Aetna Completes Acquisition of Coventry Health Care, Inc. Moved!

May 2013
Aetna Completes Acquisition of Coventry
Health Care, Inc.
One Last Reminder – Kansas City Office Has
Moved!
We’re pleased to announce that Aetna’s acquisition of
Coventry Health Care, Inc. (“Coventry”) is now complete.
Aetna and Coventry share a commitment to creating
mutually beneficial relationships with providers. And, we
share your goal of arranging for the delivery of the highest
quality care to our members.
Our Coventry office moved from Kansas City, Missouri to
Overland Park, Kansas in April. You are welcome to visit us
in our new “home” located at:
Keep working with us as you have in the past
There is nothing to do at this time. Please continue to work
with your local Coventry provider relations representative.
We will keep you updated as we integrate the two
companies.
9401 Indian Creek Parkway, Suite 1300
Overland Park, Kansas 66210
Ph: 913-202-5000
Toll free: 866-629-3975
Congratulations to our Drawing Winner!
How to Contact Us
Congratulations to Michelle Yarnall, with Pediatric
Associates of Southwest Missouri! Michelle joined us at the
Missouri Medical Manager’s Conference on May 7, 2013
and won Coventry’s $100 giveaway!
Website ........................................................ chckansas.com
Website (PHS) ............................................. phsystems.com
Provider Relations Email ... chcProviderRelations@cvty.com
Provider Relations Hotline .............................. 866-427-9719
Submit Your Email to Receive Provider
News
Customer Service Operations
Coventry (Overland Park)............................... 800-969-3343
Coventry (Wichita) .......................................... 877-609-2467
Advantra ......................................................... 800-727-9712
First Health ..................................................... 800-937-6824
Provider Relations Department
Irene Hermreck, Director ................................ 316-609-2434
Sue Busch, Manager (Wichita) ....................... 316-609-2341
Brenda Cook, Manager (Overland Park) ........ 913-202-5241
Representatives
Overland Park
Lynne Drummond ........................................... 913-202-5248
Jonette Johnson ............................................. 913-202-5247
Sherri Smitley ................................................. 913-202-5242
Bobbie Travis ................................................. 913-202-5143
Springfield
Debbie Bowling .............................................. 417-520-4251
Susan Howell ................................................. 417-837-0327
Wichita
Marie Goelz .................................................... 316-609-2799
Jessica Warren .............................................. 316-609-2362
Network Connection
Email alerts will replace the current fax blast format before
the end of 2013. If you are registered with
directprovider.com, you will receive an email from
Coventry in the near future. We will ask you to go onto our
Web link to register an email account for you and/or your
staff. This will be a one-time email – if you do not register
with us you will not continue to get electronic messages.
Please visit this Web link to enter your email information
now: http://bit.ly/provider-email
The process takes less than 30 seconds to complete. You
will then start to receive important provider information
electronically. You may enter as many emails for your staff
as you wish. Thanks for your help!
New Provider Representative in Wichita
We welcome Marie Goelz to the team. Her territory
includes providers located in the western half of Kansas
(west of I-135 to the Colorado border). With more than
12 years of experience, Marie has worked extensively with
Medicaid including Family Health Partners/Coventry Cares
of Kansas. You may contact Marie at 316-609-2799 or
mrgoelz@cvty.com.
1
“Keep it Current” – Council for Affordable
Quality Healthcare® (CAQH)
CAQH makes it easy for practitioners to access, manage
and revise credentialing and recredentialing information
and eliminates redundant paperwork. In order to eliminate
Coventry’s requests for a re-credentialing application,
please keep your CAQH application/attestation and
supporting documents current and grant access to
Coventry. If you have questions regarding Coventry’s
credentialing process, please call the Provider Hotline at
866-427-9719.
Summer Training Sessions Now Available
for directprovider.com
You or your office staff may be interested in participating in
a directprovider.com training session identified below.
Please register by sending an email with
“directprovider.com Training” with the subject line to
TrainingNetworkManagement@cvty.com. In the email,
please also identify the date, section and how many staff
members will be attending. You will receive an email
confirmation along with your login and dial-in instructions
prior to the training session.
Topics
Dates/Times
Section 1
Registration Process
Manage Accounts
EFT Registration
Resource Library
News
ePrescribing
Feedback
Tuesday, June 11th
2 to 3:30 p.m. Central Time*
Tuesday, June 25th
2 to 3:30 p.m. Central Time*
Wednesday, June 12th
2 to 3:30 p.m. Central Time*
Wednesday, June 26th
2 to 3:30 p.m.Central Time*
and/or preferences
 Medications that require prior authorization, and
applicable coverage criteria
 Medications that require step-therapy, including the
medications that must be tried/failed prior to coverage
 Explanation of medications that have limits or quotas
 Copayment and coinsurance requirements, and the
medications or classes to which they apply
 Procedures for step-therapy, prior authorization, generic
substitution, preferred-brand interchange and therapeutic
interchange
 Use of pharmaceutical management procedures
 Criteria used during the evaluation of new medications for
inclusion on the formulary
 A description of the process for requesting a medication
coverage exception
Complex Case Management
Medicare Providers Only
Case management enhances client wellness and autonomy
through advocacy, communication, education and the
identification and facilitation of services. All dual-eligible,
special needs plan members are followed by a case
manager who assists with the coordination of Medicare and
Medicaid benefits. The manager will:
including performance goals, monitoring and follow-up
 Complete a comprehensive assessment of the member's
condition
 Ensure services are provided at the most appropriate
setting
health care team
Thursday, June 13th
2 to 3:30 p.m. Central Time*
Thursday, June 27th
2 to 3:30 p.m.Central Time*
Utilize That Care Plan Registry (CPR)
The CPR is a secure online access site that is available to
you to view the care plans and member profiles that have
been created once a health risk assessment is completed. It
provides secure online access to enrollee profiles and
individualized care plans to providers. By logging into this
secure site, providers and their support staff may access
the information. Please contact your provider relations
representative regarding access to these important tools.
Network Connection
 Preferred pharmaceuticals, including any restrictions
 Provide care coordination between the patient and her
Section 3
Member Eligibility
Member ID Card
Authorizations/Referrals
HEDIS Reports
State/Product
Specific Reporting
You can access the following pharmacy information at
chckansas.com by selecting “Providers” and then
“Prescription Documents.” You will find:
 Develop and implement a case management plan
Section 2
Claim Inquiry
Remittance Advices
Message Center
PPO Fee Schedule
Client Listings
Workers’ Comp
First Health/TPA
Access Prescription Information Online
 Facilitate open communication, understanding and
involvement in the treatment plan
 Provide educational materials to help members selfmanage their conditions
 Facilitate and provide communication of planned and
unplanned transitions from one care setting to another.
This will support the best overall outcome.
To request a copy of your patient’s care plan or to speak to
her assigned case manager please contact Coventry’s
Special Needs Plan at 877-691-8138.
May 2013 • 2
NOTICE OF CHANGE:
National Coverage Determination (NCD)
(Medicare Providers Only)
TITLE: Transcatheter Aortic Valve Replacement (TAVR) –
Implementation of Mandatory Reporting of Clinical Trial
Number
EFFECTIVE: July 1, 2013
For additional information, please see:
http://www.cms.gov/Outreach-and-Education/
Medicare-Learning-Network-MLN/MLNMattersArticles/
Downloads/MM8255.pdf
http://www.cms.gov/Regulations-and-Guidance/Guidance/
Transmittals/2013-Transmittals-Items/R2689CP.html?
DLPage=2&DLSort=1&DLSortDir=descending
http://www.cms.gov/medicare-coverage-database/
overview-and-quick-search.aspx
Claims Processing Policy Spotlight
This new feature section highlights specific claims
processing procedures. Read more to learn about
Coventry’s policies:
Calculation of Anesthesia Time Units
Anesthesia time begins when the anesthesia provider
begins to prepare the patient for the induction of anesthesia
in the operating room (or in an equivalent area). Anesthesia
time ends when the anesthesiologist is no longer in
personal attendance.
Total time must be indicated for the procedure (for example,
0800-0845 or 45 minutes). Time is calculated for payment
based on 15-minute intervals. Each interval of 15 minutes
equals one unit (four units per hour).
Anesthesia time of five minutes or more will count as one
unit. Less than five minutes is rounded down to the next
lowest unit. Anesthesia units submitted on a claim are
validated against the standard 15-minute unit. Partial units
will be rounded up or down as noted.
Sublingual Immunotherapy – E/I
Designation
For the remainder of 2013, Preferred Health Systems and
Coventry (collectively “Coventry”) will grandfather any
members currently receiving sublingual immunotherapy that
has been covered by their current or previous health plans
(Coventry or other carrier). The grandfathering of sublingual
immunotherapy for these members will end on January 1,
2014. After that date, all requests (both new and ongoing) to
initiate sublingual immunotherapy for Coventry and
Preferred Health Systems members will be denied as
experimental/investigational per Coventry’s designation.
The health plan will convey this information to affected
members in writing.
Network Connection
Hospital Readmission Policy Clarification
Facilities reimbursed per MS-DRG pricing methodology
were recently notified of Coventry’s implementation of a
readmission review policy effective July 1, 2013. The policy
incorporates readmission review guidelines from the
Centers for Medicare & Medicaid Services (“CMS”). The
review is designed to help promote quality and improved
outcomes.
The hospital readmission policy was outlined in the FAQ
document that accompanied the announcement. The
contracting provider manual is currently being updated. For
your reference, the policy states:
Hospital Readmission Policy
Coventry Health Care incorporates readmission review
based upon Quality Improvement Organization Manual,
Chapter 4 - Case Review, 4240 - Readmission Review (Rev. 2, 07-11-03) guidelines from the Centers for Medicare
and Medicaid Services (“CMS”). The review is not in place
to address questions of medical necessity but instead is
designed to help promote quality and improved outcomes.
This policy will be applied to facilities reimbursed at MSDRG pricing methodology.
Readmissions are reviewed when they occur during the
concurrent review process (in order to perform review, the
discharge summary along with medical records may be
requested):
 Within 48 hours of the initial discharge
 Because of the same diagnosis, or a similar or related
diagnosis
 At the same facility
Filing a Claim Reconsideration
 Please contact us first to try to resolve the issue. You
may call Commercial Customer Service at 800-969-3343
or Advantra Customer Service at 800-727-9712.
 If the issue cannot be resolved, you must use the
Administrative Reconsideration form located at
chckansas.com (or physystems.com) > Provider > (Your
region) > Document Library.
 Reconsiderations can also be submitted via
DirectProvider.com and attachments can be sent in a
secure manner.
You can mail the Provider Administrative Reconsideration
form to:
Coventry Health Care of Kansas
P.O. Box 7708
London, KY 40742
Fax: 701.250.5392
Medicare providers should mail the form to:
P.O. Box 7371
London, KY 40742
May 2013 • 3
Healthways SilverSneakers®
(Medicare Providers Only)
Coventry’s Medicare Advantage members have access to a
®
fitness benefit through Healthways SilverSneakers Fitness
Program. SilverSneakers is a leading wellness program
designed exclusively for Medicare beneficiaries. Eligible
members receive a basic membership with access to
amenities and fitness classes including the signature
SilverSneakers classes designed to improve muscular
strength and endurance, mobility, flexibility, range of motion,
balance, agility and coordination. Providers may find these
programs appropriate for patients preparing for surgery,
recovering from surgery or who need general lifestyle
improvement activity. For more information and to find a
participating location, visit silversneakers.com or call
888-423-4632.
As an alternative for members who can’t get to a
®
SilverSneakers participating location, SilverSneakers
Steps is available. Steps is a self-directed physical activity
program that allows members to measure, track and
increase physical activities. The program provides the
equipment, tools and motivation necessary for members to
achieve a healthier lifestyle. Eligible plan members may
register for Steps at silversneakers.com/member.
View Prior Authorizations and Referrals on
Directprovider.com
Please remember that prior authorizations and referrals
may be viewed on Coventry’s secure provider Web portal,
directprovider.com. Once you have signed in to the site,
click “Authorizations & Referrals” from the left menu. You
may search for authorizations by status (approved, pending
or denied), by authorization or referral number or by
member. This self -service feature gives you immediate
access to the most current information. If you have
questions or need assistance navigating the site, contact
your provider relations representative.
ICORE Drug Management Changes for
July 1, 2013
(Coventry of Kansas plans only; not applicable to
PHS plans)
ICORE has been providing prior authorization reviews for
certain drugs since May 2010. ICORE manages specific
drugs requiring administration by health care professionals,
while ensuring quality care and affordability for our
members. The program supports a “buy and bill” model for
reimbursement of injectable drugs. ICORE encourages the
use of medically indicated lower cost alternatives with
equivalent quality and clinical outcomes.
Drug Name
Code
Aloxi
J2469
Aranesp
J0881
Avastin
J9035 (oncology)
Epogen/Procrit
J0885
Herceptin
J9355
Leukine
J2820
Neupogen
J1440/J1441
Neulasta
J2505
If you have questions about criteria or processes, ICORE
can be reached at 800-424-4157 or at ICOREhealth.com.
You can also contact your provider relations representative
at 800-562-5792.
Why Do We Ask You for Records?
This time of year, your office often gets requests for medical
record information. The request may be regarding a specific
claim or situation (member appeal or quality review), or one
of the following projects:
 Medicare retrospective chart review
– This is the evaluation of charts to validate submitted
diagnosis codes. These requests came from Verisk,
formerly known as Health Risk Partners. You may
securely fax your submissions to their attention at the
number indicated on the request form. For alternative
submission information, please contact your provider
relations representative.
 Commercial and Medicare HEDIS data collection
– This is the evaluation of a number of clinical metrics
(e.g., blood pressure control for individuals diagnosed
with hypertension). Coventry’s quality improvement
team initiates these requests. You may confidentially
fax your submissions to the fax number indicated on
the request for information.
 Many primary care physician (PCP) offices may have
received their annual Medicare Data Quality Improvement
(also referred to as Physician Education Program)
requests. These are sent to PCPs who are not
participating in other quality programs for our Medicare
Advantage plans.
We appreciate your assistance and participation in these
initiatives, which focus on improving the quality of your
patient’s health plans.
Effective July 1, 2013, Coventry will be expanding the
reviews that ICORE performs to the outpatient facility
setting. ICORE currently performs the prior authorization for
the drugs identified below in the physician office setting.
Network Connection
May 2013 • 4