March 2016 Network Updates

Totally Connected…..

A newsletter for Physician Offices…...

Our Mission: To be the industry leader in providing quality, cost effective health care for our members

Provider Services Susan Ryan, Mgr.

313-871-6589

Anita Wallace, PR 313-871-7809

Judi Idris, PR

313-871-7831

Pam Long, PR

313-293-6440

Brittaney Shiller, PR 313-293-6443

Christina Pittinato, aaCredentialing

313-871-7889

Maryanne Adam, aaNetwork Analyst

313-871-7808

Tara Starkweather,

Network Specialist 313-293-6425

Provider Only Line

844-THC-DOCS

Healthy Michigan Plan HRA UpdatesHealthy Michigan Plan HRA UpdatesHealthy Michigan Plan HRA Updates

Healthy Michigan Members are covered under Medicaid fee-for-service

when they first sign-up for coverage. During this time, the State will not re-

imburse primary care providers for submitting HRAs. Therefore:

Always check the member’s eligibility to ensure coverage under Total

Health Care before submitting the HRA to THC.

If you complete the HRA while the member is covered under FFS Medi-

caid, hold on to the HRA until the patient’s effective date with the Plan.

HRAs completed during the member’s coverage under FFS must be

faxed to THC within 30 days of the member’s effective date with THC.

Use the date you are sending us the HRA on the claim, NOT the date of

service the HRA was completed.

Reassessment

Healthy Michigan members are eligible for reassessments for the period

of 11 months to 15 months from the date of the initial or prior assess-

ment . HRAs completed before 11 months are ineligible for the incentive

for both the provider and the member.

Always use the date of submission of the HRA form as the date of ser-

vice when billing code 99420.

You do not need to wait for lab values to submit the HRA form. Just be

certain to check the box that the labs have been ordered.

Our HRA team is available to address any questions or concerns related to

submission and incentive payments for the HRAs. Contact us at 800-826-

2862, ext 3471.

Quality Improvement / Utilization Management

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Covered Services to be provided directly by Provider include all in-office services typically provided by a Primary Care Provider as specified in the list-

ing below.

Quality Improvement Program

THC has adopted the following changes to our QI Program for 2016:

Health Equity—THC will participate in the Michigan Department of Health & Human Services Equi-

ty Project. Health Equity will be integrated into all THC care management and quality improve-

ment programs using the National CLAS Standards.

Clinical Outreach Team—a dedicated team of non-clinical staff will conduct targeted outreach to

improve HEDIS measures and health outcomes for members. The focus of the clinical outreach

team will be to schedule/coordinate appointments for members with their primary care physicians.

This will help our PCPs reach their pay for performance targets while improving access to care and

increasing annual/preventive screenings.

THC will expand coordination of behavioral health services and integration into the Community

Mental Health Centers for Wayne, Oakland and Macomb Counties.

Utilization Management Program

The following policies were adopted by THC effective January 2016. Physicians may request a copy

of the guidelines by contacting the Utilization Management Department.

Bone Growth Stimulators

Benign Skin Lesion Removal

Bunionectomy/Cheilectomy

Reduction Mammoplasty

Auditory Osseointegrated Device/Bone Anchored

Hearing Aid

Blepharoplasty, Blepharoptosis Repair, Eyelid Reconstruction and Brow Lift

PT/OT/ST Authorizations

THC will impose quantity limits for services on claims received on/after 4/1/2016 for physical, occupa-

tional or speech therapies. Therefore, if the billed quantity exceeds the authorized quantity, the claim

will be denied as AA4-Authorization unit exceeded. Please ensure that the appropriate quantity for

services is included on your referral requests.

PCPs are required to write a referral for the initial evaluation of PT/OT/ST. The rendering provider of

services is required to obtain prior authorization for specific services. THC does not authorize:

Massage (97124)

Aquatic Therapy

Group Therapy

Hot/Cold Packs

Rhinoplasty/Septoplasty

Varicose Veins or Varicosities

Penile Implants

Motorized Power Wheelchairs/Scooter

Treatment for speech therapy for school-aged children during the

school year due to available treatment through school-based pro-

grams. During the summer months, authorizations will be re-

viewed on an individual basis

Clinical Practice Guidelines

Total Health Care continues to implement clinical practice guidelines and performance measures focused on ef-

fecting positive health outcomes. These guidelines are meant as guidelines. Individual patient considerations

may supersede or modify these recommendations. The following CPGs have been developed by MQIC (Michigan

Quality Improvement Consortium) and recently been approved for use by our Quality Improvement Committee:

Lipid Screening & Management

Screening, Diagnosis and Referral for Substance Use Disorders

Outpatient Management of Uncomplicated Deep Vein Thrombosis

Management and Prevention of Osteoporosis

Primary Care Diagnosis & Management of Adults with Depression

Advance Care Planning

Routine Prenatal and Postnatal Care

Tobacco Control

Access to these and other approved MQIC guidelines is available through the THC website – www.THCmi.com >

Provider Page > Clinical Resources.

Clinical Guidelines

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Provider Portal UpdateProvider Portal UpdateProvider Portal Update To enhance the user experience, THC and our vendor have made the change noted below:

HEDIS Member Incentives

THC is supporting our PCPs by incentivizing members to be complaint with their HEDIS measures through our Smarter

Health Wellness Raffle. PCPs who are interested in offering “Total Health Care Days” at their practice can additionally

offer gift cards to members to obtain appointments. Contact your Provider Relations Representative for details!

THC continues to work with our vendor to deliver a HEDIS tool that will be available to primary

care physicians through our Provider Portal. Due to the delay, our THC 2016 Pay for Performance

program will continue to be based on wellness exams. Provider Relations will provide lists of well-

ness exams due/completed for each PCP until the tool is available. Below are the proposed compo-

nents of the 2016 program. (Actual PMPM payments may be changed based on 2015 final pay-

ments):

Physicians with < 50 members are excluded from this P4P payout and will be advised of other

incentive opportunities

Pediatric patients in the W15 measure (Childhood Wellness Exams for patients 0 to 15 months)

must have multiple visits for the measure to be satisfied. From birthdate through the calendar

year, must have one visit every 2 months for the measure to be satisfied, or until they reach

their 15 month birthday).

Physicians must have an open panel if membership is below 300.

We encourage you to plan out your visits to allow for preventive exams. With a thoughtful ap-

proach to this project, you can make earn significant payment. Good luck!

Pay for Performance 2016

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A1C In office lab testing: Providers who perform HgbA1C testing in the office will

not receive reimbursement unless the test results are provided. To report results,

use CPT II codes, or ensure that THC receives results via registry reporting through

WellCentive.

Member Rights & Responsibilities

Member Rights and Responsibilities

All contracted THC providers are required to comply with the following Rights & Responsibilities for all THC members. If a THC member fails to follow this code of conduct, please notify Customer Services at 313-871-6596.

Members have the right: To get information about Total Health Care, its services, its providers and member rights and responsibil-

ities. To make recommendations regarding Total Health Care’s member rights and responsibilities policy. To be treated with respect and dignity. To have privacy while receiving care. To take part with doctors in decision-making about their health care, including the right to refuse treat-

ment. To talk openly about treatment options regardless of cost or benefit coverage. To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience

or retaliation. To be free to exercise their rights without adversely treatment. To be free from other discriminations prohibited by State and Federal regulations. To receive healthcare services consistent with their contract, State and Federal regulations. To voice their complaints or grievance/appeals about Total Health Care or the care provided.

Members have the responsibility:

To receive all their health care services through Total Health Care. To understand their healthcare benefits. To provide THC and its providers with the information needed for their care. To help their doctor decide what treatment will work best. To follow the care plan and instructions agreed upon with their doctor. To respect the rights of other patients, doctors and staff of Total Health Care.

Ordering/Referring and Attending Provider Requirements per Michigan Department of Community Health

As outlined in MSA 12-55 Bulletin, claims for services rendered as a result of an order or referral

must contain the individual NPI of the practitioner who ordered or referred the item or service.

All practitioners who order/refer services for Michigan Medicaid beneficiaries, including THC Med-

icaid, must be enrolled/registered in the Michigan Medicaid program.

Ordering/referring/attending providers who have not yet enrolled/registered in CHAMPS need

to do so as soon as possible. THC is requiring providers who participate with us to be en-

rolled in CHAMPS at the time of initial and recredentialing.

Ordering/referral providers are encouraged to share their individual NPIs with rendering pro-

viders so they may submit the information required for payment on their claims.

Referral & Authorization Guidelines

Prior Authorization from THC

PCP Initiated Referral (excludes Select POS)

No Referral or Authorization

PCP must FAX clinical information to THC Utilization Department at 313-748-1312

Must process through the Provider Portal

Services must be provided in network unless POS

Abortion - (Medicaid only) Admissions:

Inpatient Hospital – acute, emergent, elective

Long Term Acute Care Admission Skilled Nursing Facility

Acute & Sub-Acute Rehabilitation

Excluding Observation Stay (no auth required) Surgeries:

Abdominoplasty/ Panneculectomy

Bariatric (excluding lap band adjustments) Blepharoplasty

Breast Reduction / Augmentation

Bunionectomy Cosmetic Surgeries not otherwise listed

Foot - all Hammertoe Hysterectomy (need form only) Transplant, Organ, Tissue, Bone Marrow

Rhinoplasty / Septoplasty Scar Revision / Keloid Removal Surgery to Treat Varicose Veins

Device Implants- including, not limited to: Insulin pumps, continuous glucose monitors

Interstim therapy

Penile Implant Vagus nerve/bone growth stimulators

Implantable Loop Records (cardiac) Anti-emetic Drugs

Apheresis

Genetic Testing

Hearing Aids

Home Health Care

Hospice Infusion Therapy

Laser Treatment for Skin Diseases

Specialty Medication Injections (see separate list) Out of Network Services (excludes Select POS) Prosthetics/Orthotics- > $200

Sterilization-Male/Female Temporomandibular Joint (TMJ) Procedures

PT/OT/ST Treatment (excludes Select POS) Behavioral Health Substance Abuse Services

Power/motorized wheel chairs

Experimental & Investigational Services Non-emergent ambulance transportation

Cardiac LifeVest

All procedures/surgeries in an ASC (Ambulatory Surgical Center) or Outpatient Hospital :

Excluding procedures noted as requiring prior authorization

The following procedures when performed in POS 22 or Outpatient: Biofeedback Therapy

Cardiac Catheterization Cardioversion Tilt-table, TEE

Cardiac Rehabilitation

Hyperbaric Oxygen Therapy Endoscopy procedures in an outpatient setting:

GI Tract – excluding colonoscopy, sig-moidoscopy, proctoscopy

Capsule endoscopy

EGD ERCP

Gastroscopy

Laryngoscopy Respiratory Tract:

Bronchoscopy

Laparoscopy Arthroscopy

Female Reproductive System: Hysteroscopy

High-tech radiology exams: CT Scans

MRIs, MRAs

PET Scans

Nuclear Studies Cardiac Stress Test MUGA

HIDA Scan Podiatry Visits and Treatment Photochemotherapy – UV Light Treatment PT/OT/ST- initial evaluation only Sleep Studies

Wound care/ debridement Chiropractic Visits and Treatment

Allergy Testing, Injections, Treatment Ambulance Services

Audiology Testing

Cardiac Event / Holter Monitors / EKG Cardiac Exercise Stress Test (non-nuclear) Chemotherapy

Colonoscopy, sigmoidoscopy, proctoscopy Dialysis

Durable Medical Equipment: Metro Medical Equipment – all supplies J&B for incontinence supplies only (CSHCS only)

Injectable Medications:

J7321 – Euflexa

J7322 – Supartz J7323 – Synvisc 1

Neurology Studies:

EEG / EMG

Pacemaker check Prosthetics/Orthotics- < $200

Radiation Therapy

Laboratory Low-tech radiology:

X-rays, Dexa Bone Scan Ultrasounds

Mammography (screening & diagnostic) Doppler exams Echocardiography

Specialist Office Visits/Consults (POS 11 & 22) & in-office treatment (excluding Podiatry and Chiropractic) Urgent Care Services

Well Woman Care in the office: Pap Test Ultrasound, trans-vaginal ultrasound

Colposcopy, w, w/o biopsy

Cryosurgery Pregnancy Test Birth control, including insertion & removal: IUD, Implanon, Paragard, Mirena Depo-Provera (RX Benefit)

Obstetric Care in the office: Prenatal / Antepartum Care / Post-partum Care Ultrasound, Fetal non-stress test Bio-physical profile, CVS

Amniocentesis Pulmonary Function Test (PFT) Swallowing Study

Vision services- participating network

NOTE: DO NOT ENTER REQUEST INTO PORTAL for ANY service that requires a Prior Authorization as noted above. Inpatient Authorizations – will start with letter “A” All other services requiring an authorization begin with “R”

PCP initiated Referrals have no Alpha Character

In-Network Laboratory Policy in Effect for 2016 THC has an extensive network of participating laboratories, including all our contracted hospitals (see below). All laboratory benefits for THC members can be received through one of these resources. Therefore, referring a service to an out of network laboratory is not necessary, and is not a benefit. Accordingly, effective in 2016, THC will implement the following policy related to claims for out of network labs: Any lab specimen for a commercial member that is sent or referred by a phy-

sician’s office to an out of network lab will be paid and charged back to the ordering physician. Out of network labs for Medicaid members will be de-nied.

Physicians will be reviewed for compliance in the first quarter of 2016. Any

physician who referred a patient or specimen to an out of network laboratory will be contacted and given a courtesy reminder for the first instance. There-after, any out of network lab will be processed and paid according to THC’s fee schedule, and charged back to the provider. Payment will be applied to-wards future claims.

Physicians can perform in-office labs for any CLIA waived test.

In Network Laboratory ServicesIn Network Laboratory ServicesIn Network Laboratory Services

Hospital Laboratories and affiliated sites: Beaumont Hospital Dearborn Beaumont Hospital Farmington Beaumont Hospital Grosse Pointe Beaumont Hospital Royal Oak Beaumont Hospital Troy Beaumont Hospital Taylor Beaumont Hospital Trenton Beaumont Hospital Wayne Detroit Receiving Hospital Harper University Hospital Hutzel Women’s Hospital Children’s Hospital of Michigan Sinai Grace Hospital Huron-Valley Sinai Hospital

Quest laboratories - any location Page 8

Laboratory Policy - NEW

St John Hospital & Medical Center St John Hospital Macomb Oakland Hospital St John River District Hospital Providence Hospital & Medical Center Providence Park Hospital Crittenton Hospital Garden City Hospital St Mary’s of Livonia St Joseph Mercy Oakland Mercy Memorial Hospital - Monroe Barbara Ann Karmanos Cancer Institute Hurley Hospital Doctor’s Hospital of Michigan

News to Use

When to bill a member:

Contracted providers may not bill members for services that were denied as a result of not receiving the ap-

propriate referral or authorization. The only instance in which a participating provider may bill a member is if

the service is not a benefit to the member under his/her Certificate of Coverage, and the member was in-

formed of the fact prior to receiving the service. This follows the Medicare ABN methodology. Services that

are denied as a result of claim bundling/software edits are NOT eligible to be billed to members.

If you have questions, please contact our claims department at 800-826-2862.

Educational Materials about Flint Water Crisis

Dr. Eden Wells conducts weekly webinars related to Flint to educate providers serving the area. We encour-

age all medical staff to take advantage of these educational opportunities to learn how lead in water can

affect your patients. Click on the link below for webinars: http://www.michigan.gov/flintwater/0,6092,7-

345-75251_75464---,00.html; Flint water website at http://www.michigan.gov/flintwater.

In response to reports from multiple health care providers and members of the public, on January 29, 2016

the Michigan Department of Health and Human Services (MDHHS) launched an investigation to characterize

reported rashes possibly associated with Flint municipal water exposure. While rashes are very common in

the general population and there are numerous known causes, an important public health function involves

being able to identify and rapidly respond to new causes of illness including rashes as they emerge.

A CDC/ATSDR Assessment of Chemical Exposures team has been providing support to MDHHS efforts since

February 25 through standardized interviews of over 80 individuals with rash and systematic reviews of

medical records on those individuals who have seen a healthcare provider for their rash. These individuals

are offered home water testing by EPA for metals and other water quality parameters potentially associated

with rash. MDHHS has also begun collaborating with Genesee County Medical Society dermatologists who

have volunteered to conduct free dermatological screening exams. This will be a one-time evaluation and no

treatment will be prescribed. The dermatologists will send copies of each individual's assessment with any

treatment recommendations to their primary care physician.

Health care providers can assist in this effort to better characterize rashes that have a possible association

with Flint water exposure. Individuals meeting the following rash criteria may be reported to MDHHS, where

they will be interviewed and offered referrals for dermatology screening and EPA home water testing:

1. Place of residence supplied by Flint city water (or other significant exposure location), and

2. Current rash identifiable by exam, with onset on or after October 16, 2015, or existing rash with a peri-

od of obvious worsening on or after October 16, 2015, and

3. No alternative medical diagnosis that would clearly be unrelated to water exposure.

Rash is not reportable in the State of Michigan, so please ask individuals if they would be agreeable to follow

up contact by the MDHHS. If they are, their contact information can be reported directly to MDHHS at 1-800

-648-6942. Members with current rashes are encouraged to contact their PCP. They may also call 2-1-1 if

they have concerns about rash or other health effects in relation to Flint water.

April Formulary Updates

Pharmacy Updates

Medication Update

Formulary Affected

Medicaid /

CSHCS Commercial 3-Tier

QHP

(Exchange)

Rhinocort OTC Added to the Formulary. X X

X

Etodolac ER Removed from the Formulary. X X X

Etodolac 200mg and 300mg Cap-

sules Removed from the Formulary. X X X

Etodolac 400mg and 500mg Tab-

lets Removed from the Formulary. X X

X

Amoxicillin 500mg Tablets Removed (Amoxicillin 500mg Cap-

sules are covered). X X

X

Augmentin 200mg and 400mg

chewables Age Limit (AL) added (ages 0-11). X X X

Augmentin 250mg/5mL Removed from the Formulary. X

Augmentin 600mg/5mL Added to the Formulary. X

Cefadroxil 1gm tablets Removed from the Formulary. X

Cefaclor 125mg/5mL,

250mg/5mL and 375mg/5mL AL added (ages 0-11). X X X

Clarithromycin ER 500mg Removed (Clarithromycin IR 500mg is

covered). X X X

Minocycline ER 90mg Removed from the Formulary. X

Levofloxacin Tablets Removed Quantity Limits (QL). X X X

Flucytosine Capsules Removed from the Formulary. X

Lamisil Granules Removed from the Formulary. X

Itraconazole 100mg Removed from the Formulary. X

Onmel 200mg Tablets Removed from the Formulary. X

Sporanox 10mg/mL Removed from the Formulary. X

Noxafil Tablets and Susp. Removed from the Formulary. X

Vfend Tablets and Susp. Removed from the Formulary. X

Tivicay 50mg Added with QL of one tablet daily. X X X

Isentress 25mg & 100mg Added to the Formulary. X

Prezista 75mg, 150mg and 600mg

Tablets Added to the Formulary.

X

Emtriva 10mg/mL Added to the Formulary. X

Stavudine 30mg Updated QL to one capsule daily. X

Zidovudine Tabs and Syp. Added to the Formulary. X

Viread Tablets Added with QL of one tablet daily X

Rescriptor 200mg Added to the Formulary. X

Intelence 25mg Added to the Formulary. X

Truvada Tablets Updated QL to one tablet daily. X

Triumeq Added to the Formulary. X X X

Atripla Updated QL to one tablet daily. X

Complera Added with QL of one tablet daily. X X

Pharmacy Updates, continued

Medication Update

Formulary Affected

Medicaid /

CSHCS Commercial 3-Tier QHP (Exchange)

Valcyte Solution Removed from the Formulary. X

Sitavig Removed from the Formulary. X

Acyclovir 200mg/5mL AL added (ages 0-12). X

Famciclovir Tablets Removed from the Formulary. X

Relenza Updated QL to twenty per five days. X

Albenza 200mg Tablets Removed from the Formulary. X

Biltricide 600mg Tab-

lets

Removed from the Formulary. X

Pin-X 250mg Chewable Added to the Formulary. X X X X

Reeses Pinworm Susp. Added to the Formulary. X X

Clindamycin 75mg/5mL Added to the Formulary. X

Rhogam Plus 300mcg Added to the Formulary. X

Effective May 1, 2016, Orchard Pharmaceutical Mail Order Services will change its name to EnvisionPharma-

cies. Pharmacy information, such as phone number (866-909-5170), fax number (866-909-5171), National Pro-

vider Identifier (NPI) and National Association of Boards of Pharmacy (NABP) will remain unchanged. For further

information, please visit https://thcmi.com/pharmacy/ or contact THC’s Pharmacy team at 1-800-826-2862, Ex-

tension 3300.

Medicaid EHR Incentive Program & Meaningful Use Medicaid EHR Incentive Program & Meaningful Use Medicaid EHR Incentive Program & Meaningful Use

Did you know:

2016 is the last year to enroll in the Meaningful Use program to earn your full incentive of

$63,750 for Medicaid.

Help is available through MCEITA. MCEITA can assist with

EMR selection

Tool training and adoption

Attestation

To quality for Medicaid funding, your practice must meet criteria of 30% Medicaid (including fee-

for-service Medicaid and Managed Care Medicaid, such as Total Health Care) for all specialties

except for pediatrics, which requires 20%.

For your first year of in the Medicaid program, you can receive funding of $21,000 for AIU—

Adopt, Implement, Upgrade. That gives you time to work towards attestation in 2017.

Don’t delay—enroll to receive funding and avoid penalties in your Medicare payments. Ask your

Provider Relations for more information about Meaningful Use and it’s benefits.

Fraud, Waste & Abuse

How to Report Suspected Fraud, Waste & AbuseHow to Report Suspected Fraud, Waste & AbuseHow to Report Suspected Fraud, Waste & Abuse If you have any information about fraud, waste and abuse, please contact Total Health Care immediately.

Notification of suspected fraud, waste and abuse can be made anonymously. It is not required that you pro-

vide your name. Retaliation for good faith reporting is strictly prohibited. Reports can be made by calling,

writing, faxing or emailing THC at:

Total Health Care

ATTN: Fraud and Abuse Coordinator

3011 W Grand River, Ste 1600

Detroit, MI 48202

Call: 800-826-2861 or 313-871-2000

Fax: 586-461-2540

Email: eliminatefwa@THCmi.com

You may use this form found on our

website to report the information.

You may also report instances of

fraud and abuse directly to the Office

of State Health Inspector General

(OIG) without giving your name.

Call the OIG at 855-643-7283 or

send a correspondence to:

Office of State Health Inspector Gen-

eral

PO Box 30062

Lansing, MI 48909-7979

www.michigan.gov/fraud

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