Download 2012 Spring Newsletter

A newsletter for
Priority Partners,
Johns Hopkins US
Family Health Plan
and Employer
Health Programs
network providers
Hopkins
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SPRING 2012
HEDIS/Value Based Purchasing Measures
Effectiveness Data
and Information Sets
(HEDIS), as well
as Value Based
Purchasing measures.
There are a core set
of HEDIS measures
that are used in the
annual scoring for
accreditation of
health plans based on
attaining NCQA
established benchFlorence (Flo) Thompson (l), project coordinator, and Mary Ferrell, manager,
marks and thresholds.
Priority Partners, Plan Administration and Compliance at Johns Hopkins
HealthCare discuss recent Value Based Purchasing measures which are tracked
HEDIS is nationally
monthly on a thermometer grid.
recognized and used
Our organization believes in the capital C
in various programs to assess quality of care
that resides within our name….Johns
performance.
Hopkins HealthCare (JHHC). We are here
to extend the best care and services to our
Value Based Purchasing measures were
members, and to our providers who serve
developed by the Maryland Department
our members. In order to uphold our
of Health and Mental Hygiene
numerous commitments, we rely on infor(DHMH) as a mechanism to reward
mation provided by the HealthCare
improved health care services and in
instances penalize health plans when
targeted goals are not met.
The Value Based Purchasing measures are a
combination of HEDIS specified measures
and modified HEDIS specified measures
with the targeted goals and benchmarks
entirely determined by the DHMH.
The efforts extended in 2011 are evident
in the HEDIS reporting efforts that are currently in progress. We’d like to extend our
appreciation to all providers that supported
the collaboration efforts with JHHC.
Together we have made significant strides and
now is our opportunity to expand on our
efforts to report the quality care provided by
our physician groups. The final 2012 HEDIS
rates (CY 2011) will be available in June.
Practitioner Best Practices for
Health Screenings
There are two main approaches that have
been effective in getting members into early
preventative health services. Literature
Continued on page 3
Network Manager Meet and Greet
Meet Dawn Griffin…
a Servicing Network Manager in the Provider
Relations Department at Johns Hopkins HealthCare
(JHHC). As a servicing network manager, Dawn is
responsible for territories in Montgomery County,
Prince Georges County, Washington, D.C. and
Northern Virginia.
Dawn began her career at JHHC in 1998. She has
previously held positions as a network coordinator, a
INSIDE: Medical Director’s Corner Page 2
credentialing coordinator, and a provider maintenance
coordinator. Dawn has more than 14 years of health
care experience, and is an established member of the
JHHC team.
If Dawn can assist you with any questions or concerns,
please don’t hesitate to contact her at 410-424-4803 or
by email at [email protected]. You can also reach
her network coordinator, Kimberly Hoover-Byrne, at
410-762-5208 or [email protected].
Corrective Managed Care Page 6
My EHP Story Page 11
MEDICAL DIRECTOR’S
Corner
Lipids
Most often, elevated levels of “bad” cholesterol
(LDL) are the result of a poor diet and lack of
exercise. For some, however, their high LDL is a
result of a gene passed down from one or both
parents. Called familial hypercholesterolemia (FH),
it is an inherited condition occurring once out of
every 300 to 500 people and is more common
than Down syndrome.
Without proper care, FH
patients are 20 times more
likely to have premature
coronary heart disease. A
correct diagnosis is essential.
What about treatment?
Given the greater risk of
heart disease in these
patients, it is especially
important to treat aggressively. It’s not uncommon
to prescribe two or more
medications. Lifestyle
changes are imperative,
including losing weight,
eating healthy and exercising.
Remember, just a 10 to 15
percent reduction in LDL
Dr. Richard Safeer is a medical director at Johns
from such steps can make
Hopkins HealthCare.
a difference in the number
of medications the patient needs to take.
A diagnosis of FH is missed by physicians 80
percent of the time. It is likely due to a lack of
awareness of FH and because the majority of elevated
cholesterol cases come from poor lifestyle habits.
Thus, it is important for physicians to be on the
lookout for telltale signs of FH. Early detection
can pay off for many others besides the patient.
The first tip-off is a family history of early heart disease;
before age 55 for males and age 65 for females.
A second set of clues comes from a physical
examination.
FH patients may have tendon xanthomas, a thickening of the Those with severe forms of the disorder may require LDL
soft tissue caused by an infiltration of lipid-rich cells. This is
apheresis, similar to dialysis, in which blood or plasma is
frequently seen in
removed from the body so special
the Achilles and
filters can remove the extra LDL
Given the greater risk of heart disease in
metacarpal tendons
cholesterol before returning the
these patients, it is especially important to
but also the patellar
blood to the body.
treat aggressively.
and triceps tendons.
Above all, if patients are diagnosed
~Dr. Richard Safeer
FH patients also
with FH all of their blood relatives
may have waxy, yellow lesions (xanthelasmas) on or around
should be screened for this genetic disorder. It could be a
the eyelids.
life-saver for many of them.
“
”
Hopkins Across the Board is published quarterly for Priority Partners,
Johns Hopkins US Family Health Plan and Employer Health Programs
network providers by Johns Hopkins HealthCare LLC, Marketing and
Communications Department. JHHC President – Patricia Brown;
Chief Operating Officer – Jeffrey Joy; Chief Executive Officer (Priority
Partners) – Robert R. Neall; Vice President (EHP) - Keith Vander
Kolk; Vice President (USFHP) – Mary Cooke; Chief Financial
Officer (EHP) – Mike Larson; Vice President (Care Management) –
Linda Dunbar; Provider Relations Senior Director – Dina Goldberg;
Marketing and Communications Senior Director – Victoria Fretwell;
Communications Manager/Editor – Donna L. Chase. To submit
information or articles, email [email protected]
Finally, look for a ring around the outer margin of the cornea
(corneal arcus) that is lighter in color than the cornea.
LDL readings at or above 190 in adults and 160 mg/dL in
children are a signal to the physician that FH may be present.
A rare variation occurring in one out of every million
people (homozygous FH) happens when patients inherit this
disorder from both parents. Caring for them is extremely
difficult and most children die in the first few years of life.
2
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FOR ALL
Providers
HEDIS/Value Based Purchasing Measures ... Continued from page 1
published in the College of Public Health indicates that a
physician recommendation for screening is the most powerful
motivator for patients.
JHHC provides monthly opportunity reports which identify members with specific health screening care gaps. This can be used by the
office as a reminder system when members come in for care.
The second most powerful motivator comes from the use of
reminder/recall systems and can effectively increase screening
with mammography, pap, fecal occult blood tests and flexible
sigmoidoscopy.1
For specific questions regarding the HEDIS or Value
Based Purchasing measures, please contact your Provider
Relations representative.
1
Am J Pre Med 2010; 38(1):110-117
HealthLINK@Hopkins Web Portal
Due to various quality initiatives including, but not limited to HEDIS, Value Based Purchasing and Patient Centered Medical
Home, it is now even more important that our providers register with HealthLINK@Hopkins, our online web portal. Once
registered, providers can receive their monthly member opportunity reports, HEDIS tip sheet, and Patient Centered Medical
Home reports on a monthly basis, as applicable. HealthLINK is available 24/7 and provides an easy and secure internet-based
access to your patient’s health information. Claims, referral/authorization status, benefits, and eligibility are available at the click
of a button. Please call Provider Relations at 888-895-4998 for more information or visit our website at www.jhhc.com.
Easy Access to Policies
We just updated and added several of our Utilization
Management Medical Policies to our website at
www.jhhc.com. Click on Provider and Physicians, and
then on Medical Policies in the left hand column.
and High Frequency Pulsed Electromagnetic Stimulation
for Pain.
Revised Medical Policies include the following: Precutaneous
Techniques for Disc Decompression; Vagus Nerve Stimulation for
Epilepsy; Vagus Nerve Stimulation for Depression; and Procedures
for the Treatment of Gastroesophageal Reflux Disease (GERD).
New Medical Policies include the following:
Apnea Monitor for Infants; Bronchial Thermoplasty;
Esophageal pH Monitoring; Gastric Electrical Stimulation
for Gastroparesis; Nerve Conduction Velocity Studies;
Surgical Decompression for Diabetic Neuropathy;
For more information please contact Provider Relations at
410-762-5385 or 888-895-4998.
Health Education for Members
The Health Promotion and Wellness Unit at Johns Hopkins HealthCare has set a goal to provide excellent and accessible
health education programs for our members. Free health education classes are available to Priority Partners, Employer
Health Programs (EHP), and Johns Hopkins US Family Health Plan members in the following areas:
• Asthma
• Chronic disease self-management
• Diabetes
• Smoking cessation
• Weight management
Referrals and questions can be directed to [email protected] or by calling 800-957-9760.
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FOR ALL
Providers
Partners with Mom
Treatment Plan Signatures
The Partners with Mom program is comprised of a team
of Johns Hopkins HealthCare nurse care managers, who
specialize in obstetric care. They work together with you
and other health care providers to make sure our members,
your patients, get the services they need to have a healthy
pregnancy and a healthy baby. The nurse care managers
can help members with:
Effective April 1, 2012, Johns Hopkins HealthCare
(JHHC) will require that all individualized treatment plans
have an original signature by the alcohol/drug counselor
and the patient. For initial and concurrent reviews, treatment plans must be updated every thirty (30) days.
Treatment plans submitted with the notation “signature on
file” for both the clinician and the member do not meet
JHHC requirements.
• Risk assessments to find out a member’s
unique needs
• Doctors’ appointment scheduling and referrals
• Nutrition
• Exercise
• Obtaining home health equipment
• Blood sugar testing
• Asthma care
• Substance abuse treatment
• Setting personal goals toward delivering
a healthy baby
Faxed copies of the treatment plan will be accepted by JHHC;
however, the provider must maintain a copy in the member’s
file with the original signature of the patient and counselor.
This requirement is applicable to Priority Partners,
Employer Health Programs (EHP), and Johns Hopkins
US Family Health Plan (USFHP) plan members.
If you have any further questions, please contact the
Behavioral Health Department at 800-261-2429.
Partners with Mom specializes in
helping pregnant women with the
following conditions:
Winter 2011 Corrections
Quality Improvement
In the Winter 2011 edition of the Hopkins Across the
Board provider newsletter, we printed an incorrect phone
number for the Johns Hopkins HealthCare (JHHC)
Quality Improvement program. The correct number is
888-895-4998. You can also access that information on
our website at www.jhhc.com.
• History of pre-term labor
• Diabetes, including diabetes
brought on by pregnancy
• High blood pressure
• HIV/AIDS
• Substance abuse
• Asthma
• Sickle cell disease
• Adolescence
Medical Record Documentation Standards
(Please note a change in the Medical Record Documentation
Standards) JHHC has adopted standards for medical
record documentation, availability of records, and
maintaining confidentiality of medical records. The
standards are located in the provider manuals and can be
referenced on-line.
If you are aware of plan members
who fall into any of the above
categories, please let them know
about the program.
Partners with Mom:
800-261-2396 ext. 5215
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JUST FOR
Priority Partners MCO Providers
Praise for Priority Partners
More than anything, April Matthews wants to be independent.
She’s currently living in a shelter and is ready for a change. With
the help of Priority Partners and a housing organization, April is
making moves to do just that.
In addition, April is a part of Project
PLASE, an organization dedicated to
addressing Baltimore’s homelessness. Project
PLASE helps to provide traditional housing
and supportive services to Baltimore’s most
vulnerable and underserved homeless adults.
The 31-year-old Baltimorean is bipolar and suffers from diabetes
and asthma. Five years ago, April signed up for health coverage with
Priority Partners. Through Priority Partners, April’s appointments,
glasses, hospital visits and medications are all covered. She has also
linked up with Priority Partners’ Special Needs Coordinator, Sammi
Turner. Sammi helps schedule April’s appointments, transportation
and even attended April’s diabetic eye exam.
April has health care and now Project
PLASE is working with her to get individual
housing. She is close to achieving her goals
and is grateful to Priority Partners for
helping her check one off her list.
“We remove any barriers preventing the member from getting
care and we provide them with support to make sure all followups occur,” Sammi said. “April is striving to better herself.”
April Matthews
“Sammi and Priority Partners have worked wonders. Priority
Partners is willing to go out of its way to help me. Not a lot of
health care companies do that,” April said. “I now have hope.”
Healthy Kids/EPSDT Program
In Maryland, the preventive care component of the EPSDT
Program is known as the Healthy Kids Program. Preventive
health care services allow for early identification and treatment of health problems before the health problems become
medically complex and costly to treat. It is important to note
that the Maryland Healthy Kids Program must certify all primary care providers (PCPs) who plan to serve Medicaid/MCHP
children and young adults less than 21 years of age (Maryland
Healthy Kids Program Clinical and Administrative Manual).
For additional information regarding Healthy Kids Program certification, visit http://dhmh.maryland.gov/epsdt/healthykids. We
encourage providers who are already certified to visit the website
as well. It has valuable information including the Maryland
Schedule of Preventive Health Care and provider forms that will
offer guidance in continuing to provide the best health care to
Priority Partners members in addition to meeting the
regulatory requirements of the Healthy Kids/EPSDT program.
The Early and Periodic Screening, Diagnosis and Treatment
(EPSDT) program is a federal requirement that mandates states
to cover certain benefits for Medicaid recipients from birth
through 20 years of age.
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PROVIDER UPDATES
Priority Partners
Corrective Managed Care
The Corrective Managed Care (CMC) program is designed to
monitor and promote appropriate use of controlled substances,
particularly prescription opioids. CMC’s program is a collaborative
effort between Johns Hopkins HealthCare (JHHC) case
management and pharmacy teams to identify Priority Partners’
members who are abusing opiates, which are addictive. A major
goal of CMC is to secure the safety of members. Some members
are able to access large amounts of opiates by seeing multiple
physicians or making numerous emergency department visits.
Chaired by Chief Medical Officer, Dr. Chester Schmidt,
CMC meets monthly with department leaders to monitor the
prescriptive practices of providers and the adherence of members.
Most members who are having problems with opiates are
identified through pharmacy monitoring. However, case managers
and network physicians can also refer members to CMC.
When a potential member problem is identified, the pharmacy department reviews the member’s medical history, records
and pharmacy claims. The member’s physician is then called to ensure that the pharmacy prescriptions aren’t fraudulent.
Following the review, the committee makes a decision about placing the member in CMC. If the member is found to be
abusing opiates, they receive a certified letter in the mail notifying them that they will be placed in CMC. This usually
prompts the member to contact Priority Partners. The member is then connected with a case manager to help reduce opiate
prescription utilization.
Once a member is identified, there is a 30-day warning period; after which CMC locks the member into a single physician
and pharmacy for opiate prescriptions. This forces the member back to their primary care provider (PCP).
“Many of the members who are identified through the program carry a substance abuse diagnosis,” Dr. Schmidt said.
“By locking them into a single provider and pharmacy, we know that their access can be controlled.”
CMC feels educating physicians on the importance of monitoring their patients’ opiate use can help curb the problem.
By working in tandem with physicians, CMC looks to continue to assist struggling members. If you need to refer a member
to this program, please call 410-424-4476.
Importance of Accurate Medical Documentation
Accuracy of physician medical documentation and billing
is critical in reviewing the services and diagnoses of our
Medicaid population. Therefore, the following language
was added to the Priority Partners and Priority Partners
Primary Adult Care (PAC) provider manuals to ensure
providers are submitting accurate coding:
6
“Providers will ensure their medical documentation has
the correct service and diagnoses that reflect their claim
submissions.” (Priority Partners Provider Manual, page 25
and 40; Priority Parntes PAC Provider Manual, Page 18).
To view the a provider manuals online, please visit our
website at www.jhhc.com.
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Priority Partners
Health Education Classes Calendar
Free health education classes are available to your Priority Partner members/patients.
Please encourage them to register for any of the following classes:
JHCP Wyman Park
Tobacco Cessation
April 5 – April 26
4 p.m. – 5:30 p.m.
EBMC
MOVE!
June 6 – July 18
10 a.m. – 12 p.m.
JHCP Wyman Park
Diabetes
April 9 – April 30
10 a.m. – 12 p.m.
Water’s Edge
MOVE!
June 5 – July 24
4:30 p.m. – 6 p.m.
JHCP Wyman Park
Diabetes
June 4 – June 25
10 a.m. – 12 p.m.
BMS (Highlandtown Healthy
Living Center)
Waiting Room
July 12
11 a.m. – 2 p.m.
For referrals or registration, please email [email protected], or call 800-957-9760.
PRIORITY PARTNERS
IMPORTANT NUMBERS
Customer Service
410-424-4790
888-819-1043
Provider Relations
410-762-5385
888-895-4998
Care Management
410-424-4480
800-261-2421
Case/Disease Management
888-309-4576
Health Education
800-957-9760
Block Vision Services
800-428-8789
Eligibility Verification
System (EVS)
866-710-1447
HealthChoice
800-977-7388
For Primary and Secondary
Insurance Carriers
Hospitals that provide services to Medicaid
members who have third party insurance
coverage should contact both carriers for
preauthorization. This will ensure that the
hospitals will be paid for any Medicaid
allowable fees that the primary insurer does
not cover.
If the hospital does not obtain a preauthorization
from the other insurance carrier and the
MCO, the MCO can deny the claim for lack
of preauthorization. This was adopted under
COMAR 10.09.65.18, Third Party Liability,
which became effective February 6, 2012.
Please refer to Maryland Medical Assistance
Program, MCO Transmittal No. 89.
http://mmcp.dhmh.maryland.gov/
MCOupdates/SitePages/Provider%20
Transmittals.aspx
Outreach
410-424-4648
888-500-8786
ValueOptions
800-888-1965
Substance Abuse
410-424-4476
800-261-2429
Dental (DentaQuest)
800-698-9611
PAC
800-654-9728
Corporate Compliance
[email protected]
410-424-4996
Priority Partners Website
www.ppmco.org
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JUST FOR
Johns Hopkins US Family Health Plan Providers
Delaware Expansion for USFHP
Good News... In April 2012, the Johns Hopkins US Family
Relations has successfully contracted with several large health
Health Plan (USFHP) will be expanding our provider net-
systems in the state including Bay Health Medical Center,
work and coverage area, which will now include Delaware.
Inc. For further information please contact Provider
The expansion encompasses the area surrounding Dover Air
Relations at 888-895-4998.
Force Base. Johns Hopkins HealthCare (JHHC) Provider
USFHP Interactive
Provider Manual
USFHP
We have developed a new online interactive provider
manual just for you. There are a host of features, including
a search function, page curls, forward and back buttons,
options to print as a PDF, magnifications and varying page
views that will get you the information you seek, all with just
a few clicks of the mouse.
• To access the manual, go to www.jhhc.com and click
on For Providers & Physicians in the left hand menu.
Then click on Resources & Guidelines, also in the left
hand menu. In the center of the page you will see
USFHP Provider Manual New Interactive Manual!
• Click on the link and start exploring
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Johns Hopkins
US Family Health Plan
2011-2012
Provider
Provider
Manual
Manual
PROVIDER UPDATES
Johns Hopkins US Family Health Plan
Patient Centered Medical Home
USFHP IMPORTANT
NUMBERS
The Johns Hopkins US Family Health Plan (USFHP) is pleased to announce that USFHP has
elected to voluntarily participate in Maryland’s Multi-Payer Patient Centered Medical Home
Program (PCMH), effective January 1, 2012. Of the 53 practices participating in the program,
three practice groups are participating within the USFHP provider network. Participation in the
program will only help enhance the quality of care provided to our USFHP members.
Customer Service
410-424-4528
800-808-7347
Infertility Treatment Services
The Johns Hopkins University (JHU)
Department of Gynecology and Obstetrics,
Division of Reproductive Endocrinology and
Infertility and the Johns Hopkins US Family
Health Plan (USFHP) have partnered to
offer a comprehensive program of assisted
reproductive technologies for the treatment
of infertility at reduced cost to interested
USFHP plan members.
The JHU Fertility Center assists with
every step of the process from diagnostic
services to financial counseling and
patient education. Care coordination is
provided by a team of physicians, nurses
and clinic staff.
The Team
The staff includes some of the most
experienced infertility specialists in the
U.S. A profile of each staff member can
be found at the Fertility Center’s website:
http://www.hopkinsmedicine.org/
fertility/team/physicians
Fees and Pricing
Procedures and treatments are individualized for each member. USFHP members will receive a
discount for all IVF and IUI services. Diagnostic services are covered by the plan.
Interested?
Prospective members need a referral from their primary care provider (PCP) or OB provider.
Medical records with all diagnostic and relevant interventions need to be provided as well.
An initial appointment can be provided within approximately 10 days after the from referral by
calling 410-616-7140.
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Provider Relations
410-762-5385
888-895-4998
Care Management
410-424-4480
800-261-2421
Case/Disease Management
888-309-4576
Mental Health/Substance Abuse
410-424-4885
Pharmacy Services
888-819-1043
Corporate Compliance
[email protected]
410-424-4996
Health Education
800-957-9760
Health Coach Services
800-957-9760
[email protected]
USFHP Website
www.hopkinsmedicine.org/usfhp
For Your Information
Claim Submissions
Johns Hopkins
US Family Health Plan
P.O. Box 33
Glen Burnie, MD 21060-0033
Attn: Claims Department
Appeal Submissions
Johns Hopkins
US Family Health Plan
P.O. Box 33
Glen Burnie, MD 21060-0033
Attn: Appeals Department
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JUST FOR
Employer Health Programs Providers
JHHC Welcomes New Medical Director
Johns Hopkins
HealthCare
(JHHC) is always
looking for ways
to provide the best
care for its members. With the
hiring of Dr.
Richard Safeer,
M.D., F.A.A.F.P.,
JHHC continues
that trend.
"I would also like to see us compete with other health care
carriers in the region in offering our services to private
employers," Dr. Safeer said.
Dr. Safeer has set clear goals for taking EHP to the next level,
but knows it will take a team effort. He is very interested in
meeting the providers in the network and learning about
their needs. “Our providers are the key to our members’
health and happiness.”
Although the work that lies ahead is going to be challenging,
Dr. Safeer has enjoyed his first couple of months at JHHC.
He is looking forward to being an effective team player by
helping JHHC grow and by keeping its members happy.
Dr. Safeer
joined the Care
Management team
Dr. Richard Safeer is Johns Hopkins HealthCare’s
as a medical direcnewest medical director
tor in January. The
Buffalo, N.Y. native will focus on the growth of Employer
Health Programs’ (EHP) customer base.
10
“This is an interesting time for the health care industry. Johns
Hopkins is uniquely positioned in this region to insure, treat and
provide world-class resources,” Dr. Safeer said. “I think there’s a
lot of opportunity for us to build a system that provides highquality health care while maintaining costs.”
In order to expand EHP, JHHC must showcase how the plan
can improve the health of its members. Providing top-notch
health care benefits doesn’t mean astronomical costs for
members. Dr. Safeer realizes the importance of mirroring the
mission of Johns Hopkins Medicine by providing world-class
health care services at reduced costs. With these objectives in
mind, Dr. Safeer’s vision for EHP goes beyond servicing
employees of the Johns Hopkins Health System.
Prior to JHHC, Dr. Safeer was a medical director at
CareFirst BlueCross BlueShield, a family physician at Fairfax
Family Practice and an assistant professor and residency
director at The George Washington University. Dr. Safeer
attended the University at Buffalo. He completed his
medical studies at The State University of New York. He
received his residency training in family medicine at MedStar
Franklin Square Medical Center in Baltimore.
“We need to be able to compare service programs, benefits
and other interventions we provide with health care costs that
our customers pay.
When Dr. Safeer isn’t working, he enjoys biking, hiking, tennis,
and other outdoor activities. Dr. Safeer has been married to his
wife, Beth, for 13 years. The couple have three children; two
sons, Noah, 11, and Jacob, 9, and a daughter, Shayna, 5.
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Employer Health Programs Providers
My EHP Story - Cassandra Thompson
EHP IMPORTANT
NUMBERS
Just over four years ago Cassandra Thompson
accepted a customer service supervisor job at
Johns Hopkins HealthCare (JHHC). As part
of the standard pre-employment process,
Cassandra completed her physical at Johns
Hopkins Occupational Health in downtown
Baltimore. On her way back to the elevator
that day, she was stopped by a security guard
who told her that she needed to return to the
clinic. Cassandra complied, only to learn
something that would change her life forever.
also prescribed
medications that
would bring her
blood sugar levels
down. According
to Cassandra, her
mental and physical
outlook changed
significantly.
Customer Service
410-424-4450
“It was a rude
awakening, and
Cassandra Thompson
learning how to
handle this disease was truly an experience.
Diabetes changed my way of thinking about
my health, my life, and being there for my
children. It made me reevaluate a lot of
things,” Cassandra said.
United Concordia (Dental)
866-851-7576
“I was told that my blood sugar level from my
urinalysis was off the charts. It was really
high. Even then, I didn’t put all the pieces of
the puzzle together,” Cassandra recalled.
Before she could be cleared for work through
Occupational Health, Cassandra needed to see
her primary care provider (PCP) to confirm
her diagnosis.
“Another urinalysis and a finger prick from
my doctor confirmed my fears. I had Type 2
diabetes. I was scared…scared to death to
learn I was a diabetic,” admitted Cassandra.
Before her diagnosis, though, Cassandra had
physical signs that something wasn’t right, but
she always attributed it to another cause. She
was tired and sluggish, but blamed it on her
long commute to work. Her thirst was never
quenched even though she drank a lot of
water and sodas. She also had blurry vision,
but blamed it on being near-sighted.
Once Cassandra met with her regular doctor,
they had a long conversation about diabetes
and what it meant to her. He recommended
that she see a nutritional counselor so she
could understand her disease better. He
With additional help from a case manager and
a health coach, Cassandra’s quality of life has
improved immensely, and says she really feels
good now. She is more conscious of what she
eats, and she exercises on a regular basis.
Cassandra, the mother of two daughters,
Courtney, 23, and Jasmine, 20, is also a
newlywed. Her husband, Derrick, is also
diabetic, but has learned some things from
his wife.
“My husband was so impressed with the
care I was getting from my health plan that
he changed his insurance to EHP. So far it’s
been a good experience for him. With what
we’ve both learned, we’re able to take care
of each other.
Provider Relations
410-762-5385
888-895-4998
Care Management
410-424-4480
800-261-2421
410-424-4890 fax
Dental (Members)
800-516-0646
Pharmacy Prior Authorizations
888-413-2723
Mental Health/
Substance Abuse Referrals
410-424-4476
800-261-2429
Health Coach Services
800-957-9760
[email protected]
Health Education
800-957-9760
Corporate Compliance
[email protected]
410-424-4996
Website
www.jhhc.com
“Coming to Hopkins was definitely a blessing.
If I hadn’t had that physical that day, who
knows what my life would be like now.”
Hopkins
T
H
E
ACROSS BOARD
11
PRACTICALLY
Speaking
Customer Service: Can I help you?
Good customer service is the lifeblood of any business and is all about
bringing the customer back. Even if a business offers the best product on
the market, good customer service can make or break a business.
“Johns Hopkins HealthCare (JHHC) is the best of the best.
Our customer service starts with the people we hire. We look for
people with a customer service background or people who have the
ability to learn the soft skills of being a customer service representative,”
said Joe Noto, customer service director, JHHC.
Joe’s customer service team members each take approximately 30 to
40 calls per day. They answer questions from members as well as network providers, and they discuss anything from basic medical benefits,
co-payments, identification cards, inpatient stays, to explanation of
Roberta Martin-Wolfe is one of
benefits. They are knowledgeable with claim status, eligibility,
EHPs highly skilled customer
coordination of benefits and more.
service representatives.
“When a member or provider calls here, they understand what
you’re faced with, and are more than willing to help you,” said William Whitfield, customer service
manager, JHHC. “Our customer service representatives are subject matter experts. We give our
member and providers the information they need.”
MEDICAL FACTOIDS
Although it's only
2 percent of our body
weight, the brain
uses 20 percent of
all oxygen we
breathe, 20 percent
of the calories we
take in, and 15
percent of the body's
blood supply.
If you have questions regarding fraud or suspected fraudulent activities involving a Priority Partners, USFHP or EHP member,
provider or employee, please contact the Corporate Compliance Department at 410-424-4996 or by email at [email protected]
If you have questions, please contact
Provider Relations at 888-895-4998.
Go to jhhc.com. Look for
HealthLINK@Hopkins to the right
of the page and register today!
is a secure web portal for Priority Partners,
Johns Hopkins US Family Health Plan
(USFHP) and Employer Health Programs
(EHP) members and network providers. As
a provider, you can submit claims, search
for existing claims, review electronic
remittance advice, search for members,
receive reports, check the status of referrals
and authorizations, send secure messages
to Customer Service, and much, much more.
HealthLINK@Hopkins
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Adolescent Well Care Visits
Age 12 – 21 years
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One well child visit with a PCP or OB/GYN
during the measurement year.
All three components of an adolescent well
visit must be included:
• Health & Development History (physical &
mental)
• Physical Examination
• Health Educations/Anticipatory Guidance
Sick visits are opportunities to include this
information.
Visits to school based clinic practitioners
whom the organization would consider PCPs
may be counted if the documentation that a
well exam occurred is available in the medical
record or administrative system.
Well Child Visit
Age 3 – 6 years
One well child visit with a PCP during the
measurement year.
All three components of a well-child visit
must be included:
• Health & Development History (physical
& mental)
• Physical Examination
• Health Educations/Anticipatory Guidance
Sick visits are opportunities to include this
information.
Visits to school based clinic practitioners
whom the organization would consider PCPs
may be counted if the documentation that a
well exam occurred is available in the medical
record or administrative system.
Disabled (SSI) Children
0 – 20 years of age who are
enrolled for 320 days or more
Children that had at least one ambulatory care
visit in an office or other outpatient visit
3URYLGHU6SHFLDOW\
PCP: A physician or non physician (e.g.
nurse practitioner) who offers primary care
medical services. Licensed practical nurses,
registered nurses, & physician assistants are
not considered PCP’s because they are not
licensed to practice independently.
Complete immunizations on or before the
child’s second birthday:
4 – DTaP/DT
3 – IPV
3 – Hep B
3 – Hib
4 – PCV
1 – MMR
1 – VZV
The PCP does not have to be assigned to the
member.
PCP: A physician or non physician (e.g.
nurse practitioner) who offers primary care
medical services. Licensed practical nurses,
registered nurses, & physician assistants are
not considered PCP’s because they are not
licensed to practice independently.
The PCP does not have to be assigned to the
member.
No provider requirements specified.
• Office or Other Outpatient: CPT: 9920199205, 99211-99215, 99241-99245; UB
Revenue Codes: 051x, 0520-0523, 0526-0529,
0983
• Home Visits: CPT: 99341-99345, 99347-99350
• Nursing Facility Care: CPT: 99304-99310,
99315, 99316, 99318; UB Revenue Codes: 0524,
0525
• Domiciliary/Rest Home: CPT: 99324-99328,
99334-99337
• Preventive Medicine: CPT: 99391-99395,
99391-99397, 99401-99404, 99411, 99412,
99420, 99429, 99381-99385
• Newborn Care: CPT: 99461
• Ophthalmology & Optometry: CPT: 92002,
92004, 92012, 92014
• Maryland Specific Codes: T1015, S0621, S0620
No provider requirements specified.
• Chicken Pox Disease: ICD9: 052, 053
• DTaP: CPT: 90698, 90700, 90721, 90723;
ICD9: 99.39
• Hep B: CPT: 90723, 90740, 90744, 90747,
90748; HCPCS: G0010; ICD9: V02.61, 070.2,
070.3
• HiB: CPT: 90645-90648, 90698, 90721, 90748
• IPV: CPT: 90698, 90713, 90723; ICD9: 99.41
• Measles: CPT: 90705; ICD9: 055, 99.45
• Measles & Rubella: CPT: 90708
• MMR: CPT: 90707, 90710; ICD9: 99.48
• Mumps: CPT: 90704; ICD9: 072, 99.46
• PCV: CPT: 90669, 90670; HCPCS: G0009
• Rubella: CPT: 90706; ICD9: 056, 99.47
• VZV: CPT: 90710, 90716; ICD9: 052, 053,
070.0, 070.1
No provider requirements specified.
• CPT: 83655
• LOINC: 5671-3, 10368-9, 10912-4, 14807-2,
17052-2, 25459-9, 27129-6, 32325-3, 5674-7,
14807-2
Document the 1st Hep B vaccine given at
the hospital when applicable or if unavailable
name of hospital where child was born.
Lead blood test for all children between the
age 12 – 23 months.
• CPT: 99382, 99383, 99392, 99393
• HCPCS: G0438, G0439
• ICD9: V20.2, V70.0, V70.3, V70.5, V70.6,
V70.8, V70.9
Primary Care Physician includes:
• General or family practice physicians
• General internal medicine physicians
• General pediatricians
• Obstetricians/gynecologists (OB/GYN)
• Certified nurse midwives and Nurse
Practitioners under the direction of an
OB/GYN certified provider or PCP
Document all sero positives and illness history
of chicken pox, measles, mumps, and rubella.
Lead Screening
Age 12 – 23 months
• CPT: 99383, 99384, 99385, 99393, 99394,
99395
• HCPCS: G0438, G0439
• ICD9: V20.2, V70.0, V70.3, V70.5, V70.6,
V70.8, V70.9
Primary Care Physician includes:
• General or family practice physicians
• General internal medicine physicians
• General pediatricians
• Obstetricians/gynecologists (OB/GYN)
• Certified nurse midwives and Nurse
Practitioners under the direction of an
OB/GYN certified provider or PCP
All three components of a well-child visit
must be included if a well-child visit is
being performed:
• Health & Development History (physical &
mental)
• Physical Examination
• Health Educations/Anticipatory Guidance
Childhood Immunizations
On or before child’s 2nd
birthday
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Exclude target test on child’s second
birthday.
Please distribute to billing and office personnel as appropriate. Contact your Network Manager at 1-888-895-4998 with any questions.
(*) Compliance for this measure includes billing with the appropriate CPT and/or ICD-9 Diagnosis Code
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-OVER-
HEDIS Measure
Cervical Cancer Screening
Women age 21 – 64 years
Required Documentation
One screening pap test every three years.
Provider Specialty
No provider requirements specified.
Obtain copy of results or record date of test
results.
The following does not qualify:
• Lab results that indicate inadequate sample
or no cervical cells
Referral to OB/GYN alone does not meet the
measure.
Biopsies are considered diagnostic and do not
meet the measure.
Document exclusions:
• Record “total” or “complete” hysterectomy
as applicable
Breast Cancer Screening
Women age 40 – 69 years
One mammogram breast screening every two
years.
Optometrist/ophthalmologist exam every 2
years for patients without retinopathy and
every year with DM retinopathy.
No provider requirements specified.
• Mammogram: CPT: 77055-77057; HCPCS:
G0202, G0204, G0206; ICD9: 87.36, 87.37; UB
Revenue Code: 0401, 0403
• Bilateral Mastectomy: CPT: 19180, 19200,
19220, 19240, 19303-19307 with Modifier 50 or
09950; ICD9: 85.42, 85.44, 85.46, 85.48
Send exclusion documentation to:
JHHC Quality Improvement
Fax 410-424-4882
Ophthalmologist or Optometrist
• CPT: 67028, 67030, 67031, 67036, 6703967043, 67101, 67105, 67107,67108, 67110,
67112, 67113, 67121, 67141, 67145, 67208,
67210, 67218, 67220, 67221, 67227, 67228,
92002, 92004, 92012, 92014, 92018, 92019,
92134, 92225, 92226, 92227, 92228, 92230,
92235, 92240, 92250, 92260, 99203-99205,
99213-99215, 99242-99245
• CPTII: 2022F, 2024F, 2026F, 3072F
• HCPCS: Preferred Code S0620, S0621, S3000
(can be submitted by any provider)
• ICD9: V72.0 REMOVED; Procedure Codes:
14.1-14.5, 14.9, 95.02-95.04, 95.11, 95.12,
95.16
Exclusion Codes:
• Polycystic ovaries: 256.4
• Steroid Induced: 249, 251.8, 962.0
• Gestational diabetes: 648.8
A chart or photograph of retina indicating
date when photography performed with
evidence that an eye professional reviewed the
results.
or
Results can be read by a qualified reading
center under the direction of a retinal
specialist.
Identify diabetic exclusions:
A note indicating any of the following:
• Polycystic ovaries
• Steroid Induced Diabetes
• Gestational Diabetes
Postpartum Visit
A visit that occurs on or between 21 – 56 days
after delivery.
Components of a postpartum exam visit note:
• Pelvic exam
or
• Weight, BP, breast & abdominal
evaluation, breast feeding status
or
• PP check, or PP Care, or 6 week check
notation.
Appropriate Medications for
Patients with Asthma
Age 5 – 64 years
For patients with persistent asthma at least one
dispensed controller medication.
Review and assess asthma prescriptions every
visit.
• CPT: 88141, 88142, 88143, 88147, 88148,
88150, 88152-88155, 88164-88167, 88174,
88175
• HCPCS: G0123, G0124, G0141,
G0143-G0145, G0147, G0148, P3000, P3001,
Q0091
• ICD9: 91.46
• ICD9 V Codes REMOVED
• LOINC: 10524-7, 18500-9, 19762-4, 19764-0,
19765-7, 19766-5, 19774-9, 33717-0, 47527-7,
47528-5
• UB Revenue Code: 0923
Send exclusion documentation to:
JHHC Quality Improvement
Fax 410-424-4882
Obtain a copy of mammogram results or
record date of test and result.
Diabetic Eye Exam
Members 18 – 75 years of age
with diabetes
Billing Tips*
Send exclusion documentation to:
JHHC Quality Improvement
Fax 410-424-4882
•
•
•
•
•
OB/GYN practitioner or midwife
Family practitioner or other PCP
General or family practice physicians
General internal medicine physicians
General pediatricians
A practitioner with prescribing privileges,
including nurse practitioners, physician
assistants and other non-MDs who have the
authority to prescribe medications.
Bill appropriate CPT code or bill global delivery
code that includes date when the postpartum care
was rendered.
• CPT: 57170, 58300, 59430, 88141, 88142,
88143, 88147, 88148, 88150, 88152-88155,
88164-88167, 88174, 88175, 99501
• CPT II: 0503F
• HCPCS: G0101, G0123, G0124, G0141,
G0143-G0145, G0147, G0148, P3000, P3001,
Q0091
• ICD9: V24.1, V24.2, V25.1, V72.3, V76.2,
89.26, 91.46
• UB Revenue Code: 0923
• LOINC:10524-7,18500-9, 19762-4, 19764-0,
19765-7, 19766-5, 19774-9, 33717-0, 47527-7,
47528-5
Prescribe asthma controlling medication as indicated.
Exclusions:
• Emphysema
• COPD
• Cystic fibrosis
• Acute respiratory failure
Send exclusion documentation to:
JHHC Quality Improvement
Fax 410-424-4882
Disabled (SSI) Adults
Age 21 – 64 years and older
Adults that had at least one ambulatory care
visit in an office or other outpatient visit.
All three components of a well visit when
performed include:
• Health/Development History
• Physical Examination
• Anticipatory Guidance
No provider requirements specified.
• Home Visit: CPT: 99341-99345, 99347-99350
• Domiciliary or Rest Home: CPT: 99324-99328,
99334-99337
• Nursing Facility Care: CPT: 99304-99310,
99315-99316, 99318; UB Revenue Codes: 0524,
0525
• Office or other outpatient: CPT: 99201-99205,
99211-99215, 99241-99245; HCPCS: T1015;
UB Revenue Codes: 051x, 0520-0523, 05260529, 0982, 0983
• Preventive Medicine: CPT: 99381-99387,
99391-99397
• Ophthalmology & Optometry: CPT: 92002,
92004, 92012, 92014