providerNEWSSummer 2018

Important Phone Numbers 18

Pharmacy 17

We have attempted to identify each policy change by placing a red push pin to the left of the corresponding language.

• Medicaid Reimbursement Reductions for Preventable Emergency Room Visits and Hospital Readmissions

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Any policy changes communicated in this newsletter are considered official and effective immediately unless otherwise indicated, and will be reflected in the next edition of the Optima Health Provider Manual.

• Virginia Premier and Optima Health Joint Ownership

• Authorization Updates April to July 2020

• Optima Health Provider Education Opportunities

• October 2020 Formulary Changes

• Keep Your Practice Information Up to Date

• SHP Commercial Product Ambulatory Surgery Grouper Modifications

• Individual Provider Terminations

• New Measures for HEDIS 2020

• Fecal Immunochemical Test (FIT) Screening for Colorectal Cancer

• Provider Connection - Report2Web

• Clinical Guidelines

• Provider Surveys

• COVID-19 Coverage Extension Update

Authorizations and Medical Policies 10Billing and Reimbursement 13

Industry News 6Provider Resources 8

• Billing Reminder - Nursing Facility Visits for Medicaid Members

• New Provider Search Tool

Quality Improvement 14

Optima Health News 2providerNEWS

Fall 2020

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Virginia Premier and Optima Health Joint Ownership

We are pleased to announce that Sentara Healthcare and VCU Health System have finalized the transaction for joint ownership of Virginia Premier. Sentara Healthcare is the majority owner, while VCU Health System retains 20 percent ownership. Optima Health and Virginia Premier now operate as separate health insurance companies under Sentara Healthcare. This is a shared model approach; some teams will support both health plans, and other teams are dedicated solely to Virginia Premier or Optima Health business.

There is no impact to providers in the Optima Health network. You will continue to do business with us as you do today.

If you have any questions, please do not hesitate to contact your Optima Health Network Educator.

Optima Health News

providerNEWS Fall 2020

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Optima Health policy changes for COVID-19 have been extended through September 30, 2020. Any future extensions will continue to be announced on the Optima Health Provider website. Optima Health has compiled a list of Frequently Asked Questions (FAQs) specifically for our providers concerning COVID-19.

COVID-19 Coverage Extension Update

These FAQs outline Department of Medical Assistance Services (DMAS) requirements and billing information that including coding guidance, co-payment changes and billing for telehealth. The FAQs can be accessed on the Optima Health website at: https://www.optimahealth.com/providers COVID-19 coverage includes but is not limited to:

• expanded telehealth coverage, including telephone-only visits

• coverage of the cost of any COVID-19 vaccine that is approved by the Food and Drug Administration, when it becomes available

• expanded list of acceptable codes for billing

• waiving requirements, such as priorauthorizations for durable medical equipment

Additionally, we have continued to update our member FAQs to help address prevention and coverage questions. Please contact Optima Health provider relations or your Network Educator with other questions you may have as the COVID-19 pandemic continues.

Important: To ensure member responsibilities are waived, be sure to bill the codes that identify the services provided and affix the modifier 95 or GT and use place of service (POS) 02. POS 02 lets us know that services were provided through a telehealth platform. As always, please document appropriately in the medical record for audit purposes. Optima Health follows all current and future guidance offered by DMAS for Medicaid plans.

For Medicaid plans, please continue to follow guidance previously issued by DMAS which can be found at: https://www.dmas.virginia.gov/#/emergencywaiver

Optima Health News

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Fecal Immunochemical Test (FIT) Screening for Colerectal Cancer

Colorectal cancer (CRC) is the third most common cancer diagnosed in both men and women in the United States. Due to low screening rates, CRC mortality remains high in Virginia. However, in 2016 Optima Health began offering a CRC screening alternative by asking our members to complete a free, at-home fecal immunochemical test (FIT). Over twelve thousand Optima Health members have participated in this screening option. To date, seven members were found to have previously undiagnosed CRC and 132 had precancerous polyps removed by colonoscopy.

The American Cancer Society, our partner for this campaign, recommends an annual FIT as one of the screening options for people at average risk as part of the Guideline for Colorectal Cancer Screening*. FIT screening is also recommended by the U.S. Preventive Services Task Force as an effective option to screen for CRC, except for people who previously had an abnormal FIT or colonoscopy, or who have a family history of CRC. Additionally, the Multi-Society Task Force ranks FIT as one of the preferred Tier 1 screening options based on its features, cost and performance.

FIT Screening Program:

1. Members who have seen a primary care physician (PCP) in the past two years will be notified by phone that they will receive a FIT via mail. During the call, we will confirm the member’s address and PCP.

2. An Optima Health nurse practitioner orders all tests.

3. Participating members and their PCP will be notified of the results by mail.

4. Three phone attempts are made to contact members with abnormal results. Members are advised to immediately follow up with their PCP for further evaluation.

Optima Health News

providerNEWS Fall 2020

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Fecal Immunochemical Test (FIT) Screening for Colerectal Cancer

Please encourage patients to participate in this free preventive care service. Members considered at average risk who were previously screened using colonoscopy, but are interested in FIT screenings can request a test at optimahealth.com/colonhealth.

If you have any questions, please call 757-252-8400 to schedule a time to talk with us. We look forward to collaborating with you towards our common goal of improving the health of members!

*The American Cancer Society does not endorse any product or service.

Optima Health News

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New Provider Search Tool

An enhanced provider search is now available on optimahealth.com and the Optima Health mobile app! The new online provider search includes an updated and user-friendly design.

This enhanced search tool features an easy way to search by network and plan, making sure that results are personalized for accuracy. Users may search using keywords, the doctor's name, specialty, and the facility name or type of facility (i.e. lab or hospital).

If you have any questions about this change, please reach out to your Network Educator.

Optima Health News

providerNEWS Fall 2020

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Medicaid Reimbursement Reductions for Preventable Emergency Room Visits and Hospital Readmissions

DMAS has announced reimbursement changes that apply to both traditional Medicaid fee-for-service claims processed by DMAS and managed care claims processed by Medicaid managed care organizations, including Optima Health. As directed by DMAS, Optima Health implemented these changes effective July 1, 2020. We encourage you to review the July 1, 2020 DMAS Medicaid Bulletin in its entirety, accessible on the DMAS website.

The Optima Health claims processing system has been updated to meet the new DMAS requirements as indicated below:

• Inpatient Readmission Claims – Effective July 1, the Hospital Review Team will determine if the claim should be processed at a 50% reduction. The adjustment code 48GR will be indicated with the description: DMAS 6-30 days Readmission Reduction.

• Emergency Room Facility claims – Claims system updates were implemented on July 9. Billed claims appropriately submitted prior to the implementation date will be reprocessed.

• Emergency Room Physician Claims – Claims system updates were implemented on July 13. Billed claims appropriately submitted prior to the implementation date will be reprocessed.

Industry News

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Optima Health Provider Education Opportunities

Scheduled dates and times for Optima Health quarterly provider education webinars are:

• Wednesday, November 4th at 10 a.m.

• Wednesday, November 11th at 1 p.m.

Please mark your calendars. Registration details will be posted on www.optimahealth.com/providers the month preceding each session.

Individual Provider Terminations

Optima Health is required to report why providers terminate their participation in our Optima Family Care, Optima Health Community Care and Optima Community Care networks to DMAS. If you decide to terminate your contract, Please provide the specific reason with your notice of termination for reporting purposes.

Provider Resources

providerNEWS Fall 2020

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Provider Connection - Report2WebProvider Connection, the Optima Health online provider portal, offers secure and convenient access to numerous Optima Health operational functions 24/7:

• member eligibility, copayments and benefits

• view and print member ID cards

• access real-time deductible and out-of-pocket maximum information

• request prior authorization

• create OB notifications

• check authorization status and effective/expiration dates

• view claim details and status

• view, download and print PCP membership reports

• pre-adjudicate medical claims using C3-Clear Claims Connection

• view and download remits and pended claim reports (remits prior to June 8, 2020 are located in Report2Web “Provider History”)

•submit online reconsiderations for medical claims

Provides can register for Provider Connection on the Optima Health Provider website by following these steps: https://www.optimahealth.com/documents/provider-orientation/001-job-aid-provider-connection-reg-only.pdf

Providers that are registered for Provider Connection can use our online portal to access remits through Report2Web. Recently, Report2Web migrated to a cloud-based infrastructure and Providers using the Internet Explorer browser to access Report2Web have experienced technical issues. This has not been a problem for users of Mircosoft Edge or Google Chrome. To easily fix this issue, providers that use Internet Explorer should follow the following steps:

1. click “tools” at the top of the screen

2. click “compatibility view setting”

3. verify that “display intranet sites in compatibility view” is unchecked

Access the Report2Web link: https://reports3.optimahealth.com/r2w/pageMartPrint.do

Provider Resources

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Authorization Updates for April to July 2020Optima Health would like to notify you of the following authorization updates made since the last version of Network News:

POLICY DETERMINATION/COVERAGE

DME 05 - Battery Replacement • Policy has been re-instated

DME 15 - Obstructive Sleep Apnea Treatments

• Transitioned to Milliman Care guidelines for medical necessity criteria

DME 21 - Prosthetic Devices • Coverage removed for vacuum-assisted socket systems (VASS) coverage for Medicare/Medicaid. Not covered. Effective for all LOBs 12/15/2020

DME 35 - Cervical Traction Devices • Prior authorization no longer required for over the door traction equipment E0860.

DME 55 - Low-Intensity Therapeutic Ultrasound (LITUS) Devices (ZetrOZ System)

• Not medically necessary upon technology review due to lack of proven clinical utility

DME 56 - Postural Support Seat (Firefly Go To Seat)

• Not medically necessary upon technology review due to lack of proven clinical utility

DME 247 - Personal Emergency System • New policy – coverage added for OHCC and DSNP

Imaging 27 - Computer-Aided Detection (CAD)

• Title change to Computer-Aided Detection Non-Breast

Imaging 54 - Contrast Enhanced Spectral Mammography

• Not medically necessary upon technology review due to lack of proven clinical utility

Imaging 55 - Absolute Quantitation of Myocardial Blood Flow (AQMBF), Positron Emission Tomography (PET)

• Not medically necessary upon technology review due to lack of proven clinical utility CPT code 78434

Medical 13 - Enteral/Parenteral Feeding and Intradialytic Parenteral Nutrition

• Error in last newsletter-B4105 in-line cartridge containing digestive enzyme (e.g., Relizorb) is covered for Optima Medicaid and Optima Medicare plans.

Medical 29 - Non-Surgical Treatment of Temporomandibular Joint Syndrome and Treatment of

• Dry needling removed as a covered procedure effective 12/15/2020

Authorizations and Medical Policies

providerNEWS Fall 2020

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POLICY DETERMINATION/COVERAGE

Temporomandibular Disorders

Medical 34C - Genetic Testing - Cardioneurovascular and Developmental Diagnosis

• HESX1 Septo-Optic Dysplasia (SOD) - Genetic Testing: Not medically necessary upon technology review due to lack of proven clinical utility

• Hereditary Retinal Disorders Genetic Panel Lab Test: Not medically necessary upon technology review due to lack of proven clinical utility

• EPG5 Gene-VICI Syndrome considered not medically necessary upon technology review due to lack of proven clinical utility

• Tuberous sclerosis 2 gene (TSC2) Gene: Not medically necessary upon technology review due to lack of proven clinical utility

• PEX6 genetic testing: Not medically necessary upon technology review due to lack of proven clinical utility

Medical 128 - Apheresis • Added criteria for CPT codes 36511, 36512 & 36513 - previously no criteria-paid upon request. Effective 12/15/2020

Medical 173 - Dry Needling • New policy - Not medically necessary upon technology review due to lack of proven clinical utility. Effective 12/15/2020

Medical 206 - Intraoperative Radiation Treatment

• Removed coverage for intraoperative radiation treatment for endometrial cancer, pelvic cancer and pancreatic cancer. Effective 12/15/2020

Medical 285 - Bronchial Thermoplasty • Coverage removed for all LOBs except Medicaid products

Medical 327 - Transperineal Injection of Periprostatic Bulking Agents

• Coverage removed and considered not medically necessary for all LOBs. Effective 12/15/2020

Authorizations and Medical Policies

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POLICY DETERMINATION/COVERAGE

Obstetrics 01 - Elective Termination of Pregnancy

• Adopt three new indications per state and federal regulations to the applications of products: Optima Health Community Care (OHCC) only covered when life of mother is in danger; Optima Family Care (OFC) - only covered when life of mother is in danger; and Individual Product plans - only covered for rape, incest, or life of mother is in danger.

Surgical 30 - Nasal Implants • Not medically necessary upon technology review due to lack of proven clinical utility

Surgical 60 - Ophthalmic Procedures • New coverage of implantable miniature telescope for all LOBs with criteria- previously not covered

Surgical 103 - Headache Treatments • New criteria added

• Occipital and trigeminal nerve block for all of the following:

• Individuals with poor tolerance to medications and treatment for one or more of the following: occipital and trigeminal neuralgia, prolonged migraine, or cervicogenic cluster migraine headaches if conservative treatments have failed

Posaconazole Drug Assay • No prior authorization required for code 80187

Respiratory Infectious Agent Detection, Amplified Probe Technique (COVID-19, SARS, RSV, FLU & STREP)

• Cover upon request with no precert, no authorization, no medical criteria

Voriconazole Drug Assay • No prior authorization required for code 80285

Authorizations and Medical Policies

providerNEWS Fall 2020

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SHP Commercial Product Ambulatory Surgery Grouper Modifications

Effective for dates of service January 1, 2021, the SHP Commercial Product Ambulatory Surgery Grouper will be updated to include codes that the Centers for Medicare and Medicaid Services (CMS) previously considered eligible for reimbursement only if performed in an inpatient setting. CMS reviews all inpatient only codes on an annual basis and determines if these services may be performed safely in an outpatient setting. Based on the CMS reviews, 8 codes (0266T, 0499T, 22633, 22634, 31241, 63265, 63266 and 63268) will be mapped to a grouper level other than 99 within the SHP Ambulatory Surgery Grouper. This modification is only applicable to those providers that are reimbursed for commercial claims through the SHP Ambulatory Surgery Grouper payment method. The updated SHP Commercial Product Ambulatory Surgery Grouper is available on:

https://www.optimahealth.com/providers/provider-support/manuals > Providers > Provider-Support > Provider Manuals and Directories.

Billing Reminder - Nursing Facility Visits for Medicaid Members

DMAS covers nursing facility visits as medical conditions require. However, DMAS limits subsequent nursing facility services to one per month unless the medical necessity for more frequent visits is explained as an attachment to the CMS-1500 claim form and is indicated through the use of the procedure modifier 22 (Unusual Services) in Locator 24D. Optima Health reimburses nursing facility visits for Medicaid members in accordance with DMAS policy.

Billing and Reimbursement

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Clinical Guidelines

Optima Health reviews and revises clinical guidelines bi-annually. The most up-to-date, evidenced–based clinical guidelines can be found in the Clinical Reference section of optimahealth.com/providers.

If you would like a printed copy of these guidelines or have questions, comments, or suggestions about the guidelines, please contact the Optima Health quality improvement department at 757-252-8400 or 1-844-620-1015.

Please note: Clinical data in a particular case may necessitate or permit deviation from these guidelines. Optima Health guidelines are institutionally endorsed recommendations and not intended as a substitute for clinical judgment.

New Measures for HEDIS 2020

Each year, between February and May, data from the prior calendar year is collected on several standardized quality measures. Most of these measures remain the same year after year: preventive screenings, immunizations, and treatment of chronic conditions such as diabetes and hypertension. Occasionally, measures may be retired, and new measures are added. Below are a few of the new or changed measures the National Committee on Quality Assurance (NCQA) has added for HEDIS 2020:

Follow-Up After High-intensity Care for Substance Use Disorder Looks at the percentage of acute inpatient hospitalizations, residential treatment or detoxification visits for a diagnosis of substance use disorder among members 13 years of age and older that result in a follow-up visit or services for substance use disorder. Two rates are reported:

• The percentage of visits or discharges for which the member received follow-up for substance use disorder within 30 days after the visit or discharge.

• The percentage of visits or discharges for which the member received follow-up for substance use disorder within seven days after the visit or discharge.

Pharmacotherapy for Opioid Use Disorder

Looks at the percentage of new opioid use disorder (OUD) pharmacotherapy events with OUD pharmacotherapy for 180 or more days among members age 16 and older with a diagnosis of OUD.

Quality Improvement

providerNEWS Fall 2020

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Opioid Use Disorder Treatment Medications:

• Naltrexone (oral or injectable)

• Buprenorphine (sublingual, injection, or implant)

• Buprenorphine/Naloxone (sublingual tablet, buccal film, sublingual)

• Methadone (oral)

Prenatal Depression Screening and Follow-Up

Were screened for clinical depression while pregnant and, if screened positive, received follow-up care. Two rates are reported:

1. Depression screening: The percentage of deliveries in which members were screened for clinical depression during pregnancy using a standardized instrument.

2. Follow up on positive screen: The percentage of deliveries in which members received follow-up care within 30 days of screening positive for depression.

Postpartum Depression Screening and Follow-up

Looks at the percentage of deliveries in which members were screened for clinical depression during the postpartum period, and if screened positive, receive follow-up care. Two rates are reported:

1. Depression screening: The percentage of deliveries in which members were screened for clinical depression during pregnancy using a standardized instrument during the postpartum period.

2. Follow up on positive screen: The percentage of deliveries in which members received follow-up care within 30 days of screening positive for depression.

NOTE: The prenatal and postpartum depression screening and follow-up measures will only be collected from electronic medical

records. If you have questions about these new measures, please contact the quality improvement department at 757-252-8400

or 1-844-620-1015.

Quality Improvement

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2020 Provider Surveys

This fall, our contracted survey vendor will perform several surveys of participating providers. The results of these surveys help us to identify and prioritize service improvements, allocate resources, and meet NCQA and government regulatory requirements. When possible, providers that have already been surveyed are eliminated from additional survey samples.

Appointment Access Survey and After-Hours Survey: This required survey determines how well providers meet our appointment access standards and after-hours coverage requirements. SPH Analytics will perform the appointment access survey during office hours and the after-hours coverage survey after hours by phone for a random sample of providers. Current appointment standards are listed in the Optima Health provider manual and after-hours coverage requires that a person or recording be in place to immediately direct patients for emergency care.

Provider Satisfaction Survey: A random sample of provider offices will receive a mailed survey and/or will be called by our vendor, SPH Analytics, and asked to participate in our provider satisfaction survey. This survey asks you to rate the services we provide to our providers and is an excellent vehicle for anonymously giving us feedback and making suggestions for every area of the health plan.

We appreciate the time you take to assist us with these required surveys. Results will be provided in the newsletter along with action plans created to address areas of concern.

Quality Improvement

providerNEWS Fall 2020

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October 2020 Formulary Changes

The pharmacy changes, effective October 1, 2020, for plans with pharmacy benefits administered by Optima Health are now available at optimahealth.com/providers:

To view select Pharmacy, then select Formularies/Drug Lists, and scroll down to find the Current Quarterly Changes list.

Note: Pharmacy changes are made on a quarterly basis with effective dates of January 1, April 1, July 1, and October 1. For groups without a four-tier pharmacy plan, drugs listed as moving to Tier 4 will remain at Tier 3.

These pharmacy changes are specific to commercial plans only and are not applicable to our Medicare plans.

Pharmacy

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Provider Relations 757-552-7474 or 1-800-229-8822

OHCC:1-844-512-3172

Provider Relations Fax 757-961-0565

Behavioral Health Provider Relations 757-552-7174 or 1-800-648-8420

Medical Care Management(Pre-Authorization)

757-552-7540 or 1-800-229-5522

OHCC:1-866-546-7924

Network Educators 757-552-7085 or 1-877-865-9075

Health and Preventive Services 757-687-6000

Proprium Pharmacy 1-855-553-3568

Proprium Pharmacy Fax 1-844-272-1501

Keep Your Practice Information Up to Date

Please notify Optima Health of any changes to provider or practice information with 60 days’ notice, or as soon as possible, especially changes to:

• provider rosters

• panel status

• address/phone numbers

• practice email address for official communication from Optima Health

Medical providers should contact their Network Educator at 1-877-865-9075 with this information; behavioral health providers should complete the provider update form.

Thank you for your partnership in providing accurate information to our members!

Important Phone Numbers