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Provider NewsA PEHP ProvidEr rElAtions PUBliCAtion
More UseFUL News & iNForMatioN For Provider PartNers
iNside Preferred drug list Updates
Working toreduce incidents
of Prematurity» PAG E 9 » PAG E 1 0
COVER STORY» PAG E S 2 - 7
sP
rin
G 2
01
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Buckle up fora scenic tourof what’s newfor PEHP andour providers
PaGe 2
Provider News
In the healthcare business, if you’re
not constantly moving forward, you’re
falling behind. That’s never been more
true than it is today.
Recent reform at both the federal
and state level is changing the face of
healthcare. At the same time, PEHP is
also rolling out changes. They include
claims processing, member ID cards,
and dual coverage policies. Even our
website is getting a facelift.
Join us as we move forward with
a foot on the accelerator and
not a second glance in the
rear-view mirror.
CovEr storyin thisissue
3 Standardization of PEHP Member ID Cards
4-5 Compliance with Electronic Transactions and ICD Code Changes
4 Re-launching our Public Website
6 New Rules for Dual Coverage
7 PEHP and Healthcare Reform
7 Termination of PEHP (CHIP) Exclusive Care Plan
8 Additions to Pharmacy Pre-Authorization List
8 Enforcing Correct Utilization of CPT Modifiers
9 Changes to the PEHP Preferred Drug List
10 Reducing the Incidence of Prematurity
10 Provider Directory Accuracy
11 Provider Relations Representatives
12 Contact List CH
An
GE
riGHt tHis WAy
new laws, new
procedures, new
technologies – here’s
a roadmap for the
crossroads ahead
Provider News
PaGe 3
In the healthcare business, if you’re
not constantly moving forward, you’re
falling behind. That’s never been more
true than it is today.
Recent reform at both the federal
and state level is changing the face of
healthcare. At the same time, PEHP is
also rolling out changes. They include
claims processing, member ID cards,
and dual coverage policies. Even our
website is getting a facelift.
Join us as we move forward with
a foot on the accelerator and
not a second glance in the
rear-view mirror.
The Utah Legislature recently passed House Bill 52, that calls for uniform electronic standards for health insurance. As part of the new law, all carriers in Utah are required to list information in specific areas of members’ ID cards.PEHP will issue new, standardized ID cards beginning July 1, 2010, to new members. The new cards will be issued at existing members’ plan renewal dates. However, employer groups may choose to have new cards issued sooner. After the new standardization is in place, swipe-card technology will be implemented to assist providers with electronic queries. Grants to help providers obtain swipe-card readers may be available.Providers need to verify with their vendor to confirm reader capability. In addition, providers need to determine electronic eligibility with UHIN. Additional information with regard to this healthcare enhancement will be forthcoming.
COVER STORY: Standardizing Member ID Cards
setting an industry standard
» Simplifies the billing process
» Eases readability
» Increases efficiency and accuracy
» Identifies important information easily
» Enables swipe card technology
For more information about the new cards, go to the UHIN website at http://www.uhin.org/pages/posts/health-identification-card-standard-88.php
Benefits of this standardization
Office Copay $0.00
Specialist Copay $0.00
Yearly Deductible $0.00
State Regulated
Subscriber
JACK J SMITH
ID
PEHP
Space above or below the essential information may be used at the sole discretion of the card user. This area identifies the PEHP Plan.
let’s see some idThe standardization of information on PEHP member’s ID cards:
Essential information justified to left margin.
Information may be higher or lower vertically along the left and right margins. No other information may be interspersed between information elements.
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Provider News
Big changes are on the way to make claims processing faster and more accurate.
On Jan. 1, 2012, standards for electronic healthcare transactions
will change from Version 4010 to Version 5010. This applies to
functions such as claims, eligibility inquiries, and
remittance advices. Unlike the
current Version 4010,
Version 5010 accommodates the
ICD-10 (International Classification of Diseases,
10th edition) code sets. Version 5010 must be in place
before the implementation of the ICD-10 code sets to ensure adequate
testing and implementation time.Effective Oct. 1, 2013, ICD-10 will replace
the current ICD-9 code sets used to report healthcare diagnoses and procedures. The new ICD-10 code sets incorporate much greater specificity and clinical information and are more consistent with today’s practices. These changes have been mandated by the Health Insurance Portability and Accountability Act (HIPPA).
Why comply?» PEHP will not pay claims improperly coded
with ICD-9 after October 1, 2013. In order to receive proper payment, healthcare organizations must meet transition dates such as the completion of end-to-end testing prior to the compliance date. End-to-end testing with business partners is essential to ensure interoperability of processes and systems and will require significant advance planning.
» Adoption of ICD-10 will reduce payment errors and speed up reimbursement.
Provider’s Main Focus» Determine how to implement the changes» Ensure office systems are compliant with
the standards and requirements related to the change. For example:
• Existing practice management billing system software may need to be replaced or updated to accommodate the 5010 electronic transaction standards and ICD-10 code sets. (We encourage you to speak with your practice management vendor or clearinghouse to determine what they are doing to prepare for this change.)
• Vendor, clearinghouse, health plan
COVER STORY: New Technologies
Electronic transactions & iCd Code – Get ready for an Upgrade
June 1, 2010» Providers should have begun internal testing of Version 5010 standards for electronic claims.
Compliance timeline | Transition dates are definite
dec. 31, 2010» Internal testing of Version 5010 must be complete to achieve Level I, Version 5010 compliance. This means a covered entity can demonstrably create and receive compliant transactions, resulting from the compliance of all design/build activities and internal testing.
Jan. 1, 2011» Payers and providers should begin external testing of Version 5010 for electronic claims.
July 1, 2011» Payers should be on track to begin testing with providers.
PEHP claims histories and all benefit and out-of-pocket limits
are updated daily and can be viewed at www.pehp.
org. If you need more specific
information, call PEHP at 801-
366-7555 or 800-765-7347.
did YoU KNow?
PaGe 5
Provider News
PEHP will soon be launching an improved public website on July 1, 2010, with a complete redesign. We have consulted website professionals, members, and providers to create what we hope will be a much more user-friendly site. As part of our redesign, and in response to provider input, we will be adding additional content, including new information on:
» Care Management & Wellness
» Claims & Billing
» Contracts & Credentialing
» Dental
» Electronic Data Interchange (EDI)
» Online Services
» Pharmacy
We believe these modifications will allow you to quickly find important information. Please see for yourself in July at www.pehp.org.
COVER STORY:Improved Website
new-look siteto launch July 1
COVER STORY: New Technologies
Electronic transactions & iCd Code – Get ready for an Upgrade
dec. 31, 2011» External testing of Version 5010 for electronic claims must be complete to achieve Level II, Version 5010 compliance. This means a covered entity has completed end-to-end testing with each of its trading partners and is able to operate in production mode with the new versions of the standards.
Jan. 1, 2012» All providers must be in full compliance with Version 5010 for electronic transactions. Version 4010 claims will no longer be accepted.Moving to Version 5010 by the deadline would be in your best interest to ensure your claims don’t fail.
oct. 1, 2013» Claims for services provided on or after this date must use ICD-10 codes for medical diagnoses and inpatient procedures; claims submitted with ICD-9 codes after this date will fail.
contracts, and data requirements will need to be reviewed and amended or replaced.
• Super bills and corresponding mapping strategies will need to be updated.
• Billing forms may need to be revised or replaced.
training sessionsAs October 2013 approaches, implementing training sessions on the actual ICD-10 code sets can begin. Since ICD-10 is updated annually and code sets may change before the implementation date, providers are encouraged not to start training until closer to the effective date of the change.» Clinical and administrative staff will need
training on new code sets and changes to the technology.
» Physicians may need to be trained on updated clinical documentation practices for quality and accuracy.
» Certified coders will need to take certification tests.
More information about this upcoming implementation will be shared as it is available.
did YoU KNow?We are on track to complete the Version 4010 to 5010 conversion and will begin testing with providers by the third quarter of 2011.
PaGe 6
All participating providers (other than hospitals)
who have a superuser name
and password can obtain allowable
amounts on up to 10 separate
codes or an unlimited range
of codes by logging on to
www.pehp.org, clicking on for Providers and
selecting Fee Schedule Lookup. The fees obtained
can be copied into an Excel spreadsheet.
did YoU KNow?
Provider News
COVER STORY: New Rules for Dual Coverage
Consistent, standardized Claims ProcessingPEHP is changing how we pay claims for members with dual coverage.
PEHP applies the rules established by the Utah Insurance Department to claims with external coordination of benefits. However, we don’t currently apply them to dual coverage, which is defined as enrollment in two PEHP medical plans that are composed of inter and intra agency/employer groups. In order to be consistent in claims processing and the industry standard, PEHP will begin to apply those rules to dual coverage claims beginning July 1, 2010.
After that time, we will no longer waive deductibles, copayments, and coinsurances under secondary PEHP coverage. Instead, the secondary plan will administer benefits according to Maximum Allowable Fees and plan structures that may include deductibles, copayments, and coinsurance.
There may be situations when the secondary plan provides full coordination, depending on the plan benefits. However, a member’s secondary PEHP coverage will never pay more than it would if it were primary.
All claims with dates of service prior to the effective dates listed in the chart on the right will be processed under the previous dual coverage rules.
EFFECTIVE DATE
PRIMARY SECONDARY DATES OF SERVICE
9/1/10
Canyons School District Canyons School District
9/1/10and after
Jordan School District Jordan School DistrictNebo School District Nebo School District
USBA USBA
7/1/10
Canyons School DistrictAny employer group other than Canyons
School District
7/1/10and after
Jordan School DistrictAny employer group
other than Jordan School District
Nebo School DistrictAny employer group
other than Nebo School District
USBA Any employer group other than USBA
7/1/10
Any employer group other than Canyons
School DistrictCanyons School District
7/1/10and after
Any employer group other than Jordan
School DistrictJordan School District
Any employer group other than Nebo School District
Nebo School District
Any employer group other than USBA USBA
7/1/10
Any employer group other than USBA or
Canyons, Jordan and Nebo school districts
Any employer group other than USBA or
Canyons, Jordan and Nebo school districts
7/1/10and after
PaGe 7
Provider News
In March the federal healthcare reform bill was signed into law. This new law brings many changes to our healthcare system and how it will function in the future. Benefits for some PEHP employer groups, such as the policy for 26-year-old coverage and plan lifetime maximums, have already been altered. Additional modifications will begin in 2011 and continue through 2014 when the law mandates the completion of specific changes. We are working with our employer groups to plan the implementation of these
changes. Additionally, the State of Utah continues to move forward with healthcare reform programs. Significant progress has been made with the all-payer claims database, a tool to be used to support some of the healthcare reform projects. It may take a great deal of collaboration with our providers and members to execute some of the changes. Fortunately, we enjoy strong partnerships with the provider community and look forward to working with you to improve the healthcare our members receive.
COVER STORY: PEHP and Healthcare Reform
Collaborative Effort to implement Changes
PEHP will no longer administer CHIP (Children’s Health Insurance Program) for the Utah Department of Health, beginning July 1, 2010.However, PEHP will continue to pay claims received up to 12 months from date of service if the service occurred prior to July 1, 2010. When PEHP is the secondary payer, we will continue to pay claims received
up to 15 months from the date of service providing the service occurred prior to July 1, 2010.CHIP members will receive new Identification Cards reflecting this change in payer coverage. All member eligibility and benefits information after June 30 must be obtained through SelectHealth or Molina Healthcare.
PEHP Will no longer Administer CHiP
did YoU KNow?COB enhancements have been made to our adjudication system to accommodate the electronic claims submission and payments of COB claims. We are hoping to be in production soon.
PaGe 8
Provider News
Hospitals can obtain
information related to
allowed amounts by
contacting their Provider
Relations Representative.
Because hospital fee schedules
can be complex, the allowed fees can’t be
obtained online.
did YoU KNow?
Pharmacy
Additions to PEHP Pre-authorization listSome drugs require pre-authorization due to their potential for misuse, adverse reactions, safety issues, contraindications, opportunity to use first line therapy, and cost.Call 801-366-7555 or 800-765-7347 to start the pre-authorization process. Access forms at www.pehp.org. We’ll let you, the provider, know if the pre-authorization request has been approved or denied. Members may also call 801-366-7705 or 800-765-7347 for status of the request.
Pre-authorization does not guarantee payment. Coverage is subject to eligibility, benefit coverage, and pre-authorization requirements. Below is a listing of new medications that have been added to our pre-authorization list. The J or Q code is included, where applicable.
EFFECtivE dAtE
drUG nAME J or Q CodE
07/01/09 ACIPHEX07/01/09 ADCIRCA07/01/09 FERAHEME Q0138, Q013907/01/09 FERRLECIT J291607/01/09 LANSOPRAZOLE07/01/09 NASACORT AQ07/01/09 OMNARIS07/01/09 PREVACID07/01/09 PRILOSEC (BRAND NAME)
07/01/09 RHINOCORT AQ07/01/09 SAMSCA07/01/09 VENOFER J175607/01/09 VERAMYST07/01/09 ZEGERID08/01/09 LOTRONEX08/06/09 RELISTOR09/01/09 ALIMTA J930509/01/09 ONSOLIS10/01/09 INTUNIV10/01/09 SABRIL
EFFECtivE dAtE
drUG nAME J or Q CodE
10/01/09 TYVASO11/01/09 BUPRENOPHRINE11/01/09 FOLOTYN C925911/01/09 SUBOXONE11/01/09 SUBUTEX11/12/09 VOTRIENT12/01/09 ARZERRA01/01/10 SINGULAIR02/01/10 ACTEMRA02/01/10 CHENODAL02/01/10 ILARIS02/01/10 OFORTA02/01/10 ZAVESCA03/01/10 CAYSTON04/01/10 REVATIO INJ04/01/10 VPRIV05/01/10 VICTOZA 05/01/10 CESAMET05/01/10 QUTENZA07/01/10 INFED J1750
Enforcing Correct Utilization of CPt ModifiersPEHP will continue to review and enforce the correct utilization of CPT modifiers 25 and 59. When submitting claims, we encourage your office to review the CPT guidelines for a
significant and separately identifiable evaluation and management service by the same physician on the same day of a procedure (modifier 25) and a distinct procedural service (modifier 59 ).
PaGe 9
Provider News
drUG nAMEForMUlAry CHAnGE
tiEr ForMUlAry AltErnAtivE
ACEON Non-formulary 3 PERINDOPRILADCIRCA Specialty 4 NOT APPLICABLEALDARA Non-formulary 3 IMIQUIMODALTACE Non-formulary 3 RAMIPRILBONIVA Non-formulary 3 ALENDRONATECATAPRESS-TTS Non-formulary 3 CLONIDINE PATCHCELEBREX* Non-formulary 3 IBUPROFEN, NAPROXEN,
MELOXICAMCOREG CR Non-formulary 3 CARVEDILOLDUAC Non-formulary 3 BENZACLIN GEL, BENZOYL
PEROXIDEEFFIENT Non-formulary 3 PLAVIXEXELON PATCH Non-formulary 3 EXELON CAPSULE, ARICEPTFOSRENOL Non-formulary 3 PHOSLO, RENVELAHYPER-SAL Formulary 2 NOT APPLICABLEIMDUR Non-formulary 3 ISOSORBIDELACRISERT Non-formulary 3 OTC GENTEAL, SYSTANE,
REFRESH, ETC.LAMICTAL ODT Non-formulary 3 LAMOTRIGINEMONOKET Non-formulary 3 ISOSORBIDEMULTAQ Formulary 2 NOT APPLICABLE NUVIGIL Formulary 2 NOT APPLICABLEONGLYZA Non-formulary 3 JANUVIAONSOLIS Non-formulary 3 FENTANYL CITRATEPENTASA Non-formulary 3 ASACOL, BALSALAZIDE,
COLAZOL, SULFASALAZINEPLAN B Non-formulary 3 NEXT CHOICEPROVIGIL Non- formulary 3 NUVIGILRESTASIS Non-formulary 3 OTC GENTEAL, SYSTANE,
REFRESH, ETC.SAPHRIS Non-formulary 3 SEROQUEL, ZYPREXA,
GEODON, RISPERIDONESEROQUEL XR* Formulary 2 NOT APPLICABLESTARLIX Non-formulary 3 NATEGLINIDESUBUTEX Non-formulary 3 BUPRENORPHINETOPROL XL Non-formulary 3 METOPROLOL XLTUSSIONEX Non-formulary 3 HYDROCODONE WITH
HOMATROPINEURSO, URSO FORTE Non-formulary 3 URSODIOLXOPENEX HFA Non-formulary 3 PROAIR HFAZETIA Non-formulary 3 CRESTOR, LIPITOR, VYTORIN,
NIASPAN, FENOFIBRATEZYMAR Non-formulary 3 VIGAMOXZYPREXA ZYDIS Non-formulary 3 ZYPREXA TABLET
The PEHP Preferred (Formulary) Drug List can be an effective tool to assist both members and providers in choosing the most effective and economical medication to treat a specific condition.PEHP has created a Pharmacy and Therapeutics Committee (comprised of local physicians, nurses, and pharmacists) to assist in the management of formulary drugs.Quarterly, this committee reviews new and existing brand name and generic medications to ensure PEHP’s Preferred Drug List contains medications that provide our members with the best overall value based on safety, efficacy, side effect profile, adverse reactions, therapeutic category, and cost effectiveness.The committee’s recommendations are implemented twice a year (January and July) to guide our members to the safest and most effective therapy while managing the rising cost of pharmaceuticals. The chart on the right reflects the most recent changes recommended for 2010.Find the Preferred Drug List at www.pehp.org. Click Pharmacy Corner and then Preferred Drug List. * Pre-authorization no longer required.
Pharmacy
Changes to the PEHP Preferred drug list
Provider News
PaGe 10
Access to many functions on www.pehp.org requires
the completion and signing of an Electronic
Trading Partner Agreement
(ETPA). The ETPA can be
printed from the for Providers
section of www.pehp.org.
did YoU KNow?
Who should receive 17-P?» Women who have had a
previous preterm birth of a singleton pregnancy due to spontaneous preterm labor or premature rupture of membranes and who are now pregnant with a single fetus.
How is it given?» Weekly
intramuscular injections, 250 mg., beginning between 16-21 weeks (can be initiated later).
What is the cost?» About $200 for the entire
series, or $7.50 per dose. It is a covered PEHP pharmacy benefit.
How is it obtained?» Currently there are no
FDA approved sources. It can only be obtained through University Pharmacy, Salt Lake City.
Who endorses 17-P?» American College of Obstetrics and Gynecologists, March of Dimes, Utah Department of Health, and other healthcare professionals.
An important goal of WeeCare is to reduce the incidence of prematurity. A significant risk factor is OB patients who have had a previous preterm birth. A promising intervention, 17-P (17 alpha hydroxyprogesterone caproate) J3490 (NOC), has been shown to reduce the risk of a recurring preterm birth by 33%. WeeCare nurses Debbie and Kathy discuss this potential intervention with women who have had a previous preterm birth and encourage them to discuss it further with their doctors.
The accuracy of our Provider Directories depends on you. Please contact your Provider Relations Representative by mail, e-mail, or fax with updated information when:
Provider directory Accuracy
» An individual provider joins or leaves your clinic /group.
» The clinic/group/practice/facility is no longer in business.
» The name of the clinic, facility or individual changes.
» The billing address, phone number or fax number changes.
» The TIN or NPI number changes.
» Additional locations are added.
new intervention shows Promisein reducing incidence of Prematurity
WeeCare is PEHP’s pregnancy case management service. It’s a prenatal risk reduction program that offers education and consultation to expectant mothers.To contact WeeCare» Phone: 801-538-9943 | 800-662-9660» E-mail: [email protected]» Web: http://health.utah.gov/mihp/weecare
Provider News
PaGe 11
AREA #1Chantel LomaxProvider Relations Specialist
Phone: 801-366-7507 or 800-753-7407Fax: 801-245-7507E-mail: [email protected]
In-State CitiesDraper (84020), Holladay (84117, 84121 & 84124), Salt Lake City, Sandy (84070, 84090, 84091, 84092, 84093 & 84094)
Out-of-StateColorado
AREA #3Liz BeasleyProvider Relations Specialist
Phone: 801-366-7721 or 800-753-7721Fax: 801-245-7721E-mail: [email protected]
In-State CountiesCarbon, Daggett, Duchesne, Emery, Juab, Millard, Sanpete, Tooele, Uintah, Utah, Wasatch
Out-of-StateWyoming
In-State CitiesHerriman (84065 & 84096),Kearns (84118), Magna (84044), Midvale (84047),Riverton (84065, 84095 & 84096), South Jordan (84065 & 84095), Taylorsville (84084, 84118 & 84119), West Jordan (84084 & 84088),West Valley (84117, 84119, 84120 & 84128)
AREA #5Selena JohnsonProvider File Technician
Phone: 801-366-7511 or 800-753-7311Fax: 801-245-7511E-mail: [email protected]
Out-of-State All states other than those listed above
AREA #2Wendy Philbrick Provider Relations Specialist
Phone: 801-366-7753 or 800-753-7753Fax: 801-245-7753E-mail: [email protected]
In-State CountiesBox Elder, Cache, Davis, Morgan, Rich, Summit, Weber
Out-of-StateArizona, Idaho
In-State CitiesMurray (84107, 84123 & 84157)
AREA #4Glenda LoweClient Liaison
Phone: 801-366-7496 or 435-673-6300 or 800-950-4877Fax: 435-634-0654E-mail: [email protected]
In-State CountiesBeaver, Garfield, Grand, Iron, Kane, Piute, San Juan, Sevier, Washington, Wayne
Out-of-State CitiesLas Vegas, NevadaMesquite, Nevada
Provider relations representativesTo provide optimal service to PEHP providers, each Provider Relations Representative is assigned a specific area to manage. This assignment is based on the physical locations of the providers. If you are unsure who your representative is, please call PEHP at 800-365-8772 or 801-366-7700.
MAILING ADDRESSESArea #4Glenda Lowe
URS/PEHP166 North 100 East #9St. George, UT 84770
All Other Areas & Representatives
PEHP560 East 200 SouthSalt Lake City, UT 84102
Case Management . . . . . . . . . . . . 801-366-7755 or 800-753-7490
Disease Management . . . . .801-366-7755 or 800-753-7490
Customer service/ Pre-authorization . . . . . . . . . . . . . . 801-366-7555 or 800-765-7347
Edi Helpdesk . . . . .801-366-7544 or 800-753-7818
inpatient Medical Pre-notification . . .801-366-7755 or 800-753-7490
inpatient Mental Health & substance Abuse AuthorizationBlomquist Hale Consulting Group (BHCG)
Canyons School DistrictJordan School DistrictNebo School District
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 801-262-9619 or 800-926-9619 Mental HealthCare of Utah (MHCU) All other employer groups. . . . . . . . . . . . . . . . . . . . . . . . .801-293-7400 or 800-541-9432
Wellness Program . . . . . . . . . . . . . 801-366-7478 or 800-753-7478
PEHP Waist Aweigh Obesity Intervention Program
. . . . . . . . . . . . . . . . . . . . . . . .801-366-7478 or 800-753-7478
Provider relations . . . . . . . . . . . .801-366-7557 or 800-677-0457
Glenda Lowe . . . . . . . . . . . .801-366-7496 or 800-950-4877Client Liaison [email protected]
Chantel Lomax . . . . . . . . . .801-366-7507 or 800-753-7407Provider Relations Specialist [email protected]
Liz Beasley . . . . . . . . . . . . . .801-366-7721 or 800-753-7721Provider Relations Specialist [email protected]
Wendy Philbrick . . . . . . . . .801-366-7753 or 800-753-7753Provider Relations Specialist [email protected]
Selena Johnson . . . . . . . . . .801-366-7511 or 800-753-7311Provider File Technician [email protected]
Beryle Bird . . . . . . . . . . . . . .801-366-7795 or 800-753-7595Provider Relations Analyst [email protected]
Cortney Larson . . . . . . . . . .801-366-7715 or 800-753-7715Director of Provider Relations [email protected]
PEHP Website . . . . . . . . . . . . . . . . . www.pehp.org
Contact list
560 East 200 South | Salt Lake City, UT 84102-2004
05/25/10
Provider NewssPrinG 2010A PEHP ProvidEr rElAtions PUBliCAtion
