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INSIDE THIS ISSUE:
On the Cover:
CoventryCares changes name To Aetna Better Health Effective September 26, 2016
Inside:
CCWV NEWS Medicaid Provider Forums 2 Online Secure Portal 3
MCG Behavioral Health Guidelines 4
Second Opinions 4 2015 Medical Record Review Results 5-6 Zika Virus, by Dr. Gibbon 7 Diabetes Collaboration 7
Health Care Equity/Community Health Worker Program 8
Utilization Management 8 Prior Authorizations 9
CPGs and PSGs 9 Community Outreach 10 Aetna Better Health Reminder 11
Since Aetna’s acquisition of Coventry in May 2013, the companies have integrated their business. That’s why CoventryCares of West Virginia is changing its name to Aetna Better Health of West Virginia, effective September 26, 2016. Together, we are combining our strengths to best serve our providers and members.
Throughout this process, we remain committed to providing timely updates on the impact the transition has on you and your patients. You’ll receive most of these updates by mail or fax. Up until the transition, you will receive communica-tions from CoventryCares of West Virginia regarding transition activities and our Medicaid line of business. Materials that you will receive on or before September 26, 2016 include:
▪ Provider Forums ▪ Portal Registration Information ▪ Member ID card examples
▪ Claims Updates ▪ System Change
If you have any questions regarding this transition, please contact your Provider Relations Representative at 1-888-348-2922/TTY 711.
Please update us with any email changes you have to stay up-to-date on the up-coming changes!!
July 2016 -2-
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CCWV Provider News Medicaid Provider Forums
Medicaid Provider Forums CoventryCares of West Virginia will be hosting provider forums across the state in July in anticipation of the transition from CoventryCares to Aetna Better Health on September 26, 2016. All CoventryCares of West Vir-ginia providers are encouraged to attend. Representatives will review the upcoming transition and changes.
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Beckley, WV 07/19/2016
Time: 8 a.m. to 12 p.m. Location: Tamarack Conference Center Address: 1 Tamarack Park, Beckley, WV 25801
Huntington, WV 07/20/2016
Time: 8 a.m. to 12 p.m. Location: Pullman Plaza Hotel Address: 1001 3rd Avenue, Huntington, WV 25701
Charleston, WV 07/21/2016
Time: 8 a.m. to 12 p.m. Location: Embassy Suites Address: 300 Court Street, Charleston, WV 25301
Martinsburg, WV 07/25/2016
Time: 8 a.m. to 12 p.m. Location: Holiday Inn Address: 301 Foxcroft Avenue, Martinsburg, WV 25401
Wheeling, WV 07/26/2016
Time: 8 a.m. to 12 p.m. Location: Oglebay Resort—Wilson Lodge (Glessner) Address: 465 Lodge Drive, Wheeling, WV 26003
Parkersburg, WV 07/27/2016
Time: 8 a.m. to 12 p.m. Location: The Blennerhasset Hotel Address: 320 Market Street, Parkersburg, WV 26101
Clarksburg, WV 07/28/2016
Time: 8 a.m. to 12 p.m. Location: Village Square Conference Center Address: 1489 Milford Street, Clarksburg, WV 26301
CCWV Provider News ▪ Online Secure Portal
Re-Introducing the Secure Online Portal, with enhancements for member integration
CoventryCares of West Virginia is dedicated to providing great service to our providers and our members. That’s why our HIPAA-compliant web portal is available 24 hours a day. The portal supports the functions and access to information related to:
•Prior authorization submission and status •Claim payment status •Member eligibility status •eReferrals to other registered providers •Member and provider education and outreach
materials
If you’re interested in using this secure online tool, you can reg-ister on our “For Providers” page at www.coventrycareswv.com. You can also contact our Provider Services Department to sign up over the phone. Or to submit your registration via fax, you can download the form from our website or request a copy from Provider Services. Please keep in mind that internet access with a valid e-mail is required for registration.
Remember, provider groups must first register a principal user known as the "Provider Representative." Once registered, the “Provider Representative” can add authorized users within each entity or practice.
Engaging Members to help them stay healthy CoventryCares of West Virginia members can sign up for their own secure member portal accounts. However, we’ve custom-ized the member portal to better meet their needs. Members will have access to: •Health and Wellness Appraisal—This tool will allow members to self-report and track their healthy behaviors and overall risk and protective factors and allow the comparison of current re-sults to previous results, if applicable. The health assessment can be completed annually and will be accessible in electronic and print formats. ▪Educational resources and programs—Members are able to access self-management tools for specific topics such as smok-ing cessation and weight management.
•Claim Status—Members and their providers can follow a claim from the beginning to the end, including: current stage in pro-cess, amount approved, amount paid, member cost (if applica-ble) and the date paid. •Pharmacy benefit services—Members can find out if they have any financial responsibility for a drug, learn how to re-quest an exception for a non-covered drug, request a refill for mail-order medications and find an in-network pharmacy by zip code. They can also figure out drug interactions, side effects and risk for medications and get the generic substitute for a drug. •Personalized health plan services information—Members can now request a member ID card, change PCPs and update their address through the web portal (address update is a feature available for members and providers). Members can also ob-tain a referral and information on authorization requirements. They can also find benefit and financial responsibility infor-mation for a specific service. •Innovative services information—Members will be asked to complete a personal health record and complete an enrollment screening to see if they qualify for any disease management or wellness programs.
•Wellness and prevention information—We encourage healthy living. Our member outreach will continue to include reminders for needed care and missed services, sharing infor-mation about evidence-based care guidelines, diagnostic and treatment options, community based resources and automat-ed outreach efforts with references to web-based self-management tools.
You can help your patients sign up today We encourage you to promote the use of the member portal during interactions with your patients. Members can sign up online at: www.coventrycareswv.com Or they can call Member Ser-vices at 1-888-348-2922/TTY 711.
July 2016 -3-
CCWV Provider News
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July 2016 -4-
MCG Behavioral Health Guidelines Second Opinions
MCG Behavioral Health Guidelines
CoventryCares of West Virginia will be implementing MCG Behavioral Health Guidelines (MCG BHG) as the primary med-ical necessity criteria for behavioral health, effective July 2016.
MCG BHG is nationally recognized, evidence-based clinical guidelines.
MCG BHG are now part of the Aetna Medicaid Standard Op-erating Model, and will continue to facilitate the appropriate level of care, accurately manage episodes of care and en-hance the discharge planning process for our health plan members.
View the MCG website at: www.mcg.com/content/behavioral-health-care.
Please call your provider relations representative 1-888-348-2922/TTY 711 if you have any questions or need additional information.
You can also visit CoventryCares of West Virginia at: http://chcmedicaid-westvirgin-ia.coventryhealthcare.com/for-providers/index.htm
SECOND OPINION?
Is your patient asking for a Second Opinion?
CoventryCares of West Virginia members may request a sec-ond opinion for an illness, surgery and/or confirming a treat-ment plan of care. The member can contact their doctor or CoventryCares of West Virginia Customer Service for help to get a second opinion.
If an appropriate provider for the second opinion is not avail-able within the CoventryCares of West Virginia network, we will arrange to get the second opinion outside the network. An out-of-network second opinion requires preauthorization. There is no cost to the member for the second opinion.
CCWV Provider News
July 2016 -5-
CONTINUED ON PAGE 6
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2015 Medical Record Review Results
2015 Medical Record Review Results The Quality Improvement Department performs an annual, statewide medical record review to ensure compliance with current standards recognized by agencies that accredit and reg-ulate CoventryCares of West Virginia. The purpose of this audit is to evaluate the quality of medical record keeping and to de-termine if the Plan’s medical record documentation standards are being met.
Member medical records were chosen by random sample. Pri-mary care sites included general practice, internal medicine, family practice, and pediatrics. The medical records were re-viewed using the 2016 Medical Record Audit Tool, which in-cludes 23 medical record standards. The performance standard for practitioner offices is an overall score of 85% or greater. In
Additional Findings for the Audited practices were:
▪ All offices had a passing score
▪ The scores for the 17 offices ranged from 87% to 100% with one office scoring 100% and most offices scoring between 94% and 96%
addition to the standards for medical record documentation, all offices are expected to have medical records stored in a secure manner and train staff periodically in member information con-fidentiality. A total of 85 charts from 17 unique offices were reviewed. Offices who participated in the review received a letter with their individual results.
Overall results of the medical record audit showed that the fol-
Member Name or ID is present on each page of the record
95%
All entries are legible to someone other than the writer
88%
Prescribed medications, including dosages and dates of initial or refilled prescriptions
95%
Medication allergies with Adverse Reactions or NKA 96%
Inquiry is documented concerning Alcohol/Substance Abuse/Smoking for members 14 and over who have been seen 3 or more times
87%
Age appropriate immunization record (children) or immunization history (adults) is present
82%
Preventive Screening Services specific to patient age/gender/illness are offered
87%
Advanced Directives are notated in the chart for patients over age 18
38%
If there is an Advanced Directive, it is in a promi-nent place in the chart
41%
Documentation of communications contact with referred specialist & evidence of D/C summary from hospitals, HHA and SNF
97%
▪ All offices audited had secure storage of medical records
▪ All but two offices (88%) provided periodic training in medical record confidentiality
A second component of this year’s medical record audit was an assessment of the collaboration between behavioral health and medical practitioners, in order to identify opportunities to improve coordination of care between medical and behavioral healthcare. The audit included 27 members who had one or more BH medications prescribed by a psychiatrist. Records were
CCWV Provider News
July 2016 -6-
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Medical Record Review Results Cont’d.
reviewed to determine if the prescribing psychiatrist communicated to the PCP, and to see if the prescribed medications were included on the members’ medication record in the PCP chart. Results of the Behavioral Health Continuity of Care audit are as follows:
Yes No % Yes
Prescribing psychiatrist communicated to PCP 4 23 14.8%
BH Medications were listed in the member PCP record 9 18 33.3%
CoventryCares of West Virginia would like to pass on the following reminders:
▪ For members age 18 and over, discuss Advanced Directives and document discussion in the chart; if an Advanced Directive has been executed it should be not ed prominently in the chart
▪ For members age 14 and over, in- quire and document alcohol use, sub stance abuse, and smoking
▪ An age appropriate immunization record or history is required for all Members
▪ Communication between Behavioral Health and Medical providers is im- portant, especially when behavioral health medications are prescribed
For a copy of our Medical Record Stand-ards, visit the provider section of our website and click on Document Library,
July 2016 -6-
CCWV Provider News
July 2016 -7-
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Zika Virus by Dr. Gibbon, CMO Diabetes Collaborative
Z ika virus disease (Zika) is a disease caused by the Zika virus. It is spread to people primarily through the bite of an infected mosquito. Common symptoms of Zika are fever, rash, joint pain, and red eyes. It is usually a mild illness with symptoms lasting for several days to a week. People
usually don’t get sick enough to go to the hospital. It very rarely causes death. Many people might not realize they have been infected because it is so mild. However, Zika virus infection during pregnancy can cause a serious birth defect called microcephaly, as well as other severe fetal brain defects. It can also cause
Guillain-Barre syndrome. After an infection, the person is likely to be protected from future infections.
1. Prevention—Use mosquito repellant in areas with Zika. There are currently none in the US but a few in Puerto Rico, the US VirginIslands, and American Samoa. Educate anyone travelling to an area with Zika that transmission is by mosquito bite and also by sexu-al contact with someone infected with Zika.
2. Diagnosis—This is largely clinical but it is confirmed by serologic testing.Zika is most often diagnosed after the fact, such as when someone gets an itchy rash and remembers having a mild flu-like illness. No one is suggesting widespread testing in early pregnancy. Testing should be reserved for peo-ple who have been to areas where Zika is actually occurring and probably for women of childbearing age and their partners.
3. Treatment—There is no treatment. Women who have had Zika and arepregnant should be followed closely. They should have ultrasound evalua-tions for fetal malformations.
The CDC has excellent guidance which is updated as new information is re-ceived. To date there have been 6 travel-associated cases of Zika in WV and no locally-acquired cases. In the US as a whole there have been 691 travel-associated cases reported, with none locally acquired, and 11 sexually-transmitted.
For more information go to the CDC’s website: www.cdc.gov/zika/index.html
Diabetes Collaborative—Disease Education Classes for Members
CoventryCares of West Virginia has partnered with Mid Ohio Valley Public Health, WVU Medicine, Mon General Hospital and Poto-mac Valley Hospital to help arrange for participation in diabetes education classes for our members in the area of their residence.
CCWV members with diabetes can attend DSME (Diabetes Self Management Education) classes. Our Case Management Department can help you enroll in classes. If transportation is an issue for members, we can provide resources. Once the member completes the classes and obtains a follow up A1C, they will be eligible for a $25.00 gift card.
Classes are available in the following twenty counties: Calhoun, Gilmer, Mason, Pleasants, Ritchie, Roane, Jackson, Wirt, Wood, Har-rison, Marion, Monongalia, Preston, Randolph, Taylor, Upshur, Wetzel, Mineral Grant and Hampshire.
Please contact our Case Management Department at 844-835-4930 or Fax 866-373-0274 to submit a referral.
CCWV Provider News
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July 2016 -8-
Health Care Equity/Community Health Worker Program
Utilization Management National Health Care Equity/Community Health Worker (HCE-CHW) Program Pilot
C oventryCares of West Virginia continues to move forward with the National Health Care Equity/Community Health Work-er “HCE-CHW” program pilot. The goal of the program is to eliminate health care disparity by utilizing the CHW to im-prove access to care and engagement for
members who are diagnosed with asthma and diabetes. It can be a challenge to fully understand each subcul-ture within our Medicaid membership and to provide them with culturally and linguistically-sensitive infor-mation on health promotion and education. Using trusted members of the communities as educators and liaisons can improve our outreach and help us provide information in a way that it can be best received. The CHW conducts telephonic and face-to-face interactions to overcome barriers and promote engagement of the member in their wellness plan/goals.
For more information on the Health Care Equity/ Com-munity Health Worker program or referral to the pro-gram, please contact Ashli Slaven with CoventryCares of WV at 304-348-2925.
How to reach our Utilization Management Department
CoventryCares of West Virginia ‘s Utilization Manage-
ment staff is available to discuss specific cases or Utiliza-
tion Management questions by phone between the
hours of 8:30 a.m. and 5:00 p.m. by calling our Customer
Service line at 1-888-348-2922/TYY 711. Customer Ser-
vice can connect you to the language line if you need
language assistance. Utilization Management staff is al-
so available on weekends and holidays. The ability to
receive faxed information is available 24 hours per day,
7 days a week at 1-866-366-7008. When initiating or
returning calls regarding Utilization Management issues,
our staff will state they are calling from CoventryCares of
West Virginia and identify themselves by name and title.
CCWV Provider News
July 2016 -9-
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Prior Authorization Turn Around Times CPGs and PSGs
Prior Authorization Turn Around Times
In order to allow sufficient time for the prior authorization process, contact our Prior Authorization Department a minimum of 7 days pri-or to when the service is needed for elective, scheduled procedures, and diagnostic testing.
The clinical information provided and the plan of treatment will be evaluated and completed by the Prior Authorization Nurse within sev-en (7) calendar days of receipt of all necessary information to make a determination for elective procedures or testing for non-urgent requests.
For urgent procedures or testing, the determination will be made within three (3) calendar days upon receipt of request. Evaluation using CCWV approved criteria will be performed and a decision will be made on the requests. For concurrent review, a determination will be made within 24 hours of receipt of request.
If a member is admitted to the hospital in an emergency, CCWV must be notified within 24 hours or by the end of the next working day if the 24 hour deadline falls on a weekend or legal holiday.
If you take a call from a member after hours and advise them to go to the ER, please contact our Health Services Department at 1-844-835-4930 on the next working day to inform us of your action.
CLINICAL PRACTICE GUIDELINES and PREVENTATIVE SERVICE GUIDELINES (CPGs and PSGs)
CoventryCares of WV adopts evidence-based Clinical Practice Guidelines (CPGs) and Preventive Services Guidelines (PSGs) from nationally rec-ognized sources. You can access the CPGs and PSGs on our website. Once on the site, go to Providers then Practice Guidelines. For assistance in obtaining hard copies from the nationally recognized sources, contact your Provider Relations Representative. The following guidelines were adopted March 2016:
Clinical Practice Guideline
Diagnosis and Management of Asthma
Source: National Heart, Lung and Blood Institute
Standards of Medical Care in Diabetes
Source: American Diabetes Association
Diagnosis and Management of Patients With Stable Ischemic Heart Disease
Source: American Heart Association/American College of Cardiology Foundation
Helping Patients Who Drink Too Much
Source: National Institute on Alcohol Abuse and Alcoholism
Treatment of Patients With Major Depressive Disorder
Source: American Psychiatric Association
Diagnosis, Evaluation and Treatment of Attention Deficit Hyperactivity Disorder in Children and Adolescents
Source: American Academy of Pediatrics
Preventive Service Guidelines
Grades A& B for Healthy People with Normal Risk
Source: U.S. Preventive Services Task Force
CCWV Provider News ▪ Community Outreach
July 2016 -10-
CoventryCares of WV Helps Feed Those In Need
On June 7, 2016, members of the CoventryCares of West Virginia Community Outreach team spearheaded an effort to distribute food products to those in need in Boone County. This West Virginia county has been one of the hardest hit by the downturn in the state’s economy.
CCWV worked directly with the Mountaineer Food Bank to bring two large box trucks of food to the mobile pantry event. We were also joined by Remember the Miners, an organization that works to ease the plight of those in-volved in the coal industry and their families. WVU Head Basketball Coach, Bob Huggins, is a driving force behind Remember the Miners. He brought the entire WVU Bas-ketball Team, which traveled four hours from Morgan-
In addition to the produce, meat, dairy, bread and canned goods, participants received toothbrushes and easy to under-stand healthcare information.
Fifteen (15) members of CoventryCares team, representing members from all departments of the plan, worked to make the event a huge success. More than 300 families representing over 1000 individuals took part in this distribution event.
CCWV Provider News
-11-
▪ CoventryCares of WV Changing to Aetna Better Health of West Virginia
DON’T FORGET
Effective September 26, 2016
Please attend a Provider Forum near you (see Page 2)
for information on how this transition will effect you
RSVP to: [email protected]
July 2016
