BETTER RESulTS

Spring/Summer 2011
Better Results
ALERTS & REMINDERS
Click here to access all Provider forms
Requests for Clinical Edit Reconsideration
Remember to send a completed Request for Reconsideration form, including
all necessary medical records and documentation with all requests. If submitted
incomplete or without the required documentation, the form will be returned.
Timely Filing Guidelines
Remember to send a completed Request for Reconsideration form along
with EDI proof of submission (if electronically filed). In order to be reimbursed
for services rendered, all providers must comply with the timely filing limits as
outlined in their provider contract.
Demographic Changes
Please use the Demographic Change form to notify
us of all changes to your :
• Physical address
• Remit address
• Email address
• Tax ID numbers
CLICK HERE
to access forms
mentioned above,
as well as all other
QualChoice forms
• Changes in provider staffing
(moves, additions, retirements)
When To Call
CareCore
Ordering physician should
obtain authorization from
CareCore prior to scheduling
any type of high tech imaging.
CareCore
Pre-Certification Line:
800.533.1206
(7am - 7pm, M-F)
CareCore Fax Line:
888.785.2486
(24 hrs/dy; 7 dys/wk)
High Tech Imaging Prior Authorization
QualChoice utilizes CareCore National to provide prior authorization services
for high tech imaging. The ordering physician is responsible for obtaining prior
authorization whenever a member requires high tech imaging. If a procedure is
not properly authorized, it will not be reimbursed and the member cannot be
balance billed.
Spring/Summer 2011
Be sure to visit the Provider section of our website to find important
information (past provider newsletters, provider alerts, authorization
forms and much more)! Also from our website, you can sign up or
log in to access eligibility and claims status verifications. Visit
www.qualchoice.com and use your provider log-in to access information for members and providers.
GENETIC TEST PRE-AUTHORIZATION
Richard Armstrong, MD / Vice President, Medical Affairs
Personalized medicine and genetic testing continues to
grow rapidly and offers many new tools for providers to
better diagnose and treat their patients. With the advent
of many new genetic tests available to physicians, some
still under investigation, it can be cumbersome to determine which ones are clinically appropriate and useful.
QualChoice’s evidence-based policies, provided in
partnership with DNA Direct, are developed using a
systematic development process that includes extensive
and ongoing literature review. The parameters that are
reviewed include:
• Clinical Utility: The net balance of risks and
benefits associated with using a test
I am pleased to inform you that to assist QualChoice providers
in determining which genetic tests are appropriate for their patients we have released new, test category specific guidelines
for genetic tests. All genetic tests require a pre-authorization,
which QualChoice will review against the new clinical policies
and test specific criteria. The new clinical policies cover the
following test categories:
• Clinical Validity: The test accurately detects or
predicts a given phenotype or outcome
• Analytical Validity: The test accurately and
consistently detects the presence of a specific
biomarker
• Ethical, Legal, Social Implications: Liability
issues, testing for family members, etc.
33 Genetic Testing for Carrier Screening and Reproductive Planning
• The impact to medical care of the member
33 Genetic Testing for Prenatal Screening and Diagnostic Testing
For more information about how to request a pre-authorization
or to access the medical policies, click here, or call us at
501.228.7111 or 800.235.7111. We look forward to providing you a resource for better understanding genetic testing.
33 Diagnostic Genetic Testing of a Symptomatic
Patient for Diseases Other Than Cancer
33 Predictive Genetic Testing or Risk Assessment for
Diseases Other Than Cancer
33 Genetic Testing for Cancer Susceptibility and
Hereditary Cancer Syndromes
All genetic tests require
pre-authorization!
33 Genetic Testing for the Screening, Diagnosis and
Monitoring of Cancer
33 Pharmacogenomic Testing for Drug Toxicity and
Response
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Spring/Summer 2011
PREVENTIVE MEDICINE CODES
Stephen Sorsby, MD, MHA / Medical Director
Preventive medicine services should be reported with codes 99381-99386 and
99391-99396.
These codes should be used for visits during which an age and gender appropriate comprehensive history and physical is performed, and appropriate
counseling, guidance, and/or risk factor reduction interventions are provided.
If insignificant abnormalities are noted that do not require performing separate work, no additional code should be added. If an abnormality is noted or
pre-existing condition is addressed that is separate and significant enough to
require additional work to perform the key components of a problem oriented
E/M service, then the appropriate office code 99211-99215 should also be
reported with the modifier 25 added.
EXAMPLE
If a 45 year old man presents for an annual physical, and during the course of the physical you notice a
mole on his back which he says is not changing and you find to be non-concerning, you would code the
visit as 99386 only.
If instead he incidentally notes that he experienced shortness of breath walking the dog last weekend,
which leads you to do a more detailed examination of his neck, heart, lungs, and extremities and an EKG
before concluding that he is simply out of shape, you might code the visit as 99386 and 99213-25.
Over half of all unintended pregnancies in the United States happen in women who are using some form of contraception.
These usually result from “use failure” (such as missing a pill or failing to use a condom), rather than from failure of the
method itself. The failure rate of oral contraceptives in actual use is 8%; the failure rate of long acting reversible contraceptives (IUCs, implants, and injection) is less than 1%.
The copper containing IUC ParaGard® is immediately effective and can be used as long as 10 years. The levonorgestrel
containing IUC Mirena® is effective within 7 days, and can be used as long as 5 years. Unlike the IUDs of the 70’s and 80’s,
these IUCs only increase the rate of PID for the first 20 days after insertion; in WHO studies, about 4/1000 women using
IUCs developed PID. These IUCs are easier to insert and less prone to expulsion than older IUDs, and can be used in nulliparous women. ParaGard® does not disrupt the normal menstrual cycle, though women may have heavier bleeding or
longer periods. Mirena® typically reduces menstrual bleeding; 30-40% of women will have complete cessation of periods
within two years of Mirena® placement.
Implanon® delivers a constant level of etonogestrel. Implanon® becomes effective within four days, and can be used for as
long as 3 years. Implanon® commonly causes menstrual irregularity, and a small number of women experience weight gain.
Besides being more effective, these methods are also less costly for your patients, as they eliminate monthly copays.
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Spring/Summer 2011
PHARMACY NOTES
Barry Fielder, PharmD / Vice President, Pharmacy
The QualChoice formulary applies to QualChoice insured members and products only. Each member should verify the type
of health plan they have by checking their QualChoice ID card, their Benefit Summary or their Evidence of Coverage Outpatient Prescription Drug Rider.
To verify if a member’s medication does or does not require pre-authorization, click here.
PHARMACY CHANGES/ADDITIONS
1st Quarter 2011
Click here for Preferred Drug Lists (PDLs) (updated 4/1/2011)
BRAND NAME
THERAPEUTIC CLASS/TREATMENT
ENHANCED
CORE
UTILIZATION MANAGEMENT
Dulera
Antiasthmatic
3
3
Pradaxa
Anticoagulant
3
3
Lo Loestrin Fe
Oral Contraceptive
3
3
Beyaz
Oral Contraceptive
3
3
Safyral
Oral Contraceptive
3
3
Atelvia DR
Osteoporosis
3
4
Kombiglyze XR
Antidiabetic
3
3
Cycloset
Antidiabetic
4
4
Egrifta
Growth Hormone Releasing Hormone
5
5
Specialty; PA required
Halaven
Metastatic Breast Cancer
Medical
Medical
Specialty; PA required
Xgeva
Bone Density Regulators
5
5
Specialty; PA required
Carbaglu
Acute Hyperammonemia
5
5
Specialty; PA required
Gilenya
Multiple Sclerosis
5
5
Specialty; PA required
Tier 4 = 100% member cost share; Tier 5 = Specialty
NEW GENERICS
GENERIC NAME
BRAND NAME
latanoprost
Xalatan
fexofenadine/pseudoephedrine
Allegra-D 24HR
norethindrone acetate-Ethinyl Estradiol
FemHRT 1/5
voriconazole
Vfend
exemestane
Aromasin
UTILIZATION MANAGEMENT EDITS ADDED
Atypical Antipsychotics
Quantity Limits
ADHD Medications
Quantity Limits
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Spring/Summer 2011
MEDICAL POLICY UPDATES
Click here to view all medical policies.
AMENDED
PROCEDURE
IMPLEMENTATION DATE
WHAT’S CHANGED
BI049 - Hearing Aids
Feb 2, 2011
This policy updated to add codes for BICROS (transmitter and receiver)
hearing aids. This policy applies only to those plans that provide coverage for Hearing Aids.
BI099 - Interferon
Feb 2, 2011
This policy updated to include new coverage indicators.
BI157 - Immune Globulin
Feb 2, 2011
This policy amended to include Code J1559 as covered.
BI165 - Multiple Sclerosis
Feb 2, 2011
This policy amended to add Hizentra for pre-authorization.
BI272 - Obstetrical Ultrasound
Feb 2, 2011
This policy amended to clarify criteria for OB ultrasounds.
Hereditary Cancer Policy
Feb 2, 2011
Genetic Testing Update
BI018 - Percutaneous Vertebroplasty
Apr 6, 2011
This policy updated to state that codes 22523-22525 are not covered
and considered experimental/investigative.
BI020 - Chiropractic Care
Apr 6, 2011
This policy updated. Pre-authorization for more than 8 visits is not required.
BI079 - Botulinum Toxins (Botox)
Apr 6, 2011
This policy amended to add as a covered treatment for Migraines.
BI130 - Erythropoeitin Therapy
Apr 6, 2011
This policy amended to describe coverage of erythropoetin, code
J0886, a therapy used to stimulate red blood cell production.
BI165 - Multiple Sclerosis
Apr 6, 2011
This policy amended to add coverage for Gilenya NDC 00078-060751. This code requires pre-authorization.
BI170 - Provigil
Apr 6, 2011
This amended policy clarifies the coverage for Provigil (modafinil) a
medication used to treat various forms of sleepiness when other treatments are not successful. Add Nuvigil- Pharmacy benefit.
BI186 - Radiofrequency Ablation of
Tumors
Apr 6, 2011
This policy amended to update coverage criteria for radiofrequency
ablation (Also references BI293 Plantar Fasciitis).
BI196 - Stereotactic Radiosurgery
Apr 6, 2011
This policy amended to describe coverage for stereotactic radiosurgery.
Apr 6, 2011
This policy describes how some minor office procedures are covered
under the office co-payment and others are covered under the deductible coinsurance provisions of the policy. This BI provides a list of covered procedures for POS plans.
BI222 - Procedures Included
in OV Co-payment
NEW
BI282 - Lung Transplant
Feb 2, 2011
This policy describes the procedure used to treat end-stage lung
disease. Requires Pre-authorization.
BI291 - Peripheral Atherectomy
Feb 2, 2011
This policy describes the procedure used to remove plaque in clogged
arteries. Requires Pre-authorization.
BI293 - Plantar Fasciitis Treatment
April 6, 2011
This policy coverage of treatments related to plantar fasciitis.
5
Spring/Summer 2011
2010 QUALCHOICE PROVIDER SURVEY
compared to other plans in the Arkansas market in overall
QualChoice ranked well above both the state and national
satisfaction among providers.
benchmarks for Provider Satisfaction according to the
2010 Provider Survey conducted by The Myers Group, a
QualChoice improved in their own trend
National Committee for Quality Assurdata percentages in every category as
ance (NCQA) certified survey vendor.
compared to the 2009 and 2008 benchOVERALL
In the survey, respondents were asked
mark data from the previous years’
to rate QualChoice in comparison to all
SATISFACTION
surveys.
other health plans in the Arkansas marRANKING:
ket to measure how well QualChoice
QualChoice ranked higher in Overall
is meeting the provider’s expectations
Satisfaction as compared to the Myers
and needs.
Group, 2009 total Book of Business of
QualChoice
QualChoice ranked an 87.1% in Overall Satisfaction as compared to the
average benchmark score of all other
plans in Arkansas of an 86.1%.
87.1%
Provider Surveys conducted nationally
with ranking of 87.1% as compared to
an average of 81.9% by all other companies nationally. The National average
ranking is considered a benchmark for
Provider Satisfaction surveys.
All Other Plans
in Arkansas
86.1%
QualChoice rated significantly higher
in percentages in every category such as: Member Services, Provider Relations, Claims, Utilization and Quality as
QUALCHOICE PROVIDER DIRECTORY
In May 2011 QualChoice completed an
update to our Provider Directory.
The Directory is now easier to navigate
and has added features such as mapping
capabilities.
Click here to access your new and improved Provider Directory.
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Spring/Summer 2011
NETWORK SERVICES / PROVIDER RELATIONS MAP
CARROLL
BENTON
FULTON
BAXTER
BOONE
CLAY
RANDOLPH
MARION
NEWTON
SEARCY
CRAWFORD
FRANKLIN
STONE
VAN BUREN
JOHNSON
GREENE
SHARP
IZARD
MADISON
WASHINGTON
LAWRENCE
CRAIGHEAD
INDEPENDENCE
JACKSON
CLEBURNE
MISSISSIPPI
Laura Bays
POINSETT
POPE
CONWAY
LOGAN
SEBASTIAN
CROSS
WHITE
ST. FRANCIS
YELL
PERRY
SCOTT
PRAIRIE
LEE
PULASKI
MONTGOMERY
POLK
CRITTENDEN
WOODRUFF
FAULKNER
GARLAND
MONROE
PHILLIPS
HOT SPRING
HOWARD
LONOKE
SALINE
GRANT
JEFFERSON
Debi Thomas
ARKANSAS
PIKE
SEVIER
CLARK
LITTLE RIVER
DALLAS
CLEVELAND
LINCOLN
DESHA
HEMPSTEAD
NEVADA
QUACHITA
DREW
CALHOUN
BRADLEY
MILLER
CHICOT
COLUMBIA
UNION
LAFAYETTE
ASHLEY
Stacey Dority
All Out-of-State Non-Participating Providers (all types)
Out-of-State Participating Providers
Senior PR. Rep.
Stacey Dority
Senior PR. Rep.
Area
State Wide Allied Providers & In-State
Non-Participating Providers
Laura Bays
Oklahoma
Laura Bays
Missouri
Senior PR. Rep.
Provider
Debi Thomas
Tennessee
Assigned Territory Rep.
By Region Location
Debi Thomas
Mississippi
Debi Thomas
National Offices
Debi Thomas
Texas
Arkansas Territories
WRAP Networks
Senior PR. Rep.
Network
Senior PR. Rep.
Debi Thomas
BHSG
Laura Bays
Laura Bays
Coalition America/NPPN
Debi Thomas
Stacey Dority
PHCS
Stacey Dority
7
Area
Spring/Summer 2011
MEMBERS MATTER
QCARE*: Our Exclusive Population Health Management Program
QCARE is our exclusive integrated
health management program that gives
members the valuable medical services and tools they need to help them
better understand and manage their
chronic medical conditions.
Our QCARE programs keep our healthiest members healthy while helping
members with chronic illnesses get the
special attention and preventive care
they need. We believe that consumers who make informed choices and
are engaged in their own care not only
experience better health outcomes —
they experience better health!
QCARE is voluntary and available to all
plan members* at no additional cost.
Inhouse Medical Directors and a team
of registered nurses support all of our
clinical management activities.
NURSE CASE MANAGER - For those
members with severe, chronic condi-
tions, we assign an experienced and
compassionate registered nurse case
manager to serve as their personal
advocate and to help them better
understand their treatment options.
PERSONAL HEALTH COACH - Our
personal health coaches work oneon-one with members in setting and
reaching goals for a healthier life.
Members receive personalized support and educational resources for
weight management, exercise, nutrition, smoking cessation and more
– all with the focus of getting and
staying healthy.
*QCARE programs are not available
to all health plans. Additionally, some
of the QCARE program benefits may
be different for members of highdeductible health plans. The member should check with their benefits
administrator to determine eligibility.
To view all our QCARE Programs,
click here!
BETTER DAY
Diabetes Management
Personalized coaching, support, education, counseling and advocacy helps our
members with diabetes.
BETTER DAY
Healthy Heart
Comprehensive, multi-disciplinary program for the treatment of hypertension.
SPECIAL ADDITIONS
Maternity Management
A prenatal program that provides personalized guidance and information to our
moms-to-be!
CARES
Cancer Management
Compassionate and personalized support
for our members with cancer.
KICK THE NIC!
12-week personalized program with a
health coach. Offers free physician visit
and Chantix (if prescribed).
QNEWS
QualChoice welcomes Dr. Stephen Sorsby as Medical Director
Dr. Sorsby, a physician for 28 years, is responsible for oversight of quality assurance programs within
QualChoice, as well as ensuring quality of care for our members. Dr. Sorsby will assist with the development of physician reports to encourage improved efficiency of care, develop policies to maintain
quality care and manage the provider credentialing and re-credentialing process. Previously, he was
regional medical director of US HealthWorks Medical Group of Washington, where he also served
as chair of the Credentials Committee. He has worked as a family practice physician and owner, and
served in the Army as a surgeon. Sorsby was chief of primary care and community medicine while
stationed at Ft. Bragg, NC and developed a troop medical clinic that served as the standard for future building projects throughout the Army. After graduating in 1983 from UAMS, Sorsby completed his residency in family
practice at Madigan Army Medical Center in Tacoma, WA., where he was selected as chief resident in his third year. He went
on to receive his MHA from the University of Washington, Department of Health Services in Seattle, WA.
8
Spring/Summer 2011
QNEWS
Mark Johnson joins QualChoice as Provider Contracting Manager
Mark Johnson has joined QualChoice as Provider Contracting Manager where he is responsible for
leading network development and contract analysis. He will serve as the key contact to providers
and lead resolution of operational and financial issues. Previously, he held a similar management
position as network development manager at Novasys Health, and most recently as the senior
contract administrator for Mercy Health Plans. With over 15 years of experience in the health care
industry, Mark has filled many roles, including health care analyst at Electronic Data Systems in
Little Rock. He also served as a graduate assistant for both Arkansas Cardiology and the Arkansas
Department of Health. After graduating in 1999 from the University of Arkansas at Fayetteville with
a BS in Microbiology, Johnson completed his MHA at UALR.
2011 QualChoice Classic benefitting Camp Aldersgate
Monday, June 6, 2011
Chenal Valley Country Club
As the event’s Premier Sponsor, QualChoice is in its 3rd year of a multi-year commitment to the ongoing support of Camp
Aldersgate. Last year, through the
generosity and support of golfers
and sponsors, $25,000 was raised
for Camp Aldersgate.
The 2011 QualChoice Classic will take place at Chenal Country Club in Little Rock on Monday, June 6. Registration begins at
11:00am with the official shotgun start at 1:00pm. If you have any questions about the 2011 QualChoice Classic, sponsorships, or donations, please contact Kristin Aburrow, Golf Chairperson, at 501.690.4697 or kristin.aburrow@qualchoice.com.
Click Here to learn more about Camp Aldersgate
Click Here to download the 2011 QualChoice Classic Team Application
CaringBridge - Making Each Health Journey Easier
QualChoice has formed an alliance with CaringBridge, a non-profit organization that provides personal and private websites to connect people who are experiencing a significant health challenge with their loved ones. The site lets patients
and caregivers share health news with everyone who cares. Visitors can also leave messages of support for their loved
one. CaringBridge is safe and helps people overcome physical and emotional distances when ‘being there’ is essential.
To learn more about the incredible HOPE, HEALING and CONNECTION Caring Bridge offers, click here.
If you have patients facing a significant health challenge, CaringBridge is a wonderful recommendation-- 91% of patients
agreed that using CaringBridge helped make their health journey easier.
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