Volume 9, Issue 11st Quarter 2016

This material is considered part of the Provider Manual for Medical Mutual of Ohio® and its subsidiaries

Real-Time Claims Adjudication System No Longer Available after May 1, 2016Medical Mutual’s real-time claims adjudication (RTCA) system is shutting down at 12:01 a.m. on May 1, 2016. RTCA allowed claims to be submitted for immediate adjudication before a Medical Mutual member left a provider’s office. It provided a preliminary explanation of benefits detailing a patient’s liability.

In February, Medical Mutual notified providers who used the RTCA system of the impending shutdown. In place of RTCA, providers should (1) work with their clearinghouse to submit electronic claims or (2) submit paper claims. Member benefits and eligibility information continues to be available through the Provider ePortal and by calling the Provider Inquiry Unit at (800) 362-1279.

Medical Mutual is currently exploring additional options for the submission of claims.

The content of this article is effective as described above, but will be reflected in the second quarter 2016, Provider Manual update.

Formulary/Coverage Management Updates

Your patients’ insurance plans may have certain coverage limits to ensure prescribed medications follow accepted medical guidelines. Often, cost-effective alternatives are available to treat the same condition.

Medical Mutual periodically reviews these medications, drug classes and formulary updates. Please visit Provider.MedMutual.com and select Tools & Resources, Care Management, Rx Management to view coverage management and prescription formulary updates.

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Medical Policy UpdatesThe Corporate Medical Policies (CMPs) developed or revised between October 1 and December 31, 2015, are outlined in the chart below.

CMPs are regularly reviewed, updated, added or withdrawn and, therefore, are subject to change. For a complete list of CMPs, visit Provider.MedMutual.com and select Tools & Resources, Care Management, Corporate Medical Policies. For a list of services requiring prior approval or considered investigational, visit Provider.MedMutual.com and select Tools & Resources, Care Management, Prior Approval and Investigational Services.

Policy Number Title

94047 Ophthalmic Ultrasound

94052 Therapeutic Apheresis

95003 Surgical Treatment of Gynecomasita (Male) – Mastectomy

95004 Surgical Management of Obstructive Sleep Apnea

95015 Growth Stimulation Drugs (Exogenous Growth Hormone; Insulin-Like Growth Factor-1)

96010 Auditory Brainstem Implantation

98006 Botulinum Toxin Types A & B

98015 Urodynamic (Incontinence) Testing

200205 Heart-Lung Transplantation

200206 Lung Transplantation

200209 Pancreas-Kidney Transplantation

200211 Breast Cancer Screening and Diagnostic Procedures

200313 Endoscopic Thoracic Sympathectomy

200406 Fetoscopic Laser Surgery for Treatment of Twin-to-Twin

2004-E Fecal DNA Testing – Colorectal Cancer Screening

2004-I Radiofrequency Thermal Neurolysis

200506 Retinal Imaging

200520 Urinary Incontinence A. Pelvic Floor Electrical Stimulation

200521 Otoplasty

2005-L EpiFLO for Chronic Non-Healing Wounds

2005-R Transanal Radiofrequency Therapy for Fecal Incontinence

200604 Functional Electrical Stimulation

200605 Endovascular Repair of AAA

2006-D Radiofrequency Microtenotomy

2007-C Endobronchial Valves

Chart continues on next page.

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Chart continued from previous page.

Policy Number Title

200805 Etanercept (Enbrel)

200807 Infliximab

200908 Thoracic Electrical Bioimpedance

2009-D Microcurrent Electrical Therapy

201004 Peripheral Nerve Stimulation

201003 Enzyme Replacement Therapy for Gaucher Disease

201005 Intraperitoneal Hyperthermic Chemotherapy

201011 Radiofrequency Therapy for SUI in Women

201013 Sipuleucel-T (Provenge)

201017 Autologous Platelet-Rich Plasma

2010-B Tumor Chemosensitivity and Chemoresistance Assays - ChemoFx®

2011-D Applied Behavioral Analysis

201208 Lumbar Spinal Fusion

201306 Interferon Beta

201307 Glatiramer Acetate (Copaxone)

201311 Surface Electrodiagnostic Studies-Lumbar Matrix Scan

201312 Erythropoiesis Stimulating Agents

201320 Unicondylar Interpositional Spacer

2013-C Focused Aspiration of Scar Tissue (FAST)

2013-D Electrical Stimulation and Electromagnetic Therapy

201403 Golimumab (Simponi Aria)

201404 Herceptin (Trastuzumab)

201406 Prostanoid Infusion Therapy and Inhalation Therapy

201410-CC Oncology Medication

201417 Zometa (Zoledronic Acid)

201418 Abraxane (Paclitaxel)

201420 Xolair (Omalizumab)

201426 Transcatheter Pulmonary Valve Implantation

201502 Lemtrada (Alemtuzumab)

201528 Praluent (Alirocumab) – New

201529 Repatha (Evolocumab) – New

201536 Quantitative Sensory Testing – New

201537 Pulsed Radiofrequency TX of Chronic Pain – New

2015-D Breath Test for IBS – New

4 Vol. 9, Iss. 1

Step Therapy Changes Coming April 1, 2016Additional drugs will be added to Medical Mutual’s step therapy program for prescription drugs dispensed under the pharmacy benefit beginning April 1, 2016. For more information and to view the list of drugs subject to step therapy, visit Provider.MedMutual.com and select In the News, Updates to Medical Mutual’s Step Therapy Program Begin April 1, 2016.

To streamline the review process for medications that require prior approval under a member’s medical benefit, Medical Mutual offers providers access to ExpressPAth at no cost. The online tool can help reduce your staff’s administrative burden and provide your patients with a shorter path to treatment. For more information or to register for ExpressPAth, visit Express-PAth.com.

Ohio Acute Pain Opioid Prescribing Guidelines Now AvailableOn January 22, 2016, the Ohio Governor’s Cabinet Opiate Action Team issued new opioid prescribing guidelines for the outpatient treatment of patients with acute pain. The prescribing guidelines aim to:n Prevent doctor shopping for prescription opioidsn Encourage prescribers to consider alternative therapies and medicationsn Stop leftover opioids from getting into the hands of abusersn Direct providers to see what other controlled medications a patient may be taking by checking the Ohio Automated Rx Reporting System

To view the Acute Pain Opioid Prescribing Guidelines, visit OpioidPrescribing.Ohio.gov.

5Vol. 9, Iss. 1

Preventive Services Coding ReminderThe Affordable Care Act and its regulations and guidance designate the preventive services that non-grandfathered group health plans and non-grandfathered individual policies must cover with no cost-sharing for members when recommended by an in-network provider.

Medical Mutual follows guidance issued by the Departments of Health & Human Services, Labor and Treasury, including the departments’ adoption of guidelines recommended by the U.S. Preventive Services Task Force (A and B), the American Academy of Pediatrics (Bright Futures) and the Health Resources and Services Administration. When billing for annual wellness visits, the following Current Procedural Terminology (CPT)* codes should be used:

Well Child Examination: Birth to Age 21

The following CPT codes pay without cost sharing (limited to 31 visits from birth to age 21):

G0438, G0439, 99381-99385, 99391-99395, 99420 and 99429

Routine Physical Examination: Age 21 and Older

The following CPT codes pay without cost sharing (limited to one per benefit period):

G0101-G0102, G0402, G0438, G0439, 99384-99387, 99394-99397 and 99429

If the service is for preventive care, the appropriate preventive care diagnosis code also needs to appear on the claim. When a preventative care procedure code is billed with a medical diagnosis as the primary diagnosis, the claim will be rejected and the provider will be instructed to rebill with the appropriate code.

Services billed outside the established diagnosis, age or other criteria for preventive services are eligible for reimbursement based on medical necessity and according to the member’s regular, non-preventive benefits.

*CPT copyright 2016 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with applicable state and federal laws and regulations.

The content of this article, as described above, will be reflected in the first quarter 2016, Provider Manual update.

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Endoscopic Billing Procedures When submitting a claim for screening endoscopic services, please list the appropriate ICD-10-CM diagnosis code for screening as the first diagnosis on the claim. The screening V Code should be listed first on the claim even if a medical condition(s) (e.g., polyp, adenocarcinoma) is discovered during the procedure.

In addition to the V Code, list the appropriate diagnosis codes to indicate all medical conditions that were detected during the screening endoscopic procedure. The applicable Current Procedural Terminology (CPT)* and Healthcare Common Procedure Coding System (HCPCS) surgical codes for endoscopic screening services are listed below.

Colonoscopy:n CPT codes: 44388-44394, 44397, 45355, 45378-45387, 45391, 45392n HCPCS codes: G0105, G0121

Flexible Sigmoidoscopy:n CPT codes: 45330-45335, 45337-45342, 45345n HCPCS codes: G0104

ICD-10-CM procedure codes can be found on the Centers for Medicare & Medicaid Services (CMS) website. Visit CMS.gov and select Medicare, ICD-10, 2016 ICD-10-CM and GEMs.

* CPT copyright 2016 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with applicable state and federal laws and regulations.

The content of this article, as described above, will be reflected in the first quarter 2016, Provider Manual update.

Contacting Care ManagementThe Care Management department is available Monday through Friday, excluding holidays, from 8:15 a.m. to 4:15 p.m. EST to address inquiries regarding utilization management functions such as inpatient admissions, denials, appeals and referrals (including behavioral health services). Please refer to the telephone numbers on the member’s ID card.

Case Management services are available to help coordinate care, provide information on community services and arrange patient education. For more information, call (800) 258-3175.

Clinical Practice Guidelines

Medical Mutual is committed

to partnering with our network

providers to deliver the highest

quality of care to our members.

This effort includes adopting

nationally recognized professional

organization peer-reviewed clinical

practice guidelines and making

them available on our provider

website. All published guidelines

have been carefully reviewed

by a panel of actively practicing,

board-certified Medical Mutual

physician reviewers and can be

found on Provider.MedMutual.com

by selecting Tools & Resources,

Care Management, Clinical Quality,

Clinical Practice Guidelines.

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Member Rights and ResponsibilitiesThe following statement reflects Medical Mutual’s intent to allow our members to receive optimal healthcare.

Medical Mutual members have certain rights and responsibilities. Being familiar with these rights and responsibilities helps our members participate in their own healthcare. Please know that we ensure member rights and member responsibilities, which are defined as the member’s role in working with us to achieve a quality, cost-effective health outcome.

For a copy of the Member Rights and Responsibilities, visit Provider.Medmutual.com and select the Member Rights and Responsibilities link under Quick Links, or call the Provider Inquiry Unit at (800) 362-1279 for a printed copy.

Updates to Provider ManualDesignated sections of Medical Mutual’s Provider Manual are scheduled for review each quarter and updated as needed. Sections that have been reviewed are announced in the corresponding quarterly issue of Mutual News. When topics are added or updated within a section, an annotation of New or Revised appears next to the topics in the section’s Table of Contents.

During first quarter 2016, the following sections of the Provider Manual were reviewed: n Introductionn Claimsn Professional Reimbursementn Notice of Paymentn Institutional Reimbursementn Institutional Remittance Schedulen Plan Guidelinesn Medicare Advantagen Appeal

To view the current updates, visit Provider.MedMutual.com and select Tools & Resources, Provider Manual.

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For Your InformationWe remain committed to supplying providers with the programs, information and support needed to ensure the health and well-being of our members and the communities we serve. Visit Provider.MedMutual.com to access:

Main Menu

n Tools & Resourcesn Products & Servicesn Become a Network Providern Health & Wellnessn In the Newsn Quick Linksn Member Rights and Responsibilities

Clinical Quality

n Mission n Quality Improvement Program Description n Quality Improvement Program Evaluation n Technology Assessment Program Description n Affirmative Statement n Accessibility StandardsSelect Tools & Resources, Care Management, Clinical Quality.

Corporate Medical Policies

n Medical PoliciesSelect Tools & Resources, Care Management, Corporate Medical Policies.

Discharge Planning

n Initiation of Discharge Planningn Discharge Instruction SheetSelect Tools & Resources, Care Management, Discharge Planning.

Medical Drug Management

n Medical Drug Management Reimbursement Policyn Site of Care Management Programn Medical Drug Prior Approval UpdateSelect Tools & Resources, Care Management, Medical Drug Management.

Article continues on next page.

9Vol. 9, Iss. 1

Provider Manual

n Provider ManualSelect Tools & Resources, Provider Manual.

Health & Wellnessn Disease Management and Maternity ProgramSelect Health & Wellness.

Article continued from previous page.

Medical Necessity Criteria

n Clinical Review GuidelinesSelect Tools & Resources, Care Management, Medical Necessity Criteria.

Patient Safety

n Information regarding the Leapfrog GroupSelect Tools & Resources, Care Management, Patient Safety.

Prior Approval

n Individual & Family Plans (Commercial Plans) n Medicare Advantage PlansSelect Tools & Resources, Care Management, Prior Approvals and Investigational Services.

Rx Benefit Management

n Prescription Formularyn Prior Authorizationn Clinical Servicesn Pharmaceutical Educationn Mail Order PharmacySelect Tools & Resources, Care Management, Rx Management.

Credentialing

n Credentialing Applicationsn Credentialing Requirementsn Provider Credentialing RightSelect Tools & Resources, Credentialing.

Contact Us

n Department Contactsn Contracting OfficesSelect Tools & Resources, Contact Us.

Forms

n Forms Select Tools & Resources, Forms.

10 Vol. 9, Iss. 1

Is Your Information Up to Date?Medical Mutual is committed to providing our members with accurate information about our provider networks. Providers are asked to validate the demographic and other information displayed in our online provider directory at ProviderSearch.MedMutual.com on a quarterly basis.

Providers should confirm the following information:

n Namen Address, including countyn Phone numbern Group namen Gendern Hospital affiliationsn Accepting new patient statusn Languages spokenn Board certification status

Any changes should be submitted to the Provider Contracting department by visiting Provider.MedMutual.com and selecting Tools & Resources, Forms, Provider Information Form. Providers enrolled in the Provider ePortal also have the option to add, edit or remove providers, service locations and reimbursement addresses.

The content of this article, as described above, will be reflected in the first quarter 2016, Provider Manual update.

Provider Contracting Department Changes (Northeast Ohio)Staffing changes occurred within the Provider Contracting department on January 4, 2016. At that time, some providers in the following counties received new Provider Contracting representatives: n Ashtabulan Belmontn Carroln Columbianan Cuyahogan Geaugan Guernseyn Harrisonn Holmesn Jefferson

To review a list of Provider Contracting representatives assigned to the above counties, visit Provider.MedMutual.com and select In the News, Provider Contracting Department Changes (Northeast Ohio).

n Laken Lorainn Mahoningn Medinan Portagen Starkn Summitn Trumbulln Tuscarawas n Wayne

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Diabetes Stars Measures

The Centers for Medicare & Medicaid Services (CMS) uses a five-star quality rating system to measure Medicare beneficiaries’ experience with their health plans and providers, clinical outcomes and care gaps. Measures are weighted to reflect CMS priorities in judging Medicare Advantage plans’ quality performance. Because of the high prevalence of diabetes in the Medicare population and the short- and long-term effects of poorly controlled diabetes, CMS includes three diabetes Stars measures in 2016:

Medicare Advantage

Measure Name Description Stars Weight

Diabetes Care:

Blood Sugar

Controlled

Percent of plan members with diabetes who had

an A1C lab test during the year that showed their

average blood sugar is under control (< 9%).

3

Diabetes Care:

Eye Exam

Percent of plan members with diabetes who had an

eye exam (retinal) performed during the year.1

Diabetes Care:

Kidney Disease

Monitoring

Percent of plan members with diabetes who had a

kidney function test during the year.1

Documentation is vital for accurate data collection. We may periodically request medical records to monitor our progress on reaching these Stars measure standards for our Medicare Advantage plans.

Providers are the front line to ensure MedMutual Advantage members with diabetes understand their condition and receive the care that you prescribe for them. To help you, we provide MedMutual Advantage members with diabetes educational materials and access to customized support programs, such as our Diabetes Disease Management program. These are designed to augment your efforts and treatment plan.

For more information, visit Provider.MedMutual.com and select In the News, Quick Tips: Medicare Star Ratings.

Medicare Advantage Provider Network Differs From Commercial NetworksMedicare Advantage Network providers are required to direct care within the Medicare Advantage Network, subject to the member’s medical condition.

n Members enrolled in the MedMutual Advantage Select, Preferred and Premium PPO plans can access services from non-Medicare Advantage Network providers. However, payment for services provided by a non-Medicare Advantage Network provider is reduced in accordance with the member’s policy.

n Services for members enrolled in the MedMutual Advantage Classic and Choice HMO plans must be provided within the Medicare Advantage Network unless an emergency or urgent need for care arises. There are no benefits for services rendered by a provider outside the Medicare Advantage Network.

While all providers in the Medicare Advantage Network are also SuperMed Network providers (for members enrolled in commercial plans), not all SuperMed Network providers are participating in the Medicare Advantage Network.

To inquire about your network status or the status of a provider you wish to serve as a referral for a member enrolled in a Medical Mutual Medicare Advantage product, visit ProviderSearch.MedMutual.com or call the Provider Inquiry Unit at (800) 362-1279.

© 2016 Medical Mutual of Ohio X9309-PRV R2/16

This material is considered part of the Provider Manual for Medical Mutual of Ohio® and its subsidiaries | Mutual News Bulletin is published for network providers serving Medical Mutual To contact us or for more information, visit Provider.MedMutual.com

Medical Mutual, Medical Mutual of Ohio and the Medical Mutual logo are registered trademarks of Medical Mutual of Ohio. Other product names, brands and any other trademarks listed or referred to in this publication are the property of their respective trademark holders. These trademark holders are not affiliated with Medical Mutual of Ohio. Such trademark holders do not sponsor or endorse our materials.

More News and Information Available OnlineIn 2016, you’ll notice shorter, more concise newsletters, which point you to find information you need to know on the

In the News section of Provider.MedMutual.com.

Stay in the know by signing up to receive provider publications via email.

Log into the Provider ePortal at Provider.MedMutual.com and select My Account, Subscriptions.