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A newsletter for Priority Partners, Johns Hopkins US Family Health Plan and Employer Health Programs network providers Hopkins T H E ACROSS BOARD 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 Hopkins T H E ACROSS BOARD 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. Hopkins T H E ACROSS BOARD 3 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 4 Hopkins T H E ACROSS BOARD 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. Hopkins T H E ACROSS BOARD 5 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. Hopkins T H E ACROSS BOARD PROVIDER UPDATES 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 Hopkins T H E ACROSS BOARD 7 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 8 Hopkins T H E ACROSS BOARD 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. Hopkins T H E ACROSS BOARD 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 9 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. Hopkins T H E ACROSS BOARD PROVIDER UPDATES 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 3URYLGHU7LSVIRU2SWLPL]LQJ+(',65HVXOWV +(',60HDVXUH Adolescent Well Care Visits Age 12 – 21 years 5HTXLUHG'RFXPHQWDWLRQ 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 %LOOLQJ7LSV 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 /DVWUHYLVHG&RGLQJLVLQDFFRUGDQFHZLWK+(',6*XLGHOLQHV6SHFL¿FDWLRQV -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