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Fourth Quarter 2019
NewsletterMaryland HealthChoice Program
Provider
IN THIS ISSUE uuUpdate to the Formulary ......... 2 MedStar Family Choice Survey Results ..........................................2
Welcome New Providers ......... 3
1099 Statements ........................4
Member Complaint/Grievance and Appeal Process ................. 4
Report Overpayments or Improper Payments .................. 5
Health Education Schedule .... 5
Healthy Life Portal .................... 5
Emergent Care Project ............ 6
MedStar Family Choice Site Evaluations ............................... 6
Redetermination Process ........ 7
Providers Needed for Community Health Events ...... 7
Provider Contacts ..................... 8
Clinical Practice and Preventative Guidelines .......... 9
Smoking Cessation ................ 10
Pharmacy and Therapeutics Committee .............................. 11
Claims Address Reminder .... 11
Provider Training Available Now Online ............................. 12
MedStar Safety Moment ....... 12
90-Day Pharmacy Supply Now AvailableAs a participating provider of MedStar Family Choice Maryland HealthChoice, we are pleased to announce that our members can receive a 90-day supply of certain medications at participating retail pharmacies. The list of medications available for 90-day supply treat cardiovascular, central nervous system, endocrine/metabolic, gastrointestinal, hematologic, immulogic, respiratory, and other chronic conditions.
To start the process, simply send a prescription to the retail pharmacy for a 90-day supply. MedStar Family Choice members can also sign up for mail order pharmacy for chronic medications. A 90-day supply will be provided to members using mail order services. To start the process, prescribers may call CVS Caremark Mail Service Pharmacy™ at 800-996-5772 or they may submit a prescription to the CVS Caremark Mail Service Pharmacy™.
For a complete listing of medications available a 90-day supply and mail order pharmacy information, please visit our website at https://www.medstarfamilychoice.com/maryland-healthchoice/for-maryland-healthchoice-physicians/pharmacy.
For questions about coverage for any medication formulary or non-formulary, please call 800-905-1722, option 2.
HIV/AIDS Prescription Coverage ChangeAs of January 1, 2020, HIV/AIDS medicines will no longer be paid for by the State of Maryland Fee-For-Service. Instead, individual Managed Care Organizations (like MedStar Family Choice) will manage and pay for HIV/AIDS medicines for their members.
MedStar Family Choice created an “open” formulary for HIV/AIDS medicines that will be effective January 1, 2020. What this means is that all FDA approved HIV/AIDS medications are included on the formulary and available to our members. Additionally, MedStar Family Choice does not charge a copay for medication. As such, members will notice that they no longer have a copay at the pharmacy for their HIV/AIDS medicine(s).
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MedStar Family Choice Survey ResultsMedStar Family Choice wants you to stay informed on how we are doing. For updated information on survey results such as HEDIS, Satisfaction Surveys, System Performance Reviews, EPSDT audits, and the Consumer Report Card, please visit the MedStar Family Choice Quality Assurance and Monitoring webpage: MedStarFamilyChoice.com/Maryland-HealthChoice/For-Maryland-HealthChoice-Physicians/Quality-Assurance-and-Monitoring-Programs
Paper copies are available upon request by calling 888-404-3549. As we continue to improve and strive for high scores, your dedication to quality health care is very much appreciated.
HEDIS is a registered trademark of the Nation Committee for Quality Assurance (NCQA).
Update to the MedStar Family Choice FormularyDetails of the prior authorization criteria are available on the MedStar Family Choice Pharmacy webpage with the other pharmacy protocols. For more information, please call the MedStar Family Choice Provider Relations department at 800-905-1722, option 5.
CHANGES BELOW ARE EFFECTIVE AS OF OCTOBER 15, 2019.
Additions:
• Baqsimi (glucagon, nasal)
• Steglujan (ertugliflozin and sitagliptin)
Additions with Prior Authorization* required:
• Nubeqa (darolutamide)
• Piqray (alpelisib)
• Polivy (polatuzumab vedotin-piiq)
• Revatio 20 mg (sildenafil) – Effective November 22, 2019
• Turalio (pexidartinib)
Removals*:
• Invokana (canagliflozin) - to be removed on January 1, 2020.
Remocal of Prior Authorization:
• None
Managed Drug Limitations & Step Therapy**:
• None
*Details of the prior authorization criteria are on the MedStar Family Choice website in the Prior Authorization Table.
**Details of the step therapy criteria are on the MedStar Family Choice website in the Step Therapy Table.
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Welcome New Providers to MedStar Family Choice MedStar Family Choice would like to welcome the following new providers to our network!
• Aurora Health Services LLC (Family Medicine, Laurel, Prince George’s County)
• Capital Internal Medicine and Geriatrics (Internal Medicine, Washington, DC)
• Carroll Pediatric Center (Pediatrics, Sykesville, Carroll County)
• City Dermatology LLC (Internal Medicine, Bladensburg, Prince George’s County)
• Elliece S Smith MD PC (Obstetrics and Gynecology, Lanham, Prince George’s County)
• Freedom Hearing Center LLC (Audiology, Prince Frederick, Calvert County)
• Maryland Center for Neurology and Sleep (Neurology, Glen Burnie, Anne Arundel County)
• MedStar Georgetown Transplant Institute (Cardiovascular Disease, Frederick, Frederick County)
• MedStar Medical Group Fort Lincoln (Family Medicine, Colmar Manor, Prince George’s County)
• MedStar Medical Group Infectious Diseases Good Samaritan Hospital (Infectious Diseases, Baltimore, Baltimore County)
• MedStar Southern Maryland Vascular and General Surgery Ctr (General Surgery, Clinton, Prince George’s County)
• Next Level Eye Care (Optometry, Jessup, Howard County)
• Precision Eye Care (Ophthalmology, Baltimore, Baltimore County)
• Privia Medical Group Clarii Health (Physician Assistant PCP, Columbia, Howard County)
• Regional Cancer Care Associates (Hematology Oncology, Washington, DC)
• Richard S Cohen DPM PA (Podiatry, Greenbelt, Prince George’s County)
• Vinu Ganti MD PC (Internal Medicine, Germantown, Montgomery County)
• Yeshnik and Associates MD PA (Obstetrics and Gynecology, Westminster, Carroll County)
In addition, we welcome the following ancillary provider groups into the network:
• Skilled nursing facilities: Arlington West Care Center, Post-Acute Care Center, Westgate Hills Rehabilitation and Healthcare Center
• Ambulatory Surgical Center: Delmar Surgical Center LLC
• Dialysis: NxStage Kidney Care Greenbelt
• Hospice: Hospice of the Chesapeake Inc
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1099 Statements MedStar Family Choice will be mailing 1099 statements during the month of January. The 1099s are mailed to the last W-9 address we have on file. It is possible that you may not receive your statement in the mail if MedStar Family Choice was not notified that the W-9 address we have on file for your office changed in the previous year.
Providers who need to update their billing address information should email their updated billing information along with a W-9 to MedStar Family Choice Provider Relations at [email protected] or fax to 410-933-3077.
Your information will then be updated in our system. If your W-9 address did not change and you received your 1099 statement for the last calendar year through the mail, then you do not need to send an update. All requests for a copy of a 1099 statement should be directed to 800-261-3371. Please contact Provider Relations with questions and concerns at 800-905-1722, option 5.
Member Complaint/Grievance and Appeal ProcessThe MedStar Family Choice complaint/grievance and appeal procedure that members follow can be found on our website at MedStarFamilyChoice.com and in your provider manual.
If you do not have access to our website or a provider manual, you may contact Provider Relations at [email protected] or 800-905-1722, option 5, for a copy of the manual.
The process will tell you the following:
• How members can file a complaint, grievance or appeal, and the differences between them
• How quickly we will respond to the member and the provider
• What to do if the member does not agree with our decision
Please note that providers may not appeal a decision on the member’s behalf without written permission from the member.
Members have the right to contact the HealthChoice Enrollee Help Line at 800-284-4510, Monday through Friday, 7:30 a.m. to 5:30 p.m., when they have a concern about a decision made by MedStar Family Choice.
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Providers Responsible to Report Overpayments or Improper Payments Within 60 DaysMedStar Family Choice encourages providers to conduct regular self-audits to ensure accurate payment. Medicaid funds that were improperly paid or overpaid must be returned within 60 days of discovery. If your practice determines it has received overpayments or improper payments, you are required to:
• Return the overpayment to MedStar Family Choice within 60 calendar days after the date on which the overpayment was identified.
• Notify MedStar Family Choice in writing of the reason for the overpayment.
If you receive an overpayment for your claims, contact MedStar Family Choice Claims department at 800-261-3371 and then send the refund, the reason for the overpayment and a copy of the Explanation of Payment(s) identifying the overpayment to the address below:
MedStar Family Choice Maryland Claims P.O. Box 2189 Milwaukee, WI 53201 800-261-3371
Health Education Schedule We offer health education classes free of charge to MedStar Family Choice members. Classes are designed to appeal to our members on many health levels. For example, prenatal classes are available for moms-to-be, along with education for infant safety and sibling classes. These are just a few classes offered through the birth and family education listings. In addition to these classes, MedStar Health hospitals offer blood pressure screenings, and cancer, diabetes and heart disease education, as well as smoking cessation support. Providers are encouraged to refer members to these classes and document the referrals, as well as the member’s feedback, in the member’s chart.
Visit MedStarFamilyChoice.com for a complete listing of classes. If you do not have access to the Internet, you may call MedStar Family Choice Provider Relations at 800-905-1722, option 5, for a listing of classes.
The MedStar Family Choice Healthy Life PortalDid you know MedStar Family Choice offers our members access to the Healthy Life Portal to track their own health?
The Healthy Life Portal contains a meal planner as well as easy-to-use logs to track their calories, weight, blood pressure, glucose, cholesterol, and more. The portal also has health education information and offers gift cards to members for completing a health survey and other workshops. The Healthy Life Portal can help your patients earn while they learn!
MedStar Family Choice members who are 18 years and older can access the portal by visiting and registering at MedStarFamilyChoiceHealthyLife.com.
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Emergent Care ProjectMedStar Family Choice has an Emergency Room Diversion Workgroup with the goal to decrease avoidable Emergency Department (ED) usage by our members. The Emergent Care Team includes MedStar Family Choice associates from Case Management, Outreach, Social Work, Emergent Care, Community Relations, and Quality. The workgroup focuses on MedStar Family Choice members with high-dollar utilization of the ED as well as address barriers to care that members face. MedStar Family Choice is striving to improve care for its members through face-to-face visits. From these visits, MedStar Family Choice determines barriers to care and then works to overcome those barriers. Barriers to primary care can include accessibility, transportation, safety concerns, and others.
Members are being contacted by the MedStar Family Choice Emergent Care RN, who has over two decades of ED experience. She is meeting with members to discuss their recent ED visits and barriers to seeing their primary care provider. The members are provided with information regarding use of the 24-hour Nurse Advice Line, a list of available urgent care providers and the opportunity to apply for a Safelink cell phone. Initially MedStar Family Choice will reach out to the member by phone and if needed schedule a face-to-face meeting. During the initial face-to-face home visit the Emergent Care RN determines the member’s barriers to care and any other medical needs. If Case Management is needed, a second visit will be scheduled. At this visit, the Emergent Care RN accompanied by a MedStar Family Choice Case Manager will focus on the specific health care needs of the member and encourage the member to enroll in Case Management. The Emergent Care nurse and/or the Case Management Nurse will assist with transportation, social work issues, and medication/ prescription access as well as primary care access issues.
This year, MedStar Family Choice is partnering with Alegis Care (an in-home population health and clinical services company) to go out to our member’s homes to perform physical exams, medication reconciliation, evaluate social determinants of health and contact MedStar Family Choice case management for our difficult to reach high dollar members.
This face-to-face engagement will help MedStar Family Choice to establish a strong relationship with our members, with the ultimate goal of offering and coordinating improved access to appropriate care overall. Member satisfaction is measured through a post-program follow-up phone call.
MedStar Family Choice Site Evaluations Site surveys are completed for all MedStar Family Choice PCPs and specialists at the time of initial credentialing. If a member complaint is received about the physical condition of the provider office, a follow-up site audit will be performed.
New provider sites and site additions also require a site evaluation after MedStar Family Choice Provider Relations is notified of the change or addition.
Claims for visits at the new location will be treated as out of network until the site visit has taken place.
If you have any questions or comments regarding minimum standards for site evaluations, please contact your provider representative at 800-905-1722, option 5.
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Providers Needed for Community Health EventsMedStar Family Choice is dedicated to community health events and outreach. Many of our events feature health screenings for our members along with other fun and exciting activities. With events occurring throughout each year, MedStar Family Choice is always looking for providers to assist with event health screenings.
If you cannot participate at an event, MedStar Family Choice can also schedule “wellness days” in your office. The MedStar Family Choice team can work with you to help make a “wellness day” successful in your office.
If you’re interested in joining us in a community or setting up “wellness days” in your office, please email MedStar Family Choice Provider Relations at [email protected] or call 800-905-1722, option 5.
Redetermination ProcessMedicaid recipients must renew their eligibility every 12 months. This process is also known as getting a “redetermination.” Redeterminations for most Medicaid recipients will now be processed in Maryland Health Connection. Maryland Health Connection will process redeterminations for the following recipients:
• Under 65 years of age
• Parent or caretaker relative of a minor child
• Pregnant women
• Children enrolled in Medicaid
• Former foster care children
Some redeterminations will continue to be processed through the local Department of Social Services (DSS). The local DSS will continue to process redeterminations for the following recipients:
• Over 65 and are not a parent or caretaker relative of a minor child
• Blind
• Disabled
• Living in a nursing facility
• Current foster care children
Recipients are mailed letters from Maryland Medicaid 45 to 60 days in advance of their redetermination deadline. We encourage you to discuss redetermination requirements with your patients to make sure they are completing their redetermination applications in a timely manner.
For recipients who are enrolled in a managed care organization: If a recipient loses coverage due to not completing his or her redetermination application, the recipient will be re-enrolled into the same managed care organization he or she was in previously if the gap in enrollment is less than 120 days.
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MedStar Family Choice Provider ContactsEach participating MedStar Family Choice provider is assigned a provider representative to assist offices with questions regarding the MedStar Family Choice health plan. Your representative is assigned to you according to the ZIP code of your office. If you are not certain who your provider representative is, please call or email MedStar Family Choice Provider Relations, and we can assist you.
Provider Relations: [email protected] or 800-905-1722 option 5 Provider Orientation / Targeted Education, Site Evaluations for New Locations, Demographic Changes, Provider Terminations, Assistance with non-claim related Provider question/concerns, Provider Contracting
Credentialing Status Checks: [email protected]
Ancillary Network (Home Care, DME, Urgent Care, etc.): [email protected] Provider Orientation/Targeted Education, Ancillary Contracting, Assistance with ancillary questions/concerns
Outreach Department: 800-905-1722, option 1 or 888-991-2232 (fax) Newborn Coordination, Member Compliance
Care Management: 800-905-1722 or 888-243-1790 (fax) Pharmacy, inpatient and outpatient authorization (including medical vision), Case Management
Claims (Claims Status, Eligibility Verification, Member Benefits, PCP Assignment) Provider Claims Portal: https://medstarpwp.wonderboxsystem.com/PWP/Landing If you need assistance accessing the portal, please call 844-275-8756.
MedStar Family Choice Claims Processing Center PO Box 2189 Milwaukee, WI 53201 800-261-3371
EFT Assistance: [email protected]
Eligibility Verification: 866-710-1447 MD EVS
Behavioral Health/Substance Abuse: 800-888-1965 (Public Behavioral Health Systems)
Dental
• For children under 21 years and pregnant women: 844-275-8753 (Maryland Healthy Smiles Program)
• For adult members: 833-241-4248 (Avesis)
Routine Vision: 833-241-4248 (Avesis)
You may contact MedStar Family Choice, Monday through Friday, between 8:30 a.m. and 5 p.m. Providers have the option to leave a message or send a fax after normal business hours. However, any calls and faxes received after hours will be addressed the next business day.
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Participating providers should review the clinical practice guidelines, as well as the preventive guidelines, posted on the MedStar Family Choice website, MedStarFamilyChoice.com, for updates. These guidelines are updated every two years. Currently, the clinical practice guidelines include the following:
• Management of Pediatric ADHD
• Diagnosis and Management of Asthma in Adults
• Diagnosis and Management of Asthma in Children and Adolescents
• Diagnosis and Management of Pediatric Acute Asthma Exacerbation
• Treating Acute Asthma Exacerbations in Adults and Children
• Management of Acute Low Back Pain in Adults
• Management of Bronchiolitis in Pediatrics
• Management of Bronchitis in Adults
• Management of Bronchitis in Children and Adolescents
• Diagnosis, Management and Prevention of COPD
• Outpatient Diagnosis and Management of Venous Thromboembolic Disease
• Identification and Management of Clinical Depression in Adults
• Management of Adult Diabetes Mellitus
• Assessment and Prevention of Falls in the Elderly
• Management of Hyperbilirubinemia in the Healthy Newborn
• Management of Hypercholesterolemia
• Management of Hypertension in Adults
• 2019 Immunization Schedules – Adult and Pediatric
• Prescribing Naloxone in the Outpatient Setting
• Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity
• Identification, Evaluation, and Treatment of Overweight and Obesity in Adults
• Osteoporosis Screening and Management
• Managing Otitis Media in Children
• Opioids for Pain Management
• Cervical Cancer Screening for the Primary Care Physician
• Guideline for Perinatal Care
• The Diagnosis and Management of Pharyngitis in Adults
• The Diagnosis and Management of Acute Group A Streptococcal Pharyngitis in Adolescent and Pediatric Patients
• Community Acquired Pneumonia – Adult
• Community Acquired Pneumonia – Pediatric
• 2019 Preventive Screening Recommended Guidelines – Adult and Pediatric
• Outpatient Use of Proton Pump Inhibitors
• Management of Sinusitis – Adult
• Management of Sinusitis in Children Ages 1 to 18
• Outpatient Management of Pediatric Urinary Tract Infection
All clinical practice guidelines are PDFs and can be downloaded. Alternatively you may contact Provider Relations at 800-905-1722, option 5, to request hard copies of these guidelines.
Clinical Practice and Preventive Guidelines
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Did you know?When addressing tobacco dependence …
• Combining long-acting nicotine replacement treatment (NRT) options—like the patch—with short-acting NRT—such as the gum, lozenge or spray—can support quitting.
• Combination pharmacotherapy—using Varenicline and Bupropion SR together—appears to be more effective than use of either alone (Ebbert et al., 2009).
Visit MDQuit.org/Cessation-Programs.
Smoking Cessation Benefits In an effort to assist our members who are interested in or are trying to live a smoke-free life, MedStar Family Choice offers a variety of smoking cessation classes and over-the-counter smoking cessation drugs that are free of charge to our members. Providers must write a script for over-the-counter medications and give it to the member to present to the pharmacy. A full list of covered smoking cessation products can be found on our formulary. If you have a patient that can benefit from a smoking cessation classes and/or a support group, you can find dates and times for these classes on our Health Education Schedule of Classes at MedStarFamilyChoice.com.
Additional counseling resources are also available for your patients through the Maryland Tobacco Quitline at 800-QUIT-NOW (800-784-8669). Visit SmokingStopsHere.com for more information and materials. This program is available to all Maryland residents and provides confidential smoking cessation counseling 24 hours a day/seven days a week.
Individuals 18 years and older interested in nicotine replacement therapy (NRT) may be eligible for free nicotine patches or gum. Specialized support programs are available for pregnant women and adolescents (13 to 17). If you are interested in how you can refer your patients directly to the Maryland Tobacco Quitline to help them quit smoking, consider becoming a Fax to Assist certified provider!
Visit MDQuit.org/Fax-to-Assist or visit the MDQuit Resource Center web page at MDQuit.org for more information. Visit MDQuit.org or call the MDQuit Resource Center UMBC Psychology department at 410-455-3628 for more information on Maryland’s Quit Line.
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Paper Claims Address Reminder All claims should only be mailed to the following address at:
MedStar Family Choice Maryland Claims P.O. Box 2189 Milwaukee, WI 53201 800-261-3371
MedStar Family Choice accepts and encourages electronic claims submissions for both professional claims and institutional claims. Claims can be submitted using the following online services:
Professional Claims
• Capario (formerly Medavant ProxyMed) - Payer ID 00243
• SDS (Smart Data Solutions) - Payer ID 39190, 4775
• Change Healthcare (formerly Emdeon) - Payer ID 39190
• Change Healthcare (formerly Relay Health) - Payer ID 4775
Facility Claims
• Change Healthcare (formerly Emdeon) - Payer ID 39190
• Change Healthcare (formerly Relay Health) - Payer ID 3614
• Payerpath (aka Allscripts) - Payer ID 521995799
• SDS (Smart Data Solutions) - Payer ID 39190, 3614
• XactiMed (Aka MedAssets) - Payer ID 521995799
Claims are also accepted directly via 837 and online claims submissions.
Pharmacy and Therapeutics Committee MedStar Family Choice has an active Pharmacy and Therapeutics Committee that meets the third Wednesday of every other month from noon to 1:30 p.m. Please consider getting involved and bringing your expertise and input to this committee. Some of the activities of the committee include:
• Reviewing and updating policies and procedures for pharmaceutical management
• Assessing drug utilization patterns and making recommendations for projects to address issues as they arise
• Reviewing the MedStar Family Choice closed formulary, at least annually, and evaluating requests for additions/deletions to the formulary
• Developing interventions to ensure the safe use of medications. If you are interested in joining the Pharmacy and Therapeutics committee, please contact your Provider Relations representative at 800-905-1722, option 5.
95233 King Ave., Suite 400 Baltimore, MD 21237 888-404-3549 PHONE
The MedStar Family Choice Newsletter is a publication of MedStar Family Choice.
Submit new items for the next issue to MedStar Family Choice at [email protected].
Kenneth A. Samet, FACHE President and CEO, MedStar Health
Eric Wagner President, MedStar Family Choice
Margo Briscoe Manager, Provider Relations
MedStarFamilyChoice.com
19-MFCMD-0099-11222019
Providers Training Now Available OnlineAs a MedStar Family Choice provider, you are required to take annual trainings. But MedStar Family Choice has made it easier to satisfy your training requirements.
Both the Provider Orientation Training and Cultural Diversity Training are now available as on-demand online trainings. This means the trainings can be taken online at any time. There is no need to travel or schedule these trainings for a specific date and time at your office.
Both online trainings are available on the MedStar Health Simulation Training & Education Lab (SiTEL) website, which delivers online education, experiential learning, and performance support tools for all roles across the MedStar Health system.
Direct links to the Provider Orientation Training and Cultural Diversity Training online are available on the MedStar Family Choice Provider Resources webpage: https://www.medstarfamilychoice.com/maryland-healthchoice/for-maryland-healthchoice-physicians/provider-resources
If you have any questions or concerns about these online trainings or SiTEL, please email MedStar Family Choice Provider Relations at [email protected] or call 800-905-1722, option 5.
MedStar Safety Moment - Opioid Prescription RequestAfter getting their morphine prescription denied, a MedStar Family Choice member called our Outreach department and was adamant about receiving their medication immediately. Our outreach representative immediately sent the information to one of our clinical authorization nurses.
Our clinical authorization nurse checked the pharmacy benefit management system which tracks each members’ opioid requests. The system showed the rejection was for Morphine IR (Immediate-Release) 15mg 60 tabs for 30 days. One day prior, the member filled Oxycodone 10mg 120 tabs (30-day supply) so they already had a short acting medication. The Opioid prior authorization form on file is for Morphine ER (Extended-Release) 15mg. Our nurse called the pharmacy to see if the prescription was processed appropriately. The pharmacy said it did not have ER or IR. It was written just as Morphine 15mg taken for chronic pain.
Next, our nurse called the prescribers office and asked what was prescribed. Based on the prescription notes, the medication should have been Morphine ER but unfortunately doctor Extended Release was not reflected on the prescription. We informed the doctor of the potentially significant negative outcome. The doctor’s office called the pharmacy to correct the prescription and then update the patient.
The MedStar Family Choice clinical team is collectively saving lives with these opioid measures and we’re grateful to be able to help.
