Implementation of PCP Referrals for Advantra Members Coventry by pengxiang


									                                                                                               OCTOBER 2009
                                                                                             SEPTEMBER 2010

Implementation of PCP Referrals                           University of Missouri Changes
for Advantra Members
On January 1, 2011, GHP will implement a Primary          Coventry/GHP is pleased to announce the addition of
Care Physicians (PCP) referral requirement for access     the Catastrophic Program (CAT) and Retiree Indemnity
to specialist services in the Advantra Medicare           Medical Program (RIM) plans to the Choice Health
Advantage program. This will help PCPs better             Care Program for the University of Missouri. The
coordinate the care of their Advantra patients. The       following changes will apply effective January 1, 2011:
requirement has been in effect for the Gold Advantage
program since its inception in 2003. Note: Beginning          • ID cards will be issued for each of the new plans
with January 1, 2011 dates of service, we are                   and will be plan-specific (i.e., a card for the CAT
requesting that referrals be submitted at                       program and a card for the RIM program). or on Emdeon.                          • The prior authorization list has changed and will
                                                                apply to all three plans (Choice, CAT and RIM).
                                                                The new prior authorization list will be available
Coventry Health Care, Inc.                                      in the provider section of our website at
                                                       as well as the provider
Acquires Mercy Health Plans                                     section at
On October 1, 2010, Coventry Health Care, Inc.,               • Authorizations are not required for Medicare-
completed the acquisition of MHP, Inc., and its                 primary members.
subsidiaries, “Mercy Health Plans.”
                                                          Coventry/GHP is proud to partner with you to serve
We will be integrating operations over the next several   University of Missouri members.
months; however, until further notice operations will
continue without any changes. You should continue to
follow the traditional process for claims submission,     Join Us for
authorizations , concurrent review, customer service      Training in November
and provider relations support.
                                                          To register your provider office staff for a
Coventry Health Care, our parent company, is a   training session, please send an e-
diversified national managed health care company          mail to
based in Bethesda, MD. Coventry operates health           Include " Training" in the subject
plans, insurance companies, network rental and            line and the date you wish to attend.
workers’ compensation services companies. A full
range of risk and fee-based managed care products         Friday, November 19, 2010
and services to a broad cross section of individuals,     1:00 PM - 3:30 PM Central Time
employer and government-funded groups, government
agencies and other insurance carriers and                 Friday, December 17, 2010
administrators are offered. Coventry’s purchase of        1:00 PM - 3:30 PM Central Time
MHP reinforces our commitment to the Midwest
market, where we serve more than 1.2 million              All training is conducted online via Microsoft Live
members.                                                  Meeting. The instructor for the session will e-mail the
                                                          log-in and dial-in instructions prior to the training.
Coventry and MHP look forward to your continued
support. If you have any questions regarding the
transition, please contact your Provider Relations

Coventry/GHP’s Network Connection—October 2010                                                                      1
Coding Tips for Circulatory                                 documentation. ICD-9 coding assignment must
                                                            correspond with the documentation.
Testing for suspected diagnosis:                            Remember if it’s not documented in the medical
                                                            record, it never happened and you can not code for
If a condition is ruled out (i.e. negative test results),   it.
code for the signs or symptom; usually the reason for
the test.                                                   ICD-9 coding guidelines found in the link above.

Example: Sign or Symptoms of DVT
   • Pain in limb – 729.5
   • Swelling in limb – 729.81                              2010 HEDIS CAHPS® Survey and
   • Phlebitis of lower extremities – 451.2
                                                            2009 Medicare MA-PD CAHPS
If a condition is confirmed (i.e. positive test results),   Results
please code for confirmed diagnosis.
                                                            The Consumer Assessment of Healthcare Providers
Note: It is inappropriate to code for a diagnosis           and Systems (CAHPS) is a survey developed by the
that has not been confirmed.                                Agency of Healthcare Research and Quality (AHRQ) to
                                                            measure consumers’ and patients’ perspectives on
Phlebitis v/s Deep Vessel Phlebitis                         health care quality. NCQA includes CAHPS as a
    • Phlebitis of lower extremities, unspecified –         component of HEDIS.
    • Deep Vessel Phlebitis of lower extremities –          The CAHPS survey administered to GHP’s commercial
      451.1x (Requires 5th digit)                           members is conducted by a private NCQA certified
                                                            vendor. The Medicare CAHPS survey is administered
Venous Embolism and Thrombosis                              by the Centers for Medicare and Medicaid Services
   • Deep Vein Thrombosis (DVT), unspecified –              (CMS) with the current version being the MA-PD
     453.40                                                 CAHPS which reflects the addition of questions to
                                                            assess satisfaction with the Medicare Part D benefit.
   • Deep vessels of proximal lower extremity
                                                            The CAHPS survey provides information on members’
     (upper leg) – 453.41
                                                            experiences and gives a general indication of how well
   • Deep vessels of distal lower extremity (lower
                                                            the services provided by health care professionals and
     leg) – 453.42
                                                            the health plan meets members’ expectations. Member
   • History of DVT – V12.51 (Used when condition           satisfaction is measured in the areas of quality of
     no longer exists and/or is being treated)              health care and quality of service. Health care quality
                                                            is measured by overall satisfaction with health care,
Peripheral Vascular Disease                                 overall satisfaction of personal physician and getting
Peripheral Vascular Disease (PVD) – 443.9                   needed care. Health care service is measured through
Small Vessel Disease – 443.9                                satisfaction with the health plan, customer service and
Peripheral Angiopathy classified elsewhere (i.e. DM) –      claims processing.
                                                            The Commercial CAHPS table provides the CAHPS
Atherosclerosis                                             results for HEDIS 2010. The Medicare CAHPS table
   • Atherosclerosis of the Artery - 440.9                  shows the 2009 MA-PD CAHPS results.
   • Atherosclerosis of the Aorta - 440.0
   • Atherosclerosis of the Extremities (native artery),
     unspecified – 440.20

Pulmonary Embolism
   • Pulmonary embolism and infarction, other –
           o Mainly found treated in hospital setting
   • History of Pulmonary embolism – V12.51

Note: According to CMS, physicians should focus on
complete and accurate diagnosis reporting
and reporting should be processed according to the
official ICD-9 CM coding guidelines. Also, all reported
diagnoses must be supported with medical record
                                                            Continued on next page…

Coventry/GHP’s Network Connection—October 2010                                                                   2
HEDIS 2010 CAHPS Results                                                 Pharmacy Update
Rating/Composite                                           HEDIS         The following is an update from the Coventry Health
                                                            2010         Care Commercial Pharmacy & Therapeutics
Rating of All Health Care*                                 78.6%         Committee meetings in July and August 2010.
Rating of Health Plan*                                     63.9%
Rating of Personal Doctor*                                 84.1%         Formulary Additions
Rating of Specialist Seen Most Often*                      85.7%         The following drugs have been added to the
Claims Processing Composite**                              89.8%         Prescription Drug List.
Getting Care Quickly Composite***                          88.0%
How Well Doctors Communicate Composite***                  96.0%            Brand         Generic         Effective
Customer Service***                                        87.4%            Name           Name             Date
Getting Needed Care***                                     87.1%          Amerge*       Naratriptan      Immediately   Generic
Plan Information on Costs***                               67.4%                                                       available
Shared Decision Making****                                 60.5%                                                       on Tier 1
*Based on a scale using any number from 0 to 10, where 0 is the           Apriso         Mesalamine      10/1/2010     Favorable
worst and 10 is the best, members rated the quality of care and                                                        cost over
quality of service they received. These statistics show the percent of                                                 other
members surveyed who selected 8, 9, or 10 as their response.
**Percent who responded they had no problem in that area                                                               brands
***Percent who responded they usually or always have a positive           Asacol HD      Mesalamine      10/1/2010     Favorable
experience in these areas                                                                                              cost over
****Percent who responded ‘Definitely Yes’ or ‘Somewhat Yes’.                                                          other
2009 MA-PD CAHPS Results                                                  Colazal*       Balsalazide     Immediately Generic
                                                             GHP                                                       available on
 Rating/Composite                                            2009                                                      Tier 1
 Rating of All Health Care*                                  63%          Flomax*        Tamsulosin      Immediately Generic
 Rating of Health Plan*                                      60%                                                       available on
 Rating of Personal Doctor*                                  74%                                                       Tier 1
 Rating of Specialist*                                       77%          Isentress      Raltegravir     Immediately Consistent
 Rating of Drug Coverage*                                    59%                                                       with place
 Getting Needed Care**                                       73%                                                       in therapy
 Getting Care Quickly Composite**                            53%                                                       per
 How Well Doctors Communicate Composite**                    76%                                                       Guidelines
 Health Plan Customer Service Composite **                   76%          Omnitrope      Somatropin      1/1/2011      Favorable
 Getting Needed Prescription Drugs Composite**               79%          (PA)                                         cost over
 Getting Information About Prescription Drugs                55%                                                       other
 Composite**                                                                                                           brands
*Using any number from 0 to 10 (0 being the worst possible rating         Prezista       Darunavir       Immediately Consistent
and 10 being the best possible rating), members
                                                                                                                       with place
 scored GHP on the quality of care and quality of service they
received. These statistics show the percent of                                                                         in therapy
 members surveyed who selected 9 or 10 as their response.                                                              per
**Percent of members who responded they always have a positive                                                         Guidelines
experience in these areas.
                                                                          Zenpep         Pancrelipase    1/1/2011      Favorable
                                                                                                                       cost over
Avandia/Avandamet Tier Change                                                                                          brands
                                                                         *Generic available      PA – Prior Auth Required
The U.S. Food and Drug Administration (FDA) has
placed new restrictions on Avandia (rosiglitazone)
products based on a safety review suggesting an
increased risk of cardiovascular events, including heart
attack and stroke, in patients taking this medication.
The FDA will require GSK to develop a restricted
access program that will make the drug available only
to those unable to achieve glycemic control on other
medications and unable to take Actos (pioglitazone).
Due to these recent FDA recommendations, Avandia
and the combination drug Avandamet
(rosiglitazone/metformin) will be moved to Tier 3 and
                                                                         Continued on next page…
will require similar prior authorization criteria.

Coventry/GHP’s Network Connection—October 2010                                                                                 3
Formulary Deletions Effective January 1, 2011
The following drugs will be removed from formulary effective January 2011. Most members have a three tier pharmacy
copay benefit and these drugs will be available for a Tier 3 copay.

    Brand Name                Generic Name                         Comment/ Formulary Alternatives
 Accutane^ (ST)        Isotretinoin                      Oral antibiotics minocycline and doxycycline
 Agenerase             Amprenavir                        Lexiva Tier 2
 Alamast               Pemirolast                        Zaditor OTC†, Alaway OTC†
 Allegra^              Fexofenadine                      Claritin OTC*† and Zyrtec OTC*†
 Allegra-D^            Fexofenadine/PSE                  Claritin-D OTC*† and Zyrtec-D OTC*†
 Avandia               Rosiglitazone                     Metformin, Actos (PA)
 Avandamet             Rosiglitazone/metformin           Combination product; Metformin and Actos (PA)
 Combivir              Lamivudine/Zidovudine             Combination product, separate agents covered
 Creon                 Pancrelipase                      Zenpep Tier 2
 Fenoglide             Fenofibrate                       Lofibra*, Trilipix
 Lunesta (ST)          Eszopiclone                       Ambien*, Sonata*
 Neevo Brand           Prenatal Vitamin                  Multiple generic prenatal vitamins on Tier 1
 Norditropin (PA)      Somatropin                        Omnitrope (PA) exclusive (Norditropin excluded)
 Prenate Brand         Prenatal Vitamin                  Multiple generic prenatal vitamins on Tier 1
 Triglide              Fenofibrate                       Lofibra*, Trilipix
 Ulesfia               Benzoyl alcohol                   Elimite*, Lindane*
 *preferred generic available, Tier 1                      covered Tier 1 with written prescription
 ^ non-preferred generic available, Tier 3               ST=Step Therapy Required
                                                         PA=Prior Authorization Required

Prior Authorization Additions
Beginning October 1, 2010, the drugs listed below will require prior authorization or step therapy under our Standard
and Select Prior Authorization programs.

       Brand Name                Tier                        Formulary Alternatives / Comments
Allegra ODT (ST) ‡                 3         Require trial/failure of Claritin OTC*† and Zyrtec OTC*†
Aromasin (PA)                      2         Covered for breast cancer
Arimidex* (PA)                     2         Covered for breast cancer
Beconase AQ (ST)                   3         Require trial/failure fluticasone or flunisolide AND Nasonex
Femara (PA)                        2         Covered for breast cancer
Fortamet (ST)                      3         Require trial/failure metformin/ER
Glumetza (ST)                      3         Require trial/failure metformin/ER
Lialda (ST)‡                       3         Require trial/failure Apriso or Asacol or Asacol HD
Mirapex ER (ST)                    3         Require trial/failure Mirapex^
Nasacort AQ (ST)                   3         Require trial/failure fluticasone or flunisolide AND Nasonex
Omnaris (ST)                       3         Require trial/failure fluticasone or flunisolide AND Nasonex
Rhinocort Aqua (ST)                3         Require trial/failure fluticasone or flunisolide AND Nasonex
Tribenzor (PA)                     3         Benicar HCT plus amlodipine available separately
Veramyst (ST)                      3         Require trial/failure fluticasone or flunisolide AND Nasonex
Vyvanse (ST)                       3         Require trial/failure Adderall XR
Xifaxan (PA)                       3         Require trial/failure lactulose (effective immediately)
*preferred generic available, Tier 1                    PA=Prior Authorization Required
^ non-preferred generic available, Tier 3               ST=Step Therapy Required
†                                                       ‡
  covered Tier 1 with written prescription                Applies to Standard PA Program only

Continued on next page…

Coventry/GHP’s Network Connection—October 2010                                                                          4
Benefit Exclusions
The drugs listed below will be excluded from coverage beginning January 1, 2011.

  Brand Name                Generic Name                                    Comments
Jalyn              Dutasteride/tamsulosin             Combination product, separate agents covered
Fanatrex           Gabapentin oral suspension         Generic gabapentin on Tier 1
Oleptro ER         Trazodone                          Generic trazodone on Tier 1
Norditropin        Somatropin                         Omnitrope exclusive preferred growth hormone
                                                      effective January 1, 2011

Coventry/GHP’s Network Connection—October 2010                                                       5

To top