September 1, 2014  
Help Members Reduce Costs With In-Network ReferralsInNetworkReferrals
To help our members keep costs down, refer those who need additional services to in-network providers. Depending on the benefits and the type of service being provided, a member may be responsible for all or a greater portion of the charges when care is from an out-of-network provider. 
  • Routine Preventive Care - To be covered, our Choice product requires members to receive routine preventive care from a Tier 1 provider. All other products require members to receive routine preventive care from an in-network provider.
  • Emergency Care - All plans provide in-network benefits for out-of-network emergency services.
  • Other Types of Care, Including Pathology, Radiology, Anesthesia - Determined by member's coverage:
    • Premier, Choice, and CorePlus* cover out-of-network services at a higher member cost share.
    • Preferred does not cover nonemergency out-of-network services.
    • IMCP's member cost share is the same for in- and out-of-network care.

Although an out-of-netwok provider's service may be covered, he or she may balance bill a member for any differences between the billed charge and our allowance.

 

To locate an in-network provider in Iowa, Nebraska, or South Dakota:

  1. Visit provider search.
  2. Select the patient's product name.
  3. Select one of the links listed in the Local Provider search tool (Doctor, Clinic/Hospital, Pharmacy).
*CorePlus is our new product for 2015, pending Centers for Medicare & Medicaid Services (CMS) and state approval.

  

Importance of Submitting Complete DiagnosesCompleteDiagnosis

When a patient presents with more than one diagnosis or comorbidity, it's important to include all diagnoses on your claim. Appropriate coding drives appropriate benefit administration and payment.   

 

Proper coding also helps identify the health of your patient and our member. Why is this important? Three Affordable Care Act provisions - the 3 Rs - help protect financial exposure:
  • The Reinsurance program provides us with limited exposure to high-dollar claims.
  • The Risk Adjustment and Risk Corridor programs provide us with additional funds if we have attracted a disproportionately unhealthy population in total.

To learn more about the 3 Rs, see Explaining Health Care Reform: Risk Adjustment, Reinsurance, and Risk Corridors.

HealthCoaching 

Refer Patients for Personalized Health Coaching and Behavioral Strategies  

Help your patients receive the support needed to manage their conditions and optimize their health by referring to our Disease and Case Management program, a key component of our partnership with HealthPartners Administrators, Inc.

 

Disease Management provides support and coaching to patients with these conditions: asthma, coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), diabetes, cancer, and low back pain, and pregnancy. The team also supports patients with 14 additional rare neurological, pulmonary, rheumatologic, and hematologic diseases. Patients with congestive heart failure (CHF) and COPD patients have the added benefit of in-home telemonitoring for risk management.

 

Complex Case Management focuses on patients with complex medical diagnoses who are experiencing frequent hospitalizations, emergency room use, increasing medical complexity and utilization, psychosocial issues, and/or a decline in functional status.

  

Using fully integrated systems, processes and information platforms, these services have been shown to optimize health and care, reduce hospital admissions and readmissions, and maximize appropriate use of available resources - all while enhancing an exceptional experience for patients and physicians.

  

How the Services Work 

Using personalized health coaching techniques and behavioral strategies including Intrinsic Coaching and Shared Decision Making, Disease and Case Managers provide tailored interventions designed to:  

  • Support medication adherence.
  • Ensure coordination of patient care and management of barriers.
  • Identify and close gaps in care.
  • Strengthen the patient's relationship with their provider and clinic. 

Registered nurses, registered dietitians, pharmacists and social workers ensure that each patient receives the support and level of service appropriate to his or her circumstances. They collaborate with physicians frequently throughout the duration of the patient's participation in the program, including care plan updates and reports of the patient's progress toward goals.  

 

Take one of these actions to refer a patient: 

Revised ICSI Guidelines - Diabetes ProtocolDiabetesProtocol

Institute for Clinical Systems Improvement (ICSI) health care guidelines represent the most appropriate medical practice for a range of common preventive services, chronic diseases and acute conditions.

  
A Health Care Protocol is a step-by-step statement of a procedure routinely used in the care of individual patients to assure that the intended effect is reliably achieved. The following Health Care Guideline has recently been updated:

Please review and implement, if appropriate, some or all of the procedures within the clinical practice of your medical group. For complete copies of all ICSI Guidelines, Protocols and Order Sets, visit the ICSI website, or call ICSI at 1.952.814.7060 for a hard copy.

 

Taking Control of Your Diabetes Conference - September 27DiabetesConference

The Taking Control of Your Diabetes (TCOYD) national conference comes to the Iowa Events Center in Des Moines on Saturday, September 27.

 

Designed for healthcare providers, the TCOYD Making the Connection CME conference focuses on four distinct areas of diabetes management:

  • Promoting behavioral change in diabetes
  • Oral agents for use in patients with type 2 diabetes
  • Injectable agents for use in patients with type 2 diabetes
  • Intensive management strategies for patients with type 1 diabetes

Register online by Friday, September 19.

 

This CME course is being held in tandem with the large-scale patient education conference, which has separate workshop tracks, but comes together for the keynote speaker and lunch. For registration information, your patients can visit TCOYD.org (look for the Des Moines September 27 event).

 
Product and Network Changes for 2015 ProductChanges
As announced in the August Provider Alert, we will offer CoOportunity CorePlus* in Iowa for 2015. This is a new select network product with out-of-network benefits.
  
The CorePlus provider network is a subset of Midlands Choice providers which includes the University of Iowa Health Alliance member organizations. These same providers will support the 2015 CoOportunity Preferred product. We will market CorePlus and Preferred in 64 Iowa counties for 2015; we marketed Preferred in 76 counties for 2014.
  
While many providers will not see a change in their network status next year, some will. If your network status is changing on January 1, 2015, you will receive a letter from us in September. Later this fall, we will post an online 2015 Provider Directory that reflects upcoming changes. The current Provider Directory will also remain available for members to access for 2014 services. Only the 2015 directory will be available in January 2015.
  
We will continue to share more about CorePlus over the next few months.
  
*Pending Centers for Medicare & Medicaid Services (CMS) and state approval

  

Check Member Eligibility via Secure WebsiteSecureWebsite
To make sure that your patients' CoOportunity Health coverage is still in force, frequently check our secure Provider website. This service is available 24/7, and there's no hold time. Secure tools include:
  • Claims Status Inquiry
  • Eligibility and Benefits
  • Remittance Inquiry and Optional Email Notification
Want a time-and-date stamped document that contains the eligibility search results? After receiving eligibility results for the entered member, select:
  1. More actions drop-down box (top right)
  2. Print (or save) benefits to PDF
Not registered for secure access? Visit coOportunityhealth.com/provider.
  
Medical Policy UpdatesMedicalPolicyUpdates
Review September's medical policy update to review changes to the following medical policies.
Discussing Denied Authorizations for Healthcare ServicesDeniedAuthorizations
If an authorization for healthcare services or items is denied based on Medical Policy/Coverage Criteria, providers have the right to discuss the decision with a clinician.
  
For assistance, call Utilization Management at 1.888.467.0774. Staff members are available 8 a.m. to 5 p.m., CT (Central time), Monday through Friday.
  
Access Medical Policies for Pharmacy InformationMedicalPoliciesPharmacy
Two of our medical policies provide information about medications.
  • Minimum/Maximum Drug Dosage - This policy provides information about the minimum and maximum dosage and billing units allowed per administration for certain professionally-administered medications. Claims may not be paid for quantities outside these limits. A list of drugs and codes are included in this policy. 
  • Recent Food and Drug Administration (FDA) Approved Medications Coverage Policy  - This policy provides information about medications recently approved by the FDA that have not yet completed review by the CoOportunity Health Drug Formulary Committee. Until our committee completes its review, these drugs require individual review and approval for payment via our Prior Authorization process. This includes:
    • New medications that are professionally administered. A list of professionally administered drugs requiring authorizations is accessible from this medical policy. To submit a request, use the Procedures prior authorization form.
    • All self-administered medications as indicated within the EnhancedRx Drug List with a stethoscope symbol. This symbol indicates that you should check medical benefits. For example, the Drug List description for Stelara 45mg shows that a medical policy is accessible for Stelara and the a prior approval is required. To request, submit the prior authorization form within the medical policy (see Related Content). 

Two New Prior Authorization Forms for DrugsPriorAuthFormsforDrugs

For most situations, use the Prior Authorization/Exception Form to submit a prior authorization for drugs. This is also used to request a coverage exception for an excluded drug. Although CoOportunity Health may approve an otherwise excluded drug, we do not review or approve requests to reimburse drugs at a different member cost share/tier level.

 

You'll find the complete list of pharmacy forms on the Forms page, Pharmacy tab.

Information is available on our Disease and Case Management Process for Providers and at Disease/Case Management.

  
Reminder of Drug List UpdatesDrugListUpdate
Some Drug List changes that became effective July 1, 2014, did not require members who were already taking the drug to change to another product until September 1, 2014. A few of these changes follow:
  • Symbicort, an inhaler for asthma and COPD, requires prior authorization and is now a nonformulary drug. If a prior authorization request is approved, Symbicort will be covered at the member's nonformulary cost share. Members using Symbicort were asked to change to preferred products (Advair and Breo) by September 1.
  • Januvia and Janumet, oral medications for diabetes, changed to nonformulary drugs. Replacement drugs Tradjenta and Jentadueto were changed to formulary drugs. Members using Januvia and Janumet were asked to change to Tradjenta and Jentadueto by September 1.
  • Relpax, a drug for migraine headaches, was removed from the formulary. Preferred alternatives include sumatriptin and rizatriptan, faster-acting triptans. Members using Relpax were asked to change to formulary products by September 1. 
Remember, all CoOportunity Health members use the EnhancedRx Drug List, although some have different cost-share amounts.

  

Additional Information

If you have additional questions, contact our Pharmacy Customer Service 24/7:

  • Telephone: 1.800.492.7259
  • Fax: 1.888.883.5434
  • HealthPartners Pharmacy Services, PO Box 1309, Minneapolis, MN 55440  
Tools for New Providers and Staff Membersfornewprovidersandstaffmembers
Access these tools to learn more about us at coOportunityhealth.com/Provider.

For access to our secure Provider website tools, contact your organization's site delegate or register today.