchmark Summary Rate Comparisons Getting Needed Care
77% 80% 81% 81% 76% 76%
NA NA NA
Quality Compass All Plans Benchmark TMG Benchmark
*Rating of health plan based on scale of 1-10.
Performing these surveys helps us make improvements in our members’ health care experience.
As a provider, you have an opportunity to improve your patients’ satisfaction by:
• Being informed and up to date about the care the patient has received from other doctors and health care providers
• Having readily available appointments
• Spending enough time with the patient
• Explaining the patient’s health status in a way they understand
• Listening to and showing respect for the patient
Source: The Myers Group 2014 CAHPS Medicaid Adult and Child 5.0H Final Report
WELLCARE OF SOUTH CAROLINA Medicaid Child CAHPS®
100%
80%
60%
40%
20%
0% 2014
Your Plan
2013 2012
Benchmark Summary Rate Comparisons (8-10*) Rating of Health Care (Q13)
82% 84% 83% 83% 83% 84%
NA NA NA
Quality Compass All Plans Benchmark TMG Benchmark
100%
80%
60%
40%
20%
0% 2014
Your Plan
2013 2012
Benchmark Summary Rate Comparisons Rating of Health Care (Q13)
88% 85% 84% 85%
79% 81%
NA NA NA
Quality Compass All Plans Benchmark TMG Benchmark
*Rating of health plan based on scale of 1-10. 7
WE’RE JUST A PHONE CALL OR CLICK AWAY!
WellCare of South Carolina 1-888-588-9842
www.wellcare.com/South-
PROVIDER RESOURCES
SC028411_PRO_NEW_ENG
©WellCare 2015 SC_12_14 State Approved 01122015
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WEB RESOURCES
Visit www.wellcare.com/South-Carolina/Providers/Medicaid 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/South-Carolina/Providers/Medicaid.
PROVIDER NEWS
Remember to check messages regularly to receive new and updated information. Visit the secure area of www.wellcare.com/South- Carolina/Providers to find copies of the latest correspondence.
Access the secure portal using the provider drop-down menu. You will see Messages from WellCare located in the right-hand column.
