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ILLINOIS | 2015 | ISSUE I

PROVIDER Newsletter

IN THIS ISSUE

A Note from Harmony's MedicalDirector, David J. Sand................. Page 1

Provider Satisfaction Survey......... Page 2

Coming Soon! New ProviderServices Technology...................... Page 2

Harmony Medicaid Provider ManualUpdated....................................... Page 3

A Note from Harmony's MedicalDirector David J. Sand Continued...Page 3

Clinical Practice Guidelines...........Page 3

New Claim Edits for 2015..............Page 4-5

Appointment Access andAvailability Audits........................ Page 6

Availability of Review Criteria....... Page 6

New Toll-Free Phone Numberfor Medicare Providers................. Page 6

Access to UtilizationManagement Staff........................ Page 6

Antidepressant MedicationManagement................................ Page 7

Change in Review Process forMedicare Admissions EffectiveFebruary 2, 2015............................Page 7

Q1 2015 Provider FormularyUpdate......................................... Page 7

Provider Resources.......................Page 8

A NOTE FROM HARMONY’S MEDICAL DIRECTOR, DAVID J. SAND, MD, MBA I hope and trust you had a wonderful holiday season and your new yearis off to a terrific start!

We have been implementing exciting changes at WellCare over the pastfew months and are looking forward to forming new collaborations withyou as well as re-energizing existing relationships.

First and foremost, we have added new members to our managementteam, starting at the very top: Robert Hilliard, Jr., M.B.A., president; NancyWohlhart, V.P. of network management; Barbara Alexander, R.N., B.S.,CCM, senior director of field services; and me, David Sand, M.D., M.B.A.,medical director. Along with the rest of the staff, we are anxious to begood partners with you, with the goal of providing the best care for yourpatients, our members. With that in mind, we have changed the waywe will be providing you service. You will meet, if you have not alreadydone so, your dedicated team of WellCare representatives. This includesan account representative and a clinical HEDIS® practice advisor. Theseassociates will be your points of contact for WellCare and will work withyou to resolve member, administrative and clinical quality issues.

No doubt you will notice our new focus on quality, HEDIS and caremanagement. Our clinical HEDIS practice advisors (CHPAs or “chippas”)will provide extensive information regarding your patients, theirrecommended services and care gaps. They will also be able to assistyou with clinical practice guidelines and information about correctlycoding your office visits and services to receive maximum credit onyour HEDIS quality scores. In reality, HEDIS is simply best-practice carefor your patients.

Your practices in Illinois have also been chosen to benefit from WellCare'snew care management model - a highly focused case managementmodel aimed at assisting you with care for your patients with the mostsignificant chronic disease issues. This includes CHF, asthma and COPD,diabetes and behavioral health concerns. Our field-based “feet on thestreet” RNs, licensed clinical social workers, field outreach coordinators,care management coordinators and community health care workerswill help you engage with your patients, help them access services fromcommunity- and faith-based organizations, and most importantly, getthem to your offices where you can provide expert care.

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PROVIDER SATISFACTION SURVEY Harmony-WellCare continues to focus efforts on the experiences of both our members and providers. In order to better understand and remain well informed about our valued provider network, we conducted a Provider Satisfaction Survey in 2013, and again in 2014. The survey concentrated on a variety of subjects, including call center/member services, provider relations, continuity/coordination of care, provider network, utilization and quality management, finance issues, pharmacy and drug benefits, and overall satisfaction and loyalty.

Extensive reviews of our 2014 survey results are underway to ensure that our focus aligns with the needs of our providers. Current areas of focus include enhancing provider services at the local level, claim processing and issue resolution, enriching administrative tools/capabilities, and continued emphasis on quality. Harmony-WellCare is continuously engaged with several cross-functional teams working on these initiatives, and others that are aimed at better serving our providers. We anticipate incremental gains on several initiatives in 2015 and continued improvement beyond. These efforts will be further communicated as the year progresses.

Shortly, Harmony-WellCare will again conduct a Provider Satisfaction Survey. This follow-up survey will be used to measure progress from last year’s effort to better evaluate how we can become more effective and productive business partners.

Your participation is encouraged – and appreciated – as together we strive to improve the lives of our members’ overall quality of care.

COMING SOON! NEW PROVIDER SERVICES TECHNOLOGY Harmony-WellCare is excited to unveil some major technology improvements in early 2015. You will see a difference in the speed and quality of service that you get when you call us.

Are you tired of spending additional time with Customer Service to identify yourself?

Are you tired of internal transfers?

Are you tired of spending time to validate member information?

Would you prefer to complete some of these standard inquiries via self-service?

We listened to your feedback and soon you will be able to provide your information, as well as your member’s, within our Interactive Voice Response system. This will greatly reduce the time you spend on the phone when calling us.

In preparation for these changes, we want to provide some quick tips to help you navigate this new process. Have the following information available with each call:

1. Harmony-WellCare provider ID number

2. NPI or Tax ID number for validation if you do not have your Harmony-WellCare provider ID number

3. For claims inquiries – the member’s ID number, date of birth, date of service and dollar amount

4. For authorization and eligibility inquiries – the member’s ID number and date of birth

Some additional features will soon be available, including improved call menus and enhanced self-service capabilities. You will also be able to select between speaking your commands or using your touch tone keypad to enter selections. All of these changes are being implemented to make it easier to do business with us. Thank you for your support and all that you do for our members.

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HARMONY MEDICAID PROVIDER MANUAL UPDATED There have been recent changes to the Harmony Medicaid Provider Manual effective January 1, 2015. The updated manual can be viewed online (and/ or printed) at our website at www.wellcare.com/ Provider/ProviderManuals.

This update provides information regarding these and other topics, including:

Provider and member administrative guidelines

Utilization and disease management

Appeals and grievances

Behavioral health

Pharmacy

If you have any questions or would like a printed copy of the Provider Manual, please contact your PR rep or call one of the Provider Services phone numbers at the end of this newsletter.

A NOTE FROM HARMONY’S MEDICAL DIRECTOR, DAVID J. SAND The beginning of the year is also a great time to start your patients on the path toward year-round adherence on the medications you prescribe. Along with HEDIS and the state, WellCare has a goal of at least 80 percent adherence, particularly for statins, ACEs and ARBs (angiotensin converting enzyme inhibitors and angiotensin II receptor blockers), and oral medications for diabetes. Missed prescription fills now make it much tougher to hit 80 percent later in the year. Together we will aim for 100 percent.

Feel free to contact me at David.Sand@WellCare.com.

I look forward to working with you!

Dave

David J. Sand, MD, MBA, FACS, FAIHQ

CLINICAL PRACTICE GUIDELINES Clinical Practice Guidelines (CPGs) are best-practice recommendations based on available clinical outcomes and scientific evidence. Harmony-WellCare CPGs reference evidence-based standards to ensure that the guidelines contain the highest level of research and scientific content. CPGs are also used to guide efforts to improve the quality of care in our membership. The CPGs listed below are available on our Provider Resources website at www.wellcare.com/provider/cpgs.

GENERAL CLINICAL PRACTICE GUIDELINES Asthma

Cholesterol management

Chronic heart failure

Chronic kidney disease

COPD

Coronary artery disease

Diabetes in adults

Diabetes in children

HIV antiretroviral treatment in adults

HIV screening

Hypertension

Imaging for low back pain

Lead exposure

Obesity in adults

Obesity in children

Osteoporosis

Pharyngitis

Rheumatoid Arthritis

PREVENTIVE HEALTH GUIDELINES Adult preventive health

Postpartum guidelines

Preconception and interpregnancy

Pregnancy

Pediatric preventive health

BEHAVIORAL HEALTH CPGS ADHD

Depressive disorders in adults

Depressive disorders in children

Schizophrenia

Substance use disorders

Suicidal behaviors

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NEW CLAIM EDITS FOR 2015 In order to comply with the Centers for Medicare & Medicaid Services (CMS) billing guidelines, Harmony-WellCare is implementing new Medicare Strategic National Implementation Process (SNIP) edits for 837I and 837P claims in 2015.

837I SNIP EDIT DETAILS: Harmony-WellCare will edit for HIPPS codes, attending provider NPI, and correct Anesthesia units of measurements and modifiers in compliance with CMS mandates.

Health Insurance Prospective Payment System (HIPPS) Code Requirements:

Effective July 1, 2014, all claims from Skilled Nursing Facilities (SNFs) and Home Health Agencies (HHAs) must appropriately bill with a valid HIPPS code for Type of Bill 018x, 021x, or 032x (x represents the Type of Bill Frequency).

SNFs Bill Types and HHAs Bill Types must bill the HIPPS code derived from the “Initial Assessment”

The first line must be the PPS Revenue Code (0022 or 0023), and corresponding HIPPS code

Submit subsequent lines in the appropriate order as detailed in the Uniform Billing guide.

Additional information on the new CMS mandate can be reviewed at: www.csscoperations.com/internet/cssc3.nsf/files/Encounter%20Data%20-%20HIPPS%20Codes.pdf/$FIle/ Encounter%20Data%20-%20HIPPS%20Codes.pdf

EDI example:

Loop 2400 SERVICE LINE NUMBER: LX✽1~ SV2✽0022✽HP:CC160✽.00✽UN✽5~

Paper example:

42 REV.CD 43 DESCRIPTION 44 HCPCS/RATE/HIPPS CODE 45 SERV DATE 46 SERV UNITS 47 TOTAL CHARGES

0022 SNF PPS CC160 1/1/2015 1 100.00

Attending Provider for UB-04/837I Claims Requirements:

The CMS Medicare Claims Processing Manual documents the Attending Provider reporting requirements in Chapter 25 FL 76 – Attending Provider Name and Identifiers (including NPI). Attending provider’s name and NPI are required when a claim/encounter contains any services other than nonscheduled transportation services.

The attending provider is the individual who has overall responsibility for the patient’s medical care and treatment reported in this claim/encounter.

EDI example:

Loop 2310A Attending Provider Name and NPI (XX qualifier): NM1✽71✽1✽JONES✽JOHN✽✽✽✽XX✽1234567891~ Attending Provider Taxonomy (AT qualifier): PRV✽AT✽PXC✽208D00000X~

Paper example:

76 ATTENDING NPI 1234567891 QUAL

LAST JONES FIRST JOHN

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837P SNIP EDIT DETAILS: Professional Claims Unit of Measure Requirements:

The CMS 837P Companion Guide documents requirements for the Unit of Basis for Measurement when an anesthesia modifier is billed the Unit of Measure is to be an “MJ”. All other claims are to report “UN” as the Unit of Measure.

EDI example:

Loop 2400 Service Line Units: SV1✽HC:99211:25✽12.25✽UN✽1✽11✽✽1:2:3✽✽Y~ Loop 2400 Service Line Minutes: SV1✽HC:00142:QK:P1✽827✽MJ✽61✽✽✽1~

837P Companion Guide www.cms.gov/Medicare/Billing/ElectronicBillingEDITrans/CompanionGuides.html

Paper example:

24.A DATE(S) OF SERVICE B.

PLACE OF

SERVICE

C.

EMG

D. PROCEDURES SERVICES OR SUPPLIES

(Explain Unusual Circumstances)

E.

DIAGNOSIS

POINTER

F.

$

CHARGES

G.

DAYS OR

UNITS

FROM

MM DD YY

TO

MM DD YY CPT/HCPCS MODIFIER

01 01 2014 01 01 2014 11 00142 QK A 100 00 61

Anesthesia Modifier Requirements:

The CMS Medicare Claims Processing Manual Chapter 12 section 50 documents the appropriate anesthesia modifier to denote whether the service was personally performed, medically directed or medically supervised.

Specific anesthesia modifiers include: AA, AD, QK, QX, QY and QZ

EDI example:

Loop 2400 – Service Line: SV1✽HC:00142:QK:P1✽827✽MJ✽61✽✽✽1~

Medicare Claims Processing Manual Chapter 12 Section 50, pages 121 and 122: www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

Paper example:

24.A DATE(S) OF SERVICE B.

PLACE OF

SERVICE

C.

EMG

D. PROCEDURES SERVICES OR SUPPLIES

(Explain Unusual Circumstances)

E.

DIAGNOSIS

POINTER

F.

$

CHARGES

G.

DAYS OR

UNITS

FROM

MM DD YY

TO

MM DD YY CPT/HCPCS MODIFIER

01 01 2014 01 01 2014 11 00142 QK A 100 00 61

Source:

Medicare Claims Processing Manual Chapter 25, page 23. www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c25.pdf

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APPOINTMENT ACCESS AND AVAILABILITY AUDITS Harmony-WellCare is required by CMS and state regulations to administer appointment access and availability audits. The audits are conducted by a third party vendor, The Myers Group, and keep us compliant with NCQA and other accreditation entities. Auditors identify themselves when calling provider’ offices, and provide appointment examples for existing members.

If an audit of your office reveals areas for improvement, you will receive a notification letter and an outline of the appointment types and standards. You will be given an opportunity to respond, and will be re-audited in 90 days.

For more information on appointment access and availability audits, please contact your PR rep or call one of the Provider Services phone numbers at the end of this newsletter.

AVAILABILITY OF REVIEW CRITERIA The determination of medical necessity review criteria and guidelines are available to providers upon request. You may request a copy of the criteria used for specific determination of medical necessity by calling Provider Services at the number listed on your Quick Reference Guide at www.wellcare.com/provider/ quickreferenceguides.

Also, please remember that all Clinical Coverage Guidelines, detailing medical necessity criteria for certain medical procedures, devices and tests, are available on our website at www.wellcare.com/ provider/ccgs.

MEDICARE

NEW TOLL-FREE PHONE NUMBER FOR MEDICARE PROVIDERS Effective January 1, 2015, Medicare providers can reach Harmony-WellCare Provider Services directly with a new toll-free number. The new phone number, 1-855-538-0454, will be listed in the Quick Reference Guide as well as the “Contact Us” section of our website.

The benefits of this new phone number are:

Reduced scripting and menu options

Time saved reaching a particular area

Dedicated line will reduce transfers

Improved provider experience

We value our provider partners and look forward to hearing from you on the new provider line in 2015.

ACCESS TO UTILIZATION MANAGEMENT STAFF The Utilization Management (UM) section of your Provider Manual contains detailed information related to the UM program. Your patient, our member, can request translation services and materials in a different format including other languages, large print and audio tapes. There is no charge for this service.

If you have questions about the UM program, please call Provider Services at the number listed on your Quick Reference Guide located at www.wellcare.com/provider/quickreferenceguides.

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ANTIDEPRESSANT MEDICATION MANAGEMENT At Harmony-WellCare, we want to ensure that our members, your patients, are receiving appropriate and timely treatment for behavioral health issues such as depression. Depression can be safely and appropriately treated by PCPs. With an established relationship with their PCP, patients are more likely to follow up for behavioral health treatment and may not require a referral to a psychiatrist. In addition, patients are better able to access appointments with PCPs, which means a greater likelihood that they will follow up on concerns that they and their loved ones have regarding symptoms of depression.

To help ensure that our members receive appropriate treatment once diagnosed with depression and prescribed antidepressants, we follow up with providers to verify that during the patient’s acute phase of treatment, they remain on antidepressants for at least twelve (12) continuous weeks; and for the effective continuation phase of treatment, that patients continue to take their medication for at least six (6) months.

Talking with the patients about the importance of continuing antidepressant medication, even when they feel better, is crucial. Some patients and their families may need education that focuses on the fact that they may be feeling better because the medication is working as it was intended.

If you have any questions about how Harmony-WellCare evaluates the treatment of antidepressants with our members, please contact us at 1-800-608-8158.

MEDICARE

CHANGE IN REVIEW PROCESS FOR MEDICARE ADMISSIONS EFFECTIVE FEBRUARY 2, 2015 To reduce the administrative burden on behavioral health providers, WellCare is eliminating the requirement for concurrent reviews for members in an inpatient psychiatric unit. An initial review at the time of admission is still required. When medical necessity criteria are met for the inpatient level of care, you will receive an authorization of days for treatment of the member. If additional days beyond the initial authorization are required, you should continue to treat the member and submit the medical record at the time of discharge for medical review. This process change is only for Medicare members.

Q1 2015 PROVIDER FORMULARY UPDATE MEDICAID:

The Harmony Medicaid Preferred Drug List (PDL) has been updated. Visit harmonyhpi.com/provider/ pharmacyservices to view the current PDL and any pharmacy updates.

You can also refer to the Provider Manual available at harmonyhpi.com/WCAssets/illinois/assets/il_caid_ providermanual_eng_11_2014.pdf to view more information regarding Harmony Health Plan’s pharmacy Utilization Management (UM) policies/procedures.

MEDICARE:

The Medicare Formulary has been updated. Find the most up-to-date complete formulary at www.wellcare.com/ medicare/medication_guide.

You can also refer to the Provider Manual available at www.wellcare.com/WCAssets/corporate/assets/na_ care_providermanual_eng_01_2015.pdf to view more information regarding WellCare’s pharmacy UM policies/ procedures.

IL028399_PRO_NEW_ENG©WellCare 2015 IL_12_14 Internal Approved 01162015

O r>nMD

Harmony Health Plan, Inc.29 N. Wacker DriveSuite 300Chicago, IL 60606

PROVIDER RESOURCES

WEB RESOURCESVisit www.wellcare.com (Medicare) or harmonyhpi.com (Medicaid) to accessour Preventive and Clinical Practice Guidelines, Clinical Coverage Guidelines,Pharmacy Guidelines, key forms and other helpful resources. You may alsorequest hard copies of any of the above documents by contacting your PRrep. For additional information, please refer to your Quick Reference Guide at www.wellcare.com/provider/quickreferenceguides.

PROVIDER NEWSRemember to check messages regularly to receive new and updatedinformation. Visit the secure area of www.wellcare.com (Medicare) orharmonyhpi.com (Medicaid) to find copies of the latest correspondence.Access the secure portal using the “Member/Provider Secure Sign-In” areaon the right. You will see Messages from WellCare located in the right handcolumn.

WE'RE JUST A PHONECALL OR CLICK AWAY!

WellCare of Illinois, Inc.

Medicare:1-855-538-0454www.wellcare.com

Medicaid:Harmony Health Planof Illinois1-800-504-2766harmonyhpi.com