providerINSIGHT · Insight newsletter. Here, you’ll find medical, dental, and pharmacy information as well as updates to our plans: > Commercial > SelectHealth Advantage® ... profit

Welcome to the Provider Insight newsletter

Here yoursquoll find medical dental and pharmacy information as well as updates to our plans

gt Commercial

gt SelectHealth Advantagereg (Medicare)

gt SelectHealth Community Carereg (Medicaid)

gt Federal Employee Health Benefits (FEHB) plans

We encourage you to read Provider Insight to stay up to date on policies affecting our membersthinsp and your patients

To return to the Table of Contents click on at the top of any pageproviderINSIGHTreg

providerINSIGHTreg

SelectHealthreg | August 2020

WHATS INSIDE

SELECTHEALTHreg NEWS 2

Mike Cotton Selected as New President and CEO of SelectHealth 2

Pharmacy News 2

SelectHealth is Now an NCQA Partner in Quality 3

Varicose Vein Procedure Authorization Changes in 2021 4

Pediatric Preventive-only Dental Benefits 4

INTERMOUNTAIN HEALTHCAREreg NEWS 5

Immunization Update and ACIP Highlights 5

Provider Publication Updates 6

SELECTHEALTH ADVANTAGEreg (MEDICARE) NEWS 7

FraudWasteAbuse Compliance Trainings and Attestations 7

Dental Advantage Preventive-only Dental Coverage 7

SELECTHEALTH COMMUNITY CAREreg (MEDICAID) NEWS 8

Enrollment During the COVID-19 (novel coronavirus) Pandemic 8

Medicaid Integration Reminders 8

Donrsquot Forget to Revalidate with Utah Medicaid 9

Medicaid and CHIP Networks Merge 9

PRACTICE MANAGEMENT RESOURCES 10

New Provider Onboarding Tools 10

Medical Home Online Resources 10

New Care Management Resource 11

Enhanced Security Online 11

MEDICAL POLICIES CODING amp REIMBURSEMENT 12

Medical Policy Update Bulletin 12

August 2020 Coding Updates 14

providerINSIGHTregAUGUST 2020

selecthealthorg | 2

SelectHealthreg News

Mike Cotton Selected as New President and CEO of SelectHealth

Following an extensive national search the Executive Leadership Team and the Intermountain and SelectHealth Boards of Trustees have selected Mike Cotton as the new President and CEO of SelectHealth Mike will start his new role in mid-November

Who is Mike CottonMr Cotton is a seasoned healthcare leader with extensive experience in integrated health systems He is a strategic thinker consumer centered and a member advocatemdasha positive and collaborative leader who is committed to our mission-driven growth member experience and doing the right thing for all we serve

Experience Since 2015 Mike has been CEO of Providence Health Plan part of the Providence St Joseph Health System a national not-for-profit Catholic health system based in Portland Oregon Prior to that he was vice president and chief operating officer for Humana responsible for their Medicaid and state-based contract programs He previously held leadership positions with Evolent Health and Alere Health as well as provider-sponsored health plans affiliated with University Hospitals Health

System and Premier Health System based in Ohio

Mikes leadership has been instrumental in the success of growing overall plan membership long-term care and Medicaid programs and population health products and programs as well as expanding partnership relationships

Education Mike graduated from Cleveland State University earning an MBA in healthcare administration He also holds

a certificate of executive healthcare management from Case Western Reserve University and completed his undergraduate studies at Franklin University and The Ohio State University in Columbus Ohio

How will leadership transition occurCurrent SelectHealth CEO Pat Richards will retire on August 31 2020 Bert Zimmerli Intermountainrsquos executive vice president and chief financial officer will serve as the interim SelectHealth president and CEO until Mike joins us in November Bert also served in this interim capacity prior to Pat Richards joining SelectHealth 10 years ago

Read the latest Pharmacy amp Therapeutics newsletter along with Formulary Updates

These contain information about recent formulary decisions specific therapeutic class updates and industry news

Access these key resources for opioid prescribing

gt Providers Clinical Support System gt How to Monitor Opioid Use for Your Patients with Chronic Pain (AAFP article) gt HHS Tapering Guidelines gt Opioid amp Benzodiazepine Co-Prescribing

Pharmacy News

selecthealthorg | 3

SelectHealth is Now an NCQA Partner in Quality

NCQA Recognition Program Benefits

1 Helps reduce costs and improve patient satisfaction and health

2 Gives practices a framework for transitioning to value-based care

3 Provides clinicians in recognized PCMH practices key industry credits such as

gt Medicare MIPS Quality Payment Program creditsmdashAutomatic credit under the ldquoImprovement Activitiesrdquo category

gt Professional Maintenance of Certification Credits from

bull American Board of Family Medicine (PCMH DRP HSRP)

bull American Board of Internal Medicine (PCMH PCSP)

bull American Board of Pediatrics (PCMH) bull American Board of Physical Medicine

and Rehabilitation (PCSP)4 Offers additional practice management

benefits per these publications

gt NCQA PCMH Evidence Report which demonstrates how medical homes improve patient care and safety and reduce costs

gt The Milliman White Paper which examines the operational and financial considerations for becoming a PCMH-recognized entity from the perspective of a primary care practice

SelectHealth recently became a National Committee for Quality Assurance (NCQA) Partner in Quality As a result we can now provide a code for a 20 discount on the NCQA initial application fee for practices applying for NCQA Recognition (initial only) Learn more about how applying will benefit your practice

What is the NCQA Partner in Quality (PIQ) ProgramThe NCQA Partner in Quality (PIQ) program recognizes organizations that provide financial incentives or support services to practices seeking recognition for one of NCQArsquos Recognition programs

SelectHealth qualified for this program by helping practices move to a medical home delivery model and providing care coordination payments to sites participating in the SelectHealth Advanced Primary Care medical home program

The NCQA PCMH Recognition program helps transform a primary care practice into a well-functioning PCMH by helping

gt Structure leadership and care team responsibilities to best partner with patients families and caregivers

gt Set standards for data collection medication reconciliation evidence-based clinical decision support and other activities

gt Ensure continuity of care through patient-centered access to clinical advice

gt Set up care management protocols to identify patients who need more closely managed care

gt Better manage care coordination and transitions among primary and specialty care clinicians via effective information sharing and patient referral management that minimizes cost confusion and inappropriate care

gt Measure performance set goals and implement performance-improvement activities

What are the benefits of the Medical Home Program

Modeled after the patient-centered medical home (PCMH) this program offers providers technical assistance learning collaboratives care management support and enhanced reporting Research shows that PCMHs help improve healthcare quality reduce costs improve the patient experience and reduce clinician burnout

SelectHealth News Continued

selecthealthorg | 4

Pediatric Preventive-only Dental Benefits SelectHealth ClassicSM network individual and small employer dental plans include embedded preventive dental benefits for pediatric patients Not all plans cover pediatric dental services contact Member Services at 800-538-5038 for details

Please review and share the information in Figure 1 below with your staff

Figure 1 Pediatric Preventive Dental Benefits

Preventive Service PEDIATRIC Allowable BenefitTime Frame Applicable Codes Cleanings 2 cleaningscalendar year D1110 D1120

Fluoride Application 2 applicationscalendar year D1206 D1208

Oral Examinations 2 examscalendar year D0120 D0140 D0145 D0150 D0160

Sealants 1 sealant5-year period on permanent molars with no occlusal restoration

Bite-Wing X-Rays

For members age 17 and younger 2 full series bite-wingscalendar yearOR2 vertical bite-wings in lieu of full series bite-wings

For members age 18 only 1 vertical bite-wingcalendar year

D0270 D0272 D0273 D0274 D0277

PanorexComplete Mouth X-rays

1 Panorex36-month period OR1 complete mouth X-ray36-month period

Effective January 1 2021 SelectHealth will only authorize varicose vein procedures for members on commercial plans and SelectHealth Advantage (Medicare) that are done in a facility with Intersocietal Accreditation Commission (IAC) accreditation as a vein center As a result of this requirement on the same date SelectHealth will also remove specific clinical criteria in lieu of accreditation

SelectHealth is constantly working to manage utilization which has historically been by means of preauthorization only Moving to oversight via an accreditation process ensures quality outcomes for our members and is more consistent with our goals as an organization The IAC provides quality and safety oversight by

gt Reviewing imaging with inter-rater monitoring gt Reviewing processes around procedure types and volumes gt Requiring outcomes documentation

Facility accreditation Facilities not currently accredited with the IAC must become accredited by January 1 2021 or procedures must be moved to accredited facilities

Learn about obtaining IAC accreditation a process that typically takes between three and six months

Preauthorization Preauthorization is still required and the preauthorization forms will include a question about IAC accreditation Procedures performed without preauthorization will be denied to the provider Codes not covered will remain uncovered regardless of facility accreditation

Questions Contact your Provider Relations representative at 801-538-5054

Varicose Vein Procedure Authorization Changes in 2021

selecthealthorg | 5

Immunization Update and ACIP Highlights

Figure 2 Key Vaccine Guidance Highlights from June 2020 ACIP Meeting

2020ndash2021 influenza vaccine recommendations approved including bull Three updated vaccine components (AH1N1 AH3N2 BVictoria) this being the first time that the variations in the reference strains for non-egg based products (RIV and ccIV) are being listed Children (ages 6 months to 8 years) needing 2 doses in a season should receive the second dose even if they turn 9 years of age between doses

bull The listing of two new products Fluzonereg high-dose quadrivalent (with a volume of 07mLdose) and Fluadreg adjuvanted quadrivalent for ages 65 years and older

Y Added the newly approved Meningococcal quadrivalent vaccine conjugated to tetanus toxoid protein MenACWY-TT (MenQuadfiTMSanofi Pasteur) to the Vaccines for Children (VFC) program

In addition the meeting included the following

gt The preliminary report on the 2019-2020 influenza season

gt COVID-19 (novel coronavirus) presentation by the newly formed COVID-19 work group This presentation focused on COVID-19 epidemiology immunology of SARS CoV-2 and vaccine development as well as principles regarding its distribution

Intermountain Healthcare News

The Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control (CDC) met on June 24 2020 in a shortened one-day virtual meeting to provide guidance on vaccines Learn more by accessing these resources

gt Figure 2 below which summarizes the key guidance from this meeting

gt Meeting minutes and slides which can be found on the ACIP meeting website click on Meeting Materials

gt Related details for each recommendation (vaccine evidence presented committee discussion and votes) which can be accessed online at ACIP Meeting Updates

New Online ResourceYou can now access details about this

and other recent ACIP meetings at selecthealthphysicianorg and on the

Provider Portal

selecthealthorg | 6

Intermountain Healthcare News Continued

Multidisciplinary clinical experts from Intermountain Healthcare develop Care Process Models (CPMs) related clinical guidelines and best practice flash cardsmdashbased on national and other guidelinesmdashas part of a comprehensive care management system

Updated CPMs and related tools

Find all Intermountain CPMs at either

gt mintermountainnetclinicalPagesAll-Care-Process-Models-(CPMs)aspx

gt intermountainphysicianorgclinicalPagesCare-Process-Models-28CPMs29aspx

CPMs are updated by the clinical programs every two years to reflect the most current evidence-based standards

Recently updated CPMs include gt Asthma Albuterol Escalation for Pediatrics

gt Venous Thromboembolism (VTE)

gt Tapering Opioid Pain Medication

gt Preterm Birth (Spontaneous and Indicated)

Provider Publication Updates

Best practice flash cards

Flash cards are printed or electronic point-of-care tools that summarize key decision pointsnotes from a CPM or clinical guideline

New or updated flash cards recently published include

gt Adult Diabetes Mellitus

gt Nutritional Care after Bariatric Surgery

gt Metabolic and Bariatric Surgery (MBS) Procedures

gt Pediatric Traumatic Stress Primary Care (6-18 years)

gt Pediatric Traumatic Stress Child Advocacy Centers (6-18 years)

gt Sepsis (Severe Sepsis and Septic Shock)

gt Treatment of Cystitis

Reference

ADULT B E S T P R A C T I C E F L A S H C A R D

Sepsis (severe sepsis and septic shock)

copy2018 Intermountain Healthcare CPM101fca - 1218 Reference CPM101

Not intended to replace physician judgment with respect to individual variations and needs

TREATMENT

DOCUMENT time zero

What was patientrsquos initial lactate

le 221 ndash 40

CONTINUE

treatment for

severe sepsis

REPEAT

lactate within

3 hours of

initial

CONTINUE

treatment for

severe sepsis

COMPLETE

Septic Shock

Bundle within

6 hours

COMPLETE Severe Sepsis Bundle within 3 hours

COMPLETE Septic

Shock Bundle

within 6 hours

COMPLETE Maintenance Bundle within 24 hours

Still hypotensive

GIVE fluid bolusPatient hypotensive

or lactate ge 4

Reference Link

TREATMENT DOCUMENT time zero

What was patientrsquos initial lactatele 2

21 ndash 40ge 40

CONTINUE treatment for severe sepsis

REPEAT lactate within 3 hours of initialCONTINUE treatment for severe sepsis

COMPLETE Septic Shock Bundle within 6 hours

COMPLETE Septic Shock Bundle within 6 hoursCOMPLETE Maintenance Bundle within 24 hours

Still hypotensive

GIVE fluid bolus

Patient hypotensive or lactate ge 4

MEASUREMENT amp GOALS

This CPM aims to help reduce the rate of PTB

among patients and improve clinical and financial

outcomes associated with it As part of its

implementation Intermountain measures the

number of patients who

bull Are screened for a short cervix

bull Are given progesterone due to prior PTB and or

having a short cervix

bull Are offered cervical cerclage due to having a

short cervix

bull Have threatened PTB and are

ndash Admitted transferred to appropriate facility

per leveling criteria

ndash Administered steroids to lower respiratory

distress syndrome (RDS) risk and or

magnesium sulfate for fetal neuroprotection

bull Have delayed cord clamping (recommended in

all vigorous term and preterm infants 30 ndash 60

seconds after delivery)

Indicates an Intermountain measure

WHATrsquoS INSIDE

PREVENTION

PTB Prevention Map 2

PTB Risk Factors Interventions 3

Recommended Evaluations 4

Estimating PTB Recurrence 5

Supporting Planned amp

Healthy Pregnancies 9

Substance Use Screening amp

Intervention 11

Risk-specific Protocols

for Care in Pregnancy 12

Cervical Cerclage Considerations 20

MANAGEMENT

Assessment amp Management 21

PTL PTB Medication Table 22

PTL Management Algorithm 23

RESOURCES amp REFERENCES

Intermountain Resources 24

References 26

This care process model (CPM) was developed by Intermountain Healthcarersquos

Obstetrics Development Team under the guidance of the Women and

Newborns Clinical Program It recommends an evidence-based approach for

preventing and managing spontaneous or medically indicated deliveries before

37 weeks gestation

Why Focus on PRETERM BIRTH

bull Itrsquos common Approximately 10 ndash 12 of US births occur before term MAN1

bull Itrsquos dangerous Preterm birth (PTB) is associated with 33 of all infant

deaths in the US and is a major determinant of short- and long-term

morbidity in infants and children MAN1 Up to 50 of cases of long-term

neurologic impairment in children are attributed to PTB ACOG1

bull Itrsquos expensive The Institute of Medicine (IOM) estimates that the

combined annual cost of PTB in the US is $262 billion mdash more than

$51000 per infant IOM

bull Consistent evidence-based care can improve outcomes Studies

suggest that clinical outcomes can improve if providers consistently

identify patients at risk for PTB and when possible provide appropriate

risk-specific treatment to prevent or mitigate it GOL MAN2-3 IAM Additionally a

practical and evidence-based approach to managing preterm labor (PTL)

should promote wise resource use and knowing which women can be safely

discharged without treatment

Key Recommendations

bull Identify patient risk factors for PTB and implement best-practice

interventions to lower these risks This CPM gives numerous recommendations

for screening education medication monitoring and other measures to prevent PTB

bull Use every contact with your patient mdash before during and after

pregnancy mdash to educate her about PTB and what she can do to lower her

risk of delivering early For a woman with a prior PTB education should include

an individual PTB recurrence risk assessment

bull Follow the risk-specific care protocols presented in this CPM noting that

among the clinical interventions supported by evidence the appropriate use of

progesterone and cerclage yield the most improvement in outcomes

D E V E L O P M E N T A N D D E S I G N O F

Care Process ModelsC a r e P r o c e s s M o d e l

M O N T H 2 0 1 5

2 015 U p d a t e

PREVENTION AND MANAGEMENT OF

Preterm Birth

(Spontaneous and Indicated)C a r e P r o c e s s M o d e l

J U N E 2 0 2 0

2 0 2 0 U p d a t e

MEASURES amp GOALSIntermountain goal to reduce adverse outcomes

related to opioid use will focus on reducing the

number of patients who arebull Admitted for opioid overdose

bull Taking opioids and benzodiazepines

concurrentlybull Taking a morphine equivalent dose

ge 90 MME dayIndicates an Intermountain measure

WHATrsquoS INSIDEALGORITHMSAlgorithm 1 Evaluation 2

Algorithm 2 Planning and initiation 4

Algorithm 3 Follow up 5

EDUCATION AND GOAL SETTING

Shared decision making 6

TAPERING SCHEDULES 7

FOLLOW UP 8

MEDICATIONS AND RELATED

CONSIDERATIONS 9

SPECIAL POPULATIONS 10

RESOURCES 11

REFERENCES 11

The Functional Restoration Chronic Pain Development Team developed these guidelines to assist providers with safe opioid tapering

and to improve the quality of life of patients living with chronic pain These guidelines were developed using the Utah Clinical

Guidelines on Prescribing Opioids for Treatment of Pain

UTA Washingtonrsquos Interagency Guideline on Opioid Dosing for Chronic Non-

cancer Pain

JAV the CDC 2016 guideline for prescribing opioids for chronic pain DOW and other peer-reviewed clinical guidelinesCDC FSMB

Why Focus ON TAPERING OPIOID MEDICATION

Opioids may play a role for some patients in managing chronic pain Tapering

(lowering the dose or discontinuing) opioid medication may help minimize

these inherent risks associated with opioid use

bull Serious consequences of long-term opioid use which include respiratory

depression and death accidents and increased disability The CDC

describes prescription pain medication overdose as an epidemic DOW

bull Adverse effects associated with opioid use which include functional

limitations respiratory depression disability decreased cognitive function

constipation and higher levels of overall pain

bull Hyperalgesia which can result after opioid use The long-term

effectiveness of opioid pain medication is not clear

KRE and many patients

report less pain when they discontinue opioids

bull Opioid use disorder unhealthy use (including dangerous aberrant

behaviors) and diversion which represent significant and ongoing risks

that increase in patients taking opioids for longer durationsKEY POINTS IN THIS CPMbull Tapering is usually a slow process that requires preparation planning monitoring

and follow up No single approach to tapering is appropriate for all patients

bull Although potentially unpleasant many withdrawal symptoms associated with

tapering can be reduced with symptomatic treatments

bull Consider referral to an addiction or pain specialist if

ndash Aberrant behavior is detected or suspected

ndash Dose equals or exceeds 90 MME day

ndash Pain is uncontrolled

Care Process Models

C a r e P r o c e s s M o d e l

M O N T H 2 0 1 5

2 015 U p d a t e

Tapering Opioid Pain Medication

M A Y 2 0 2 0

2 0 2 0 U p d a t e

selecthealthorg | 7

SelectHealth Advantagereg (Medicare) News

Dental Advantage Preventive-only Dental CoverageIncluded in all Dental Advantage Medicare plans are preventive-only benefits as indicated in Figure 4 below Access a complete member benefit guide for SelectHealth Advantage plans (Utah) This booklet details counties included in Utah as well as specific included and optional benefits copays and maximum out-of-pocket amounts

Figure 4 Preventive-only Dental Benefits for Dental Advantage

Questions Contact Medicare Member Services at 855-442-9900

Preventive Service Allowable BenefitTime Frame Applicable CodesCleanings 2 cleaningscalendar year D1110 D1120

Oral Examinations 2 examscalendar year D0120 D0145 D0150

Bite-Wing X-Rays 2 full series bite-wingscalendar yearOR2 vertical bite-wings in lieu of full series bite-wingscalendar year

D0270 D0272 D0273 D0274 D0277

Centers for Medicare and Medicaid Services (CMS) requirements for fraud waste and abuse (FWA) compliance trainings and attestation are described in Figure 3 below

Compliance Program Training ProgramImplement or adhere to a compliance program including

bull Adoption of policies and procedures to prevent FWA promoting ethical conduct and ensuring compliance with Federal and State laws regulations and other requirements relating to the Medicare program

bull A Code of Conduct

bull Exclusion screening (via the Department of Health and Human Services Office of Inspector General [OIG] List of Excluded Entities and Individuals [LEIE] and the General Services Administration System for Award Management [GSASAM])

bull A program for maintaining reporting and communication channels

bull Auditing and monitoring any contracted vendors that perform Medicare functions

bull Ten-year records retention

Train employees and contractors supporting SelectHealth Medicare Advantage plans on compliance policies and FWA although use of the CMS material is not required

Note that

bull You should administer training within 90 days of contracthire as a best practice

bull The content of the training is at the discretion of your organization The use of previous CMS-issued content is no longer mandatory however you can access the existing online CMS-issued trainings for your reference (SelectHealth retains this link at selecthealthphysicianorg)

Figure 3 Compliance and Training Requirements

FraudWasteAbuse Compliance Trainings and Attestation

selecthealthorg | 8

SelectHealth Community Care (Medicaid) News

Where to direct patients who may qualify for Medicaid

gt Department of Workforce Services

gt Utah Department of Health Medicaid

gt Take Care Utah

How can I tell if someone is on an integrated planFor a member on an integrated plan the word ldquointegratedrdquo appears in the plan name (eg SelectHealth Community Care Integrated or Integrated SelectHealth) Providers can verify eligibility and plan information by

gt Using either of these tools

bull The Utah Medicaid Patient Eligibility Lookup Tool

OR bull The Provider Benefit Tool on the SelectHealth Provider Portal (secure content login required)

gt Submitting an EDI Eligibility Benefit Inquiry and Response (270271) transaction

gt Calling SelectHealth Member Services at 855-442-3234

Where can Medicaid members get mental health careMembers on an integrated Medicaid plan may receive care at any in-network provider Members on other Medicaid plans may continue to receive care through the county mental health system or a Federally Qualified Health Center (FQHC)

Several Intermountain Healthcare clinics are contracted for behavioral healthcare with county mental health systems and can provide services to our Medicaid members

Medicaid Integration RemindersEnrollment During the COVID-19 (novel coronavirus) Pandemic

On March 18 2020 the Families First Coronavirus Response Act was signed into law Part of this legislation provided additional funding for Medicaid that was only available if the state implemented continuous eligibility for enrollees through the end of the emergency period

Because Utah has taken advantage of this funding Utah Medicaid will not close any Medicaid or CHIP cases during the national emergency This is being called continuous enrollment or forced enrollment

Key elements related to this funding include

gt Medicaid enrollees who were eligible as of March 18 2020 will continue to receive benefits through the end of the national emergency

gt Cases will only be closed if the member contacts the state and requests that their enrollment be terminated or if the member moves and is no longer a resident of the state

gt Enrollees who would have had their case review during the pandemic will be reviewed once the emergency period ends

As a result we anticipate

gt A sharp decline in enrollment once the pandemic ends as enrollees whose eligibility status changed during the emergency period are removed

gt That the state will begin to do outstanding case reviews which will result in additional enrollees being removed

gt Continued growth in enrollment due to the adult Medicaid expansion and the current economic situation

Learn more at the Utah Medicaid website

selecthealthorg | 9

SelectHealth Community Care (Medicaid) News Continued

Medicaid and CHIP Networks MergeOn January 1 2020 SelectHealth combined the SelectHealth Community Care (Medicaid) and Childrenrsquos Health Insurance Program (CHIP) networks Changes in federal regulations aligned the two programs and required CHIP providers to be enrolled with Medicaid

Merging these networks means improved continuity of care and retention when members transition between the two plans along with simpler plan administration

Most providers who already see CHIP members have been added to the Medicaid network and will be reimbursed at the same rate as before the merge

SelectHealth continues to evaluate areas with limited healthcare access to provide options for all of our members

Donrsquot Forget to Revalidate with Utah Medicaid

In January 2020 the Utah Administrative Rule R414-23-4 went into effect resulting in greater consequences for providers who fail to revalidate with Medicaid (in accordance with federal regulations)

To summarize the rule Utah Medicaid will close provider contracts if ANY of the following occur

1 The provider fails to revalidate within the required 3- or 5-year cycle as directed by 42 CF 42451 Please note that

gt Reminder notification is sent via USPS to the mailing address on file for the provider as follows

bull 90 days prior to validation cycle expiration

bull 30 days after the first notification if revalidation efforts have not begun

gt A termination letter will be generated at the end of the 90-day validation cycle if the provider has not completed the revalidation

2 The providerrsquos professional license expires This also applies to expiration of a license associated with the program for Clinical Laboratory Improvement Amendments (CLIA)

Please note that

gt The state sends a reminder notification via USPS to the mailing address on file for the provider 45 days prior to the license expiring

gt The provider needs to submit license dates as well as a copy of the updated license as a modification in PRISM

gt A termination letter will be generated if a modification is not submitted prior to the license expiring

3 State or federal reporting indicates that the provider is deceased

4 The provider fails to bill Medicaid for one or more years without notice

selecthealthorg | 10

Practice Management Resources

New to SelectHealth For newly contracted providers we provide key information for navigating our online resources and provider support services

Now you can find onboarding information for those new to the SelectHealth networks including a Welcome Flyer and short presentations on

gt Claims Management

gt Practice Management Online Tools

gt Getting Help for Your Practice Needs

New Provider Onboarding Tools

Medical Home Online ResourcesThe Provider Portal (requires a secure content login) now offers a variety of resources and reports related to Medical Home (see Figure 6 at right)

Click on the Medical Home icon on the Portal home page to access this one-stop location for program benefits participation requirements and more

Questions Contact your Medical Home or Provider Relations representative

SelectHealth offers a wide range of online resources to support your practice needs

Practice Management Online Tools

SelectHealth representatives offer exceptional personal assistance and support

Getting Help for Your Practice Needs

Figure 5 Get Started with SelectHealth

Figure 6 Medical Home Online Resources

SelectHealth strives to meet and exceed benchmarks for on-time claims payment

Claims Management

Practice Management Resources Continued

Enhanced Security Online

QUICK LINKS Enroll in 2-step verification Access ldquoHow Tordquo Help Documents

New Care Management Resources

We are making some login changes to increase security for the applications we use at SelectHealth With an ever-increasing number of cyberattacks against hospitals and health providers the FBI and other enforcement agencies highly recommend 2-step verification for external access to SelectHealth resources to protect our members personal health information

How does 2-step verification work This secure method for allowing access to computer systems requires two steps (or two forms of identification) to gain access

1 Enter your typical User ID and password

2 Use a pass code generated by your smart-phone or other smart device using the PING software platform (see Quick Links)

PING is a free app that can even use facial and fingerprint authentication further enhancing simplicity and security

How will this change occur This change will occur over time A new interface for entering your user name and password debuted on May 22 2020 Now when you log in to the Provider Benefit Tool you will see a new screen that allows you to either sign up for 2-step verification or skip it until later At some point in the future you will be required to enroll in 2-step verification to access Provider Benefit Tool Care Affiliatereg or Provider Reports Please check out the Quick Links below to learn more

Questions Call support services at 801-442-5731 in the Salt Lake Valley or 800-442-4566 for other areas

Care Management at SelectHealthregMany of us need help navigating the healthcare system Finding the right doctor or therapist managing chronic pain or simply getting to an appointment can be tough

At SelectHealth we believe in a proactive holistic approach to treating the overall person

Figure 7 Care Management Resources (video rack card) Now you can access care management information and resources (eg the video and rack card shown in Figure 7 at right) Check out this new area of selecthealthphysicianorg

A care manager can support your patients by

gt Reminding them to get preventive care such as immunizations and recommended screenings gt Designing a care plan that improves physical and mental well-being gt Communicating with providers regarding complicated chronic conditions such as diabetes asthma heart diseasemdasheven cancer gt Coordinating care through our Medical Home team to get treatment and any needed medications gt Carefully explaining health insurance benefits gt Creating an action plan and getting needed support to improve health gt Connecting your patients with community resources such as finding a ride to an appointment

Medical Policies Coding amp Reimbursement

Continued on page 13

Medical Policy Update Bulletin

REVISED Policy (Number)

Effective Date

Summary of Change (only applies to commercial plan policy unless otherwise indicated in BOLD type)

Bariatric Surgery Guidelines (295) 070120

Modified criterion (2-di) concerning behavior modification The member must demonstrate behavior modification including improvement in nutritional intake and physical activity during the program which is at least 90 days supervised by a qualified professional hellip

Diagnostic and Therapeutic Interventions for Spinal Pain (626)

061920

Added clarification SelectHealth may cover two MBBs or two diagnostic anesthetic facet blocks and Physical therapy (minimum of 4 visits over a 6-week period) or chiropractic therapy (minimum of 4 visits over a 6-week period)

Eustachian Tube Balloon Catheter (623) 061720 Revised age requirement from Patient is over the age of 22

to Patient is 18 years of age or older

Revised policiesPolicies are listed alphabetically for quick access Each policy title is linked to the full policy on the SelectHealth Provider Portal where all policies can be accessed alphabetically and by category

This bulletin provides access to new and revised medical as well as coding and reimbursement (CampR) policies in their entirety along with an overview or summary of changes Beginning in September the Medical Policy Update Bulletin will be published monthly to provide more timely information to providers

The appearance of a policy in the Medical Policy Update Bulletin indicates that SelectHealth has recently adopted or revised a CampR policy but does not indicate whether or not SelectHealth provides coverage for the procedures listed

For any inconsistency or conflict between the information provided in this bulletin and the posted medical policy the provisions of the posted policy will prevail

New policies

Two new policies were recently created and published

gt Small Bowel Transplant (640) effective 051820

gt Office-Based Anesthesia (641) effective 062420

Reminder for Primary Care Providers

Effective January 1 2020 Policy 295 (Bariatric Surgery Guidelines) identifies the following as the only covered bariatric surgeries when criteria are met

gt Laparoscopicopen gastric bypass (Roux-en-Y) with short limb (lt 150 cm)

gt Laparoscopicopen sleeve gastrectomy

gt Biliopancreatic bypass with or without duodenal switch

Note This policy revised in the first row of the table below applies to commercial plan policies (for groups selecting this benefit)

Medical Policies Coding amp Reimbursement Continued

Continued from page 12

Home Anticoagulation Monitoring (410) 052720

Implemented the following modifications bull Removed age requirement of gethinsp18 years old bull Added Kawasaki Disease and congenital heart disease

(requiring chronic anticoagulation) to list of qualifying diagnoses

bull Changed requirement concerning attempt at prior anticoagulation from 6 continuous months to 3 continuous months

bull Updated documentationcommunication requirements between provider and memberguardian

Hypoglossal Neurostimulation (Inspire Upper Airway Stimulation) (608)

052820

Changed requirement for BMI from BMI lt 32kgmeter squared to BMI lt 35kgmeter squared and modified requirement concerning CPAP failure

Hysterectomy (620) 061720Removed Long-term IUD usage as a high-risk indicator for ovarian cancer from Oophorectomy Criteria section

Implanted Intraocular Devices for the Treatment of Glaucoma (471)

050120

Reformatted and separated criteria according to type of device and incorporated other forms of glaucoma in addition to open-angle as qualifying conditions (within scope of requirements)

Kidney Transplant and Re-Transplantation (141) 061920

Modified Absolute Contraindication regarding Hepatitis C Active Hepatitis C and HIV positivity

Minimally Invasive Fusion of the Sacroiliac Joint (595)

042420Removed physical examination documentation requirements for The Fortin Finger Test and ldquoNeurological testing from criteria for coverage

Phototherapies for the Treatment of Skin Conditions (351)

051120Added morphea as a qualifying condition for office-based PUVA or narrowbandbroadband UVB phototherapy when criteria are met

Reduction Mammoplasty (Breast Reduction) (172)

070120Reformatted qualifying conditions pertaining to female breast hypertrophy

Total Ankle Arthroplasty (Total Ankle Replacement) (358)

042920

Generalized criteria 2 to require ankle joint damage to be attributed to arthritis modified criteria 4 to require only 12 weeks of failed conservative treatment as well as removed physical therapy as a necessary aspect of failed conservative treatment removed criteria regarding contralateral ankle requirements (previously criteria 5) and clarified that revisions are covered with clinical documentation

Vagal Nerve Stimulation (VNS) (186) 052020

Changed age requirement to one year of age or older instead of 6 years of age or older and modified non-coverage statement to exclude VNS treatment for all indications except intractable epilepsy

Disclaimer SelectHealth refers to many of the products in this issue by their respective trademarks but SelectHealth does not own those trademarks the manufacturer or supplier of each drug owns the drugrsquos trademark By listing these products SelectHealth does not endorse or sponsor any drug manufacturer or supplier And these manufacturers and suppliers do not endorse or sponsor any SelectHealth service or plan and are not affiliated with SelectHealth

Newly archived policiesSelectHealth archives a policy when a certain set of criteria is no longer applicable or necessary such that a code (or codes) is either set to be automatically covered or automatically not covered This nullifies the need for any clinical criteria and corresponding medical policy

August 2020 Coding Updates

Effective October 1 2020 there will be over 1000 updates to ICD-10-CMICD-10-PCS codes as well as many updates to HCPCSProcedure codes Please be sure to use the applicable version of your coding books based on your dates of service to ensure you remain current and code accurately

For more info regarding these changes please visit the CMS website

Beginning in September coding updates will be published online each month to provide more timely information to providers

There is one newly archived policy this period Proton Beam Therapy (456) effective 100119 (retroactive) this policy is now administered by AIM Specialty Health

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selecthealthorg | 2

SelectHealthreg News

Mike Cotton Selected as New President and CEO of SelectHealth

Following an extensive national search the Executive Leadership Team and the Intermountain and SelectHealth Boards of Trustees have selected Mike Cotton as the new President and CEO of SelectHealth Mike will start his new role in mid-November

Who is Mike CottonMr Cotton is a seasoned healthcare leader with extensive experience in integrated health systems He is a strategic thinker consumer centered and a member advocatemdasha positive and collaborative leader who is committed to our mission-driven growth member experience and doing the right thing for all we serve

Experience Since 2015 Mike has been CEO of Providence Health Plan part of the Providence St Joseph Health System a national not-for-profit Catholic health system based in Portland Oregon Prior to that he was vice president and chief operating officer for Humana responsible for their Medicaid and state-based contract programs He previously held leadership positions with Evolent Health and Alere Health as well as provider-sponsored health plans affiliated with University Hospitals Health

System and Premier Health System based in Ohio

Mikes leadership has been instrumental in the success of growing overall plan membership long-term care and Medicaid programs and population health products and programs as well as expanding partnership relationships

Education Mike graduated from Cleveland State University earning an MBA in healthcare administration He also holds

a certificate of executive healthcare management from Case Western Reserve University and completed his undergraduate studies at Franklin University and The Ohio State University in Columbus Ohio

How will leadership transition occurCurrent SelectHealth CEO Pat Richards will retire on August 31 2020 Bert Zimmerli Intermountainrsquos executive vice president and chief financial officer will serve as the interim SelectHealth president and CEO until Mike joins us in November Bert also served in this interim capacity prior to Pat Richards joining SelectHealth 10 years ago

Read the latest Pharmacy amp Therapeutics newsletter along with Formulary Updates

These contain information about recent formulary decisions specific therapeutic class updates and industry news

Access these key resources for opioid prescribing

gt Providers Clinical Support System gt How to Monitor Opioid Use for Your Patients with Chronic Pain (AAFP article) gt HHS Tapering Guidelines gt Opioid amp Benzodiazepine Co-Prescribing

Pharmacy News

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TREATMENT

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Reference

TREATMENT

DOCUMENT time zero

le 221 ndash 40

CONTINUE

treatment for

severe sepsis

REPEAT

lactate within

3 hours of

initial

CONTINUE

treatment for

severe sepsis

COMPLETE

Septic Shock

Bundle within

6 hours

COMPLETE Septic

Shock Bundle

within 6 hours

Still hypotensive

or lactate ge 4

Reference Link

21 ndash 40ge 40

Still hypotensive

GIVE fluid bolus

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WHATrsquoS INSIDE

PREVENTION

Intervention 11

MANAGEMENT

References 26

37 weeks gestation

Key Recommendations

M O N T H 2 0 1 5

2 015 U p d a t e

Preterm Birth

J U N E 2 0 2 0

2 0 2 0 U p d a t e

FOLLOW UP 8

CONSIDERATIONS 9

RESOURCES 11

REFERENCES 11

cancer Pain

Care Process Models

M O N T H 2 0 1 5

2 015 U p d a t e

M A Y 2 0 2 0

2 0 2 0 U p d a t e

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gt Take Care Utah

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Effective Date

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Bite-Wing X-Rays

D0270 D0272 D0273 D0274 D0277

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Provider Portal

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Reference

TREATMENT

DOCUMENT time zero

le 221 ndash 40

CONTINUE

treatment for

severe sepsis

REPEAT

lactate within

3 hours of

initial

CONTINUE

treatment for

severe sepsis

COMPLETE

Septic Shock

Bundle within

6 hours

COMPLETE Septic

Shock Bundle

within 6 hours

Still hypotensive

or lactate ge 4

Reference Link

21 ndash 40ge 40

Still hypotensive

GIVE fluid bolus

short cervix

WHATrsquoS INSIDE

PREVENTION

Intervention 11

MANAGEMENT

References 26

37 weeks gestation

Key Recommendations

M O N T H 2 0 1 5

2 015 U p d a t e

Preterm Birth

J U N E 2 0 2 0

2 0 2 0 U p d a t e

FOLLOW UP 8

CONSIDERATIONS 9

RESOURCES 11

REFERENCES 11

cancer Pain

Care Process Models

M O N T H 2 0 1 5

2 015 U p d a t e

M A Y 2 0 2 0

2 0 2 0 U p d a t e

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gt Take Care Utah

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Claims Management

Effective Date

061920

New policies

052820

050120

042920

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selecthealthorg | 5

Provider Portal

selecthealthorg | 6

Reference

TREATMENT

DOCUMENT time zero

le 221 ndash 40

CONTINUE

treatment for

severe sepsis

REPEAT

lactate within

3 hours of

initial

CONTINUE

treatment for

severe sepsis

COMPLETE

Septic Shock

Bundle within

6 hours

COMPLETE Septic

Shock Bundle

within 6 hours

Still hypotensive

or lactate ge 4

Reference Link

21 ndash 40ge 40

Still hypotensive

GIVE fluid bolus

short cervix

WHATrsquoS INSIDE

PREVENTION

Intervention 11

MANAGEMENT

References 26

37 weeks gestation

Key Recommendations

M O N T H 2 0 1 5

2 015 U p d a t e

Preterm Birth

J U N E 2 0 2 0

2 0 2 0 U p d a t e

FOLLOW UP 8

CONSIDERATIONS 9

RESOURCES 11

REFERENCES 11

cancer Pain

Care Process Models

M O N T H 2 0 1 5

2 015 U p d a t e

M A Y 2 0 2 0

2 0 2 0 U p d a t e

selecthealthorg | 7

D0270 D0272 D0273 D0274 D0277

Note that

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gt Take Care Utah

selecthealthorg | 9

Please note that

Claims Management

Effective Date

061920

New policies

052820

050120

042920

_GoBack

selecthealthorg | 6

Reference

TREATMENT

DOCUMENT time zero

le 221 ndash 40

CONTINUE

treatment for

severe sepsis

REPEAT

lactate within

3 hours of

initial

CONTINUE

treatment for

severe sepsis

COMPLETE

Septic Shock

Bundle within

6 hours

COMPLETE Septic

Shock Bundle

within 6 hours

Still hypotensive

or lactate ge 4

Reference Link

21 ndash 40ge 40

Still hypotensive

GIVE fluid bolus

short cervix

WHATrsquoS INSIDE

PREVENTION

Intervention 11

MANAGEMENT

References 26

37 weeks gestation

Key Recommendations

M O N T H 2 0 1 5

2 015 U p d a t e

Preterm Birth

J U N E 2 0 2 0

2 0 2 0 U p d a t e

FOLLOW UP 8

CONSIDERATIONS 9

RESOURCES 11

REFERENCES 11

cancer Pain

Care Process Models

M O N T H 2 0 1 5

2 015 U p d a t e

M A Y 2 0 2 0

2 0 2 0 U p d a t e

selecthealthorg | 7

D0270 D0272 D0273 D0274 D0277

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061920

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Note that

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gt Take Care Utah

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Effective Date

061920

New policies

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gt Take Care Utah

selecthealthorg | 9

Please note that

Claims Management

Effective Date

061920

New policies

052820

050120

042920

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selecthealthorg | 9

Please note that

Claims Management

Effective Date

061920

New policies

052820

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042920

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Claims Management

Effective Date

061920

New policies

052820

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Effective Date

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Effective Date

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