Spring 2017 1

Provider NewsletterSpring 2017

Medical director’s cornerDr. Barry Lachman, MD, MPH

Bright Smiles: Fluoride varnish at well-checkThis article highlights the efforts to reduce the incidence of nursing bottle caries through the application of dental varnish during a well-check appointment at the pediatrician’s office. For children aged 18 months to 5 years, fluoride will be applied biannually by the primary care provider (PCP), which can be a pediatrician, registered nurse or physician’s assistant. It is a safe, quick and simple procedure, which will provide significant savings in anesthetic costs.

Introduction: PCPs have a key role in providing preventive dental care at the well-check visits for children in the age group 18 months to 5 years.

One out of every five (20 percent) children, between the ages of 5 to 11 years, has at least one untreated decayed tooth with high prevalence in low income groups. The lack of knowledge and access to dental care has resulted in an increased incidence of nursing bottle caries or early childhood caries.

Parkland Community Health Plan (PCHP) aims towards reducing the incidence and cost associated with nursing bottle caries

Children with nursing bottle dental caries is one of the preventable public health challenges of the 21st century. It’s labeled a “Silent Epidemic” by the U.S. Surgeon General. Caries develop infections and abscesses resulting in ER visits. They may need to undergo dental anesthesia, resulting in increased risk of morbidity or mortality due to anesthetic and operative complications, as well as unnecessary medical costs.

Continued on page 2

Table of Contents

Medical director’s corner ..................1

Pills and Potions Corner .....................2

Availability and accessibility requirements .............................................3

Depression screening and treatment in pregnancy ..............................................4

Provider Advisory Committee .............5

Who to call? ................................................5

Help us stop fraud ....................................5

Reminder on balance billing ................6

Behavioral health transition .................6

Changes to our website .........................6

AM-00690

2 Parkland Community Health Plan, Inc.

Medical director’s corner Continued from page 1

Intervention: Early childhood caries or nursing bottle caries affects the tooth of infants and young children. It starts with the anterior teeth (incisors) and later affects the posterior teeth. Though not life threating, it results in pain, function impairment, negatively influences growth rate, body weight and ability to thrive, thus reducing the quality of life. It’s the leading oral health problem for young children. Application of fluoride varnish to the teeth reduces the incidence of caries and high anesthetic costs. Fluoride works to control early decay by inhibiting the demineralization of sound enamel and enhances the remineralization of the demineralized enamel. It reduces the incidence of caries by 30 to 60 percent. Further, the varnish is BPA and dye free making it safe for children.

Driscoll Children Hospital - Increase, expand and enhance oral health: Driscoll Children’s Hospital conducted a trial of fluoride varnish use from 6 to 35 months of age. They reduced the cost and number of children who required dental anesthesia by over 50 percent per year. PCHP is implementing its fluoride varnish program - Bright Smiles - for children, 6 months to 5 years. The change in the age group targeted for intervention is due to the increased incidence of caries in the specified age group.

Bright Smiles Program: Oral Evaluation and Fluoride Varnish (OEFV) in the medical home aims at improving oral health of children, ages 18 months to 5 years.

Physician, physician’s assistants and advanced practice nurses, who have completed online training at Texas Health Steps, may provide intermediate oral evaluation, apply varnish and bill Texas Medicaid for enhanced reimbursement. The reimbursement amount is $34.16 in addition to the regular checkup amount. You can utilize the code 99429 with U5 modifier and bill with one of the following medical checkup codes - 99381, 99391, 99382, and 99392 - in conjunction with Texas Health Steps.

Fluoride varnish must be applied biannually along with the well-check appointment for children, ages 18 to 35 months. Children, ages 3 to 5 years, must have fluoride varnish applied annually, then get referred to a dental home for follow up, subsequent application and comprehensive assessment.

Cost of application of fluoride varnish is $1 to $2 depending on the brand.

Application of fluoride is easy. It can be done in 60 seconds with the presence of parent or caregiver.• Perform evaluation factoring risks, such as parent’s oral health

history, nutrition status and any other fluoride exposure (risk/oral assessment form in the notes).

• Advise parents or caregivers to remove bottle in the night; clean gums and teeth after feeding with wash cloths; or brush the teeth to reduce the risk of nursing bottle caries.

• Encourage using a cup for children older than one year.• Provide nutrition counseling. Encourage a healthy snack or

drink and reducing the exposure to carbohydrates.• Follow up is important. Encourage patients to keep their

appointments, which will help in evaluating the incidence of caries and reduce future costs.

• Refer children older than one year to dental homes for a periodic dental preventive screening.

• Provide take home messages to parents or caregivers. These messages should include nutritional guidelines and dental varnish application care, which requires the user to avoid brushing till the next day.

Conclusion: Preventing caries can improve growth and health of children, leading to their overall healthy development. Application of dental varnish at the pediatrician’s office provides preventive dental and medical care for low income families and helps in reducing the anesthetic costs associated with caries.

Pills and Potions CornerDr. Nneka Cos-Okpalla, BS, PharmD

HHSC transformation: Program name changesThe Vendor Drug Program has a new name - HHSC Pharmacy Benefit Management (HPBM). Expect to see this designation on future correspondence from HHSC.

GI motility agents clinical prior authorization updateHHSC has updated the criteria for the agents for GI motility clinical prior authorization to include Xtampza, in the lookback for history of opioid therapy, Relistor tablets and associated criteria. HHSC will activate the revised prior authorization criteria on January 18, 2017. This prior authorization is optional for MCOs. MCOs that link to agents for GI motility prior authorization document should adjust systems to accommodate the revision.

December 2016 Specialty Drug List publishedThis list is now available. Newly-added items are identified by red text. Visit: http://www.txvendordrug.com/formulary/specialty-drugs.shtml

Antipsychotics clinical prior authorization document revisionThe Antipsychotics clinical prior authorization went into effect on January 9, 2017. You can access the forms on the website or at the following links:

Prior authorization forms:https://www.navitus.com/Misc-Pages/PDF-Form-Viewer.aspx?FormID=5264d812-b3d9-45f7-9b7a-a48eefca8adc

Clinical edit form/Antipsychotics clinical edit forms:https://www.navitus.com/Misc-Pages/PDF-Form-Viewer.aspx?FormID=8a0c1daa-5b73-42de-aa34-ac664e988a96

Spring 2017 3

Availability and accessibility requirementsHelp us ensure your patients have timely and appropriate access to care. We want to remind providers of the required availability and accessibility standards, and ask that you review the standards listed below.

After hours accessThe following are acceptable and unacceptable phone arrangements for contacting primary care providers (PCPs) after normal business hours.

Acceptable:• Office phone is answered after hours by an answering service*

that can contact the PCP or another designated medical practitioner. All calls answered by an answering service must be returned by a provider within 30 minutes.

• Office phone is answered after normal business hours by a recording* directing the patient to call another number to reach the PCP or another designated provider. Someone must be available to answer the designated provider’s phone. Another recording is not acceptable.

• Office phone is transferred after office hours to another location. Someone will answer the phone and be able to contact the PCP or another designated medical practitioner, who can return the call within 30 minutes.

*meets the language need of the major population groups served

Unacceptable:• Office phone is only answered during office hours.• Office phone is answered after hours by a recording, which

tells the patients to leave a message.• Office phone is answered after hours by a recording, which

directs patients to go to an emergency room for any services needed.

• Returning after hour calls outside of 30 minutes.

4 Parkland Community Health Plan, Inc.

Depression screening and treatment in pregnancyIn 2015, the American College of Obstetrics and Gynecology recommended universal screening for depression in pregnancy. The Committee opinion included a number of validated screening tools.

Screening Tool Number of Items

Time to Complete (Minutes)

Sensitivity and Specificity Spanish Available

Edinburgh PostnatalDepression Scale

10 Less than 5 Sensitivity 59–100%Specificity 49–100%

Yes

Postpartum DepressionScreening Scale

35 5–10 Sensitivity 91–94%Specificity 72–98%

Yes

Patient Health Questionnaire 9Specificity 90%

9 Less than 5 Sensitivity 75% Yes

Beck Depression InventorySpecificity 85.9–89%

21 5–10 Sensitivity 47.6–82% Yes

Beck Depression Inventory-IISpecificity 97–100%

21 5–10 Sensitivity 56–57% Yes

Center for EpidemiologicStudies Depression Scale

20 5–10 Sensitivity 60%Specificity 92%

Yes

Zung Self-ratingDepression Scale

20 5–10 Sensitivity 45–89%Specificity 77–88%

No

The Edinburgh and PHQ9 have the fewest questions and take the least time. The ideal instrument would have a high specificity and sensitivity. A sensitive test finds everyone with the condition. A specific test means that the person has the condition. Both the Edinburgh and PHQ9 have acceptable levels of sensitivity and specificity.

Most providers are aware of the risk of postpartum depression for suicide. Less publicized are the effects of maternal depression during pregnancy. A number of studies have indicated an association for a variety of negative pregnancy outcomes, including double the risk of preterm birth. Even less well known are the long-term effects of maternal depression on children. The American Academy of Pediatrics has recommended maternal depression screening since 2010. A recent review states the following: “Clinicians should weigh the growing evidences suggesting the detrimental and prolonged effects in offspring of untreated antenatal depression and depressive symptoms during pregnancy against the known and emerging concerns associated with in utero exposure to antidepressants.”

Treatment with antidepressants is controversial with some articles implicating the drugs altered brain development. Supportive treatment is found in a number of studies to be beneficial. In addition, a number of studies have shown that use of community health workers decreased preterm birth. It’s our view that the positive effect on preterm birth is due to supportive depression treatment.

The end of the NorthStar and the carveout of behavioral health services in Medicaid Managed Care gives you and PCHP a great opportunity to eliminate the artificial silos that prevent optimum care delivery of both behavioral and physical health. PCHP is delighted to have Beacon Health Options as a partner in delivering behavioral health services to your patients who are PCHP members. Beacon has established a national reputation in integrating behavioral health and physical health. We welcome your comments and feedback on ways in which we can work together to integrate behavioral health and physical health.

As an important starting point, we encourage you to screen all pregnant women for depression and refer those in need of intervention.

References1R L Goldenberg et al., “Epidemiology and Causes of Preterm Birth,” The Lancet, 2008.

American College of Obstetricians and Gynecologists, Screening for Perinatal Depression. Committee Opinion No. 630, (Obstet Gynecol, 2015), doi:10.1097/01.AOG.0000465192.34779.dc.

C Liu et al., “Prenatal Parental Depression and Preterm Birth: a National Cohort Study.,” BJOG : an International Journal of Obstetrics and Gynaecology 123, no. 12 (November 2016): 1973-82, doi:10.1111/1471-0528.13891.

D Li, L Liu, and R Odouli, “Presence of Depressive Symptoms During Early Pregnancy and the Risk of Preterm Delivery: a Prospective Cohort Study,” Human Reproduction 24, no. 1 (January 1, 2009): 146-53, doi:10.1093/humrep/den342.

S Gentile, “Untreated Depression During Pregnancy: Short- and Long-Term Effects in Offspring. a Systematic Review.,” Neuroscience 342 (February 7, 2017): 154-66, doi:10.1016/j.neuroscience.2015.091S Gentile, “Untreated Depression During Pregnancy: Short- and Long-Term Effects in Offspring. a Systematic Review.,” Neuroscience 342 (February 7, 2017): 154-66, doi:10.1016/j.neuroscience.2015.09.001.1D Li, L Liu, and R Odouli, “Presence of Depressive Symptoms During Early Pregnancy and the Risk of Preterm Delivery: a Prospective Cohort Study,” Human Reproduction 24, no. 1 (January 1, 2009): 146-53, doi:10.1093/humrep/den342.1C Liu et al., “Prenatal Parental Depression and Preterm Birth: a National Cohort Study.,” BJOG : an International Journal of Obstetrics and Gynaecology 123, no. 12 (November 2016): 1973-82, doi:10.1111/1471-0528.13891.

Spring 2017 5

Help us stop fraudIt’s your responsibility as a Medicaid program provider to report suspected fraud and abuse. To report fraud or abuse, call the Parkland Community Health Plan (PCHP) compliance hotline at 1-800-436-6184. We prefer, but don’t require, that you provide enough information to help us investigate, including:• Name of the PCHP member or provider you suspect of

fraud• Member’s PCHP card number

• Name of doctor, hospital or other health care provider• Date of service• Amount of money that PCHP paid for service, if applicable• Description of the acts you suspect involve fraud or abuse

You can also visit the PCHP website at www.parklandhmo.com and email us suspected fraud information.

Thank you for your continued support.

Provider Relations and Member Services

1-888-672-2277 (HealthFirst)1-888-814-2352 (KidsFirst)

Migrant farm worker 1-800-327-0016

Extension numbers

Member services 5428

Member services (Spanish) 5432

Pre-certification 4021

Provider relations 5430

Claims 5191

Nurse 4120

Superior Vision 1-800-879-6901

LogistiCare(medical transportation for Medicaid members only)

1-877-633-8747 (24/7)1-855-687-3255 (8 a.m. - 5 p.m., M-F)

Nurse line 1-888-667-7890

Report fraud, waste or abuse 1-800-436-6184

Behavioral health benefits 1-800-945-4644

Fax numbers

Prior authorization fax # 1-800-240-0410

Dental

MCNA Dental 1-855-691-6262

Denta Quest 1-800-516-0165 (Medicaid)1-800-508-6775 (CHIP)

Pharmacy

Navitus BIN# 610591 PCN: ADV GROUP# RX8801

1-877-908-6023

Prior authorization fax # 1-920-735-5312

Who to call?

Provider Advisory CommitteeWe strongly encourage you to join our Provider Advisory Committee. Our committee meets quarterly. The committee consists of providers who serve Medicaid beneficiaries, other indigent populations and members with special needs.

Your input is valuable. We may use your recommendations to improve quality management activities and policy and operations changes. If you’re interested in joining the Provider Advisory Committee, please contact Provider Relations.

6 Parkland Community Health Plan, Inc.

Reminder on balance billingAre you preparing to bill a Medicaid and or Children’s Health Insurance Program (CHIP) member? If so, please remember the following:

Medicaid: 42 C.F.R. § 447.15 Acceptance of State payment as payment in full.

CHIP: Health and Human Services Commission (HHSC) rule at §370.453 prohibits balance billing CHIP members.

This means a provider shouldn’t bill the difference between the amount paid by Parkland Community Health Plan (PCHP) and the provider’s customary charge to the patient, the patient’s family or a power of attorney for the patient. Balance billing for Medicaid or CHIP services is a violation of your provider contract.

The number one highest volume of member complaints is balance billing issues.

In essence, PCHP Member Advocates have to contact the billing provider’s business office to resolve the issue and zero balance the member. Many of these issues are sent to a collection agency, which requires an additional discussion with your office. In effect, this becomes a non-issue but countless hours are spent on resolution.

PCHP will continue to resolve balance billing issues as received. However, we wanted to provide this gentle reminder for your reference when preparing bills for Medicaid members.

Changes to our websiteOver the next few months, we’re planning to implement several changes that positively impact our website. Our goal remains to serve you, so you can take care of your patients. Stay tuned for more information.

Behavioral health transitionJanuary 1, 2017 marked a transition from the NorthStar Behavioral Health (BH) model to the MCO model. Parkland Community Health Plan (PCHP) employs Beacon Health Options as its BH service provider. Services include provider contracting and provider relations; member services and member relations;

and care coordination and BH management. While referrals aren’t necessary for BH services, prior authorization requirements do exist.

You can call 1-800-945-4644 if you have any questions or concerns regarding BH services in the Dallas SDA.