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NEWSLETTER
Practice Links aims to provide useful information and
resources to enhance care, as well as
increasing awareness of community practice
guidelines and quality of care outcome measures. We
look forward to receiving your comments about our
provider newsletter and suggestions for any topics you
would like addressed in future issues
Update on Quality Measures
PEDIATRIC
ADHD: Follow Up Care for Children Prescribed an
ADHD medication.
Description: The percentage of children 6-12 yrs. of
age newly prescribed attention deficit hyperactivity
disorder (ADHD) medication who had at least three
follow-up care visits within a 10-month period, one of
which was within 30 days of when the first ADHD
medication was dispensed.
YourCare's Recommendations: Educate
parents/caregivers regarding the importance of followup care for children taking ADHD medications.
Facilitate scheduling of ADHD follow-up appointments.
ADULT
Rate of adherence in the use of Antidepressants
by Individuals with Major Depression during the
initial phase of treatment (12 weeks)
Description: The American Psychiatric Association
(APA) and NYS Quality Guidelines recommend that
individuals being treated for MAJOR DEPRESSION
with antidepressants should remain on these
medications for at minimum 12 weeks to achieve
maximal response to treatment.
Differentiating mental health conditions can be difficult.
Major Depression can be identified through a high
PHQ-9 (Patient Health Questionnaire) with a score of
≥ 10 and/or the presence of at least 5 of the following
symptoms that have been present for at least 2 weeks
and represent a change from previous functioning:
OCTOBER 2015
• Depressed mood most of the day, particularly in the
morning
• Loss of interest in normal activities and relationships
• Fatigue or loss of energy almost every day
• Feelings of worthlessness or guilt almost every day
• Impaired concentration, indecisiveness
• Insomnia or hypersomnia
• Markedly diminished interest or pleasure in almost all
activities nearly every day
• Restlessness or feeling slowed down
• Recurring thoughts of death or suicide
• Significant weight gain or loss (change of more than
5% of body weight in a month)
Other conditions should be considered if the patient
does not meet the above criteria. These conditions
include:
• Masked medical conditions that mimic some or all of
the symptoms of Major Depression (i.e. Chronic
Fatigue Syndrome, Dietary disorders, Blood
disorders, Endocrine system disorders, Neurological
conditions, medication effects, Sleep Disorders)
• Other Psychiatric conditions such as Bipolar Disorder,
Adjustment Disorder with Depressed Mood,
Dementia, Dysthymic Disorder, Mood Disorder due
to a general condition, Substance-induced Disorder,
Anxiety Disorder and Schizoaffective Disorder.
YourCare's Recommendations:
A diagnosis of Major Depression or Depression NOS
requires a 12 week course of Antidepressants. This is
measured by prescription adherence and refills. If you
are prescribing an antidepressant PRN or the
presenting symptoms do not match the ones above,
consider one of the differentiating diagnoses listed or
in the DSM V (Diagnostic and Statistical Manual of
Mental Disorders)
Quality Measure: HIV Annual Syphilis Testing
Description: The percentage of members 19 years of
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NEWSLETTER | OCTOBER 2015
age and older from the eligible population who have
had one syphilis screen performed within the
measurement year.
ADULT & PEDIATRIC
Chlamydia Screening
Description: The percentage of women 16-24 years of
age who were identified as sexually active and who
had at least one test for chlamydia during the
measurement year.
YourCare's Recommendations: It is recommended
that physicians perform the required chlamydia
screening for sexually active women between the ages
of 16–24 who:
• Have a suspicion of being pregnant
• Have a history of an STD
• Are seeking contraception
• Are receiving gynecological services
• Have been sexually assaulted or abused
HIV Management Recommendations
The three HIV measures (Adult & Pediatric) reflect
evidence based care recommendations that include
screening for syphilis annually.
Early infectious syphilis cases have also increased
30% in NYS in the year 2013 compared to 2012 with
72% of cases involving men who have sex with men.
Helping Your Patients, Our Members
Some Guidance for Helping Depressed Patients
Many patients who are depressed are
seen exclusively by their primary care
practitioner. If you are treating patients who have
depression, you know that there are
many factors that affect adherence to
antidepressants. Nonadherence is often
related to lack of knowledge and understanding
HIV Engagement in Care
of the disease and treatment.
Description: The percentage of eligible members 2
years of age and older who had at least one outpatient
visit with practitioners managing HIV and preventative
care needs (PCP or Infectious Disease) occurring on
or between January 1 and June 30 and at least one
qualifying visit occurring on or between July 1 and
December 31 of the measurement year.
We recommend strongly that practitioners
Quality Measure: HIV Viral Load Monitoring
ask during their office visit include:
Description: The percentage of eligible members 2
years of age and older who had a viral load test
performed during each half of the measurement year.
At least one viral load test conducted on or between
January 1 and June 30 and at least one viral load test
conducted on or between July 1 and December 31 of
the measurement year.
• When will I feel better once I begin
talk periodically to their patients who
have depression about medication adherence,
identify any barriers, and provide resources
as needed to empower them.
Some common questions patients may
my medication?
• Is depression curable? If not, how
do I manage the disease?
• Is there anything I can do to prevent
a flare-up?
• Who should I contact if I think I’m
Practice Links aims to provide useful information and resources to enhance care, as well as increasing awareness of community practice guidelines
and quality-of-care outcome measures. We look forward to hearing your comments and any topics you would like addressed in
future issues.
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NEWSLETTER | OCTOBER 2015
experiencing side effects from my
medication or feeling worse?
• Once I feel better, can I just stop
taking my antidepressant?
currently living with HIV/AIDS. Surveillance data from
2012 also demonstrates that approximately 46,000
people, or 35 percent of the 132,000 persons living
with diagnosed HIV infection, had no reported
laboratory data documenting they received HIV care.
Case & Disease Management
Additional information, resources, and health bulletin
advisories can be found at:
YourCare offers care management services to our
members who are experiencing barriers to managing
their conditions.
http://www.health.ny.gov/diseases/aids/providers/testing/law/docs/u
pdates.pdf
We encourage you to refer any YourCare member
who may benefit from this free service by calling 844337-7144 or email [email protected]. For
more information about our Case & Disease
Management programs visit our website at
www.yourcarehealthplan.com .
http://ceitraining.org/documents/NYSDOH_Syphilis_Alert_February_
2014.pdf
YourCare does not advertise products or services to
patients or practitioners engaged in its case
management/disease management programs, as
disclosed on our website at
https://www.yourcarehealthplan.com/About.
HIV Screening Recommendations
NYS Public Health Law regarding the screening of
people for HIV infection has recently changed. Refer to
NYS HIV Testing Law Update: May 2014 (next page)
We highly encourage providers to aggressively screen
for this infectious disease.
An estimated 1,148,200 persons aged 13 and older
are living with HIV infection in the United States
according to the Center for Disease Control. Of those,
18.1% or 1 out of 5 persons are unaware of their
status.
New York State HIV/AIDS Surveillance Report shows
that NYS leads the nation in the number of living
HIV/AIDS cases, with approximately 130,000 people
http://www.health.ny.gov/diseases/aids/providers/testing/
HIV Resistance Laboratory Testing
The Department of Health (DOH) mandated that HIV
laboratory testing be carved in for Medicaid Managed
Care (MMC) effective 4/1/14.
Laboratory test to be covered are: Genotypic testing;
Phenotypic testing; HIV tropism assay
87900
Infectious agent drug susceptibility phenotype
prediction using regularly updated genotypic
bioinformatics.
87901
Infectious agent genotype analysis by nucleic acid
(DNA or RNA); HIV-1, reverse transcriptase
and protease regions.
87903
Infectious agent phenotype analysis by nucleic acid
(DNA or RNA); HIV 1, through 10 drugs
tested.
Additional phenotype analysis - each
additional drug tested (List separately in
addition to primary procedure).
Miscellaneous Reimbursement (Trofile co-receptor
tropism assay).
87904
87999
These laboratory tests may be used in any
combination to identify specific HIV strains and drug
resistance in order to determine the most effective
treatment.
Practice Links aims to provide useful information and resources to enhance care, as well as increasing awareness of community practice guidelines
and quality-of-care outcome measures. We look forward to hearing your comments and any topics you would like addressed in
future issues.
3
NEWSLETTER | OCTOBER 2015
Appointment Availability Standards
We're committed to ensuring that the provider network
is sufficient for members to receive care in a timely
manner. Quality Management staff monitor access and
availability through phone and on-site surveys. The
New York State Department of Health also periodically
conducts "secret shopper" surveys. Please be sure
that staff is familiar with the Appointment Availability
Standards for our managed care population.
Waiting times within a primary care site should
meet the following standards:
Appointment waiting times should not exceed 1 hour
for scheduled appointments.
Walk-in members with non-urgent needs should be
seen within 2 hours or scheduled for an appointment
consistent with the above scheduling guidelines.
Walk-in members with urgent needs should be seen
within one hour.
24-Hour Telephone Coverage The PCP is
responsible for arranging on-call and after-hours
coverage to ensure 24-hour telephone access to all
members.
All participating providers are required to maintain 24hour, 7-day-a-week telephone access for their patients.
The standard for returning a member call is 30 minutes.
It is not acceptable to have an answering machine in
place that does not connect directly to the provider,
e.g., a direct beeper connection. The message must
direct the member to a live voice.
Urgent Care
Non Urgent Sick
Well
Child/Preventive
Routine Preventive
(non urgent)
Within 24 hours
Within 48-72 hours (as
clinically indicated)
Specialist Referral
Non Urgent
Adult
Baseline/Routine
Physical
New Born Initial Visit
Initial Prenatal Visits
1st Trimester
2nd Trimester
3rd Trimester
Within 4-6 weeks
Within 12 weeks
Within 2 weeks of hospital
discharge
Within 3 weeks
Within 2 weeks
Within 1 week
Did You Know?
Excluded Lists
Under the Medicaid, Medicare and Title XX programs
Participating Providers are required to verify the
eligibility of all employees and other provider
personnel working within the practice on a
monthly basis through the following websites:
The DHHS Office of Inspector General maintains List
of Excluded Individuals and Entities (LEIE)
http://oig.hhs.gov/exclusions/ (OIG LEIE)
New York State Office of Medicaid Inspector General
(OMIG) maintains a listing of Restricted,
Terminated or Excluded Individuals or Entities to
ensure the integrity of the Medicaid program
https://www.omig.ny.gov/component/content/article/11information/372-restricted-terminated-or-excludedindividuals-or-entities
Within 4 weeks
General Services Administration (GSA) system for
Award Management (SAM)
https://www.sam.gov/portal/SAM/#1 (formerly the
Excluded Provider Parties List [EPLS])
Within 4 weeks
Providers must be able to certify that all employees
are licensed, certified or qualified, as applicable,
Practice Links aims to provide useful information and resources to enhance care, as well as increasing awareness of community practice guidelines
and quality-of-care outcome measures. We look forward to hearing your comments and any topics you would like addressed in
future issues.
4
NEWSLETTER | OCTOBER 2015
practice in accordance with all applicable laws and
regulations and that all of their employees are eligible
and not excluded or otherwise prohibited from
participating in any federal healthcare program.
Neonatal Intensive Care Program Update
Currently the Progeny Neonatal Intensive Care
authorization program is in effect for YourCare Health
Plan members who are admitted to the NICU.
ProgenyHealth will initiate the concurrent review
process to monitor the medical necessity and
appropriateness of level of care.
ProgenyHealth supports the process for discharge
planning and provides case management services for
the first year of life. The family will have 24/7 access to
a ProgenyHealth nurse care manager who will provide
education and support as needed.
Other important details are outlined below.
Inpatient Reviews
• Upon notification to YourCare Health Plan,
ProgenyHealth contacts the hospital utilization
management nurses to conduct the inpatient
reviews. ProgenyHealth does not contact the
hospital’s NICU nurses directly.
•Medical necessity determinations for inpatient care
are based on clinical status and guidelines using the
application of evidence based national criteria.
Experienced neonatologists are actively engaged in
this process. Reviews will be conducted by
telephone or fax during normal business hours.
• Our standard appeal process applies to these
determinations. Please refer to the YourCare Health
Plan Participating Provider Manual for further
information.
ProgenyHealth will:
• manage NICU transfers
• facilitate discharge planning, including home care
and DME pre-authorizations, if required
• manage all hospital readmissions for the first year of
life
Case Management Services
• ProgenyHealth’s case management staff will begin
contact with the family while the infant is inpatient,
and will continue to be engaged with the infant and
family for the first year of life, assisting with
coordination of care while the infant is home. If
indicated, ProgenyHealth may contact the infant’s
primary care physician.
• When an infant is readmitted to the hospital within
the first year of life, ProgenyHealth will continue to
provide care management services that include a
nurse case manager’s engagement. The
authorization process will remain the same for
readmissions.
• If the infant requires case management services after
his/her first birthday, ProgenyHealth will transfer
case management services to the health plan.
We hope that you find this information helpful.
Remember, as always, that failure to obtain
preauthorization, comply with your participation
agreement, our member contract requirements, or UM
policies and procedures, may result in a claim denial.
If you have questions, please contact Customer Care
at 1-888-638-7149.
Please share this important information with all
practice locations or corporate offices as well as with
your utilization management, discharge planning and
social service departments.
Helping Patients Quit Smoking
Tobacco use continues to be the leading cause of
preventable diseases and death in the Unites States.
Effective treatments are available but not always
utilized. It is proven that when clinicians help patients
stop smoking, success rates increase dramatically.
One of our initiatives at YourCare Health Plan is to
direct our members to the NYS Quitline for smoking
Practice Links aims to provide useful information and resources to enhance care, as well as increasing awareness of community practice guidelines
and quality-of-care outcome measures. We look forward to hearing your comments and any topics you would like addressed in
future issues.
5
NEWSLETTER | OCTOBER 2015
cessation support. This service is free and confidential
for your patients. You can direct them to call 1-866NY-QUITS (1-866-697-8487).
Your patients may be given a 2 week supply of
nicotine patches. After that, your patients will be
instructed to call you for continued nicotine
replacement therapy. This connection is so important
to the overall success of your patients. Nicotine
products (all patches, nasal spray, lozenge, gum),
Chantix, and Zyban are covered. A 90 day supply per
365 days is covered.
Check out YourCare online
www.yourcarehealthplan.com
www.facebook.com/YourCareHealthPlan
Practice Links aims to provide useful information and resources to enhance care, as well as increasing awareness of community practice guidelines
and quality-of-care outcome measures. We look forward to hearing your comments and any topics you would like addressed in
future issues.
6