Second Quarter 2017

NewsletterMaryland HealthChoice Program

Provider

IN THIS ISSUE uu2016 Consumer Report Card ..2

Report Fraud and Abuse .........3

MedStar Safety Moment .........3

Screening for Hypertension ....3

CAHPS 2016 Final Report .......4

Coordinating an Organ Transplant ..................................4

EPSDT Changes and Program Key Areas ...................................5

HIPAA Notice of Privacy Practices .....................................5

Requirements Pertaining to False Claims and Statements ..6

Clinical Practice Guidelines .....7

Pass-Through Billing .................7

Provider Health Education Survey.........................................8

Case Management for Total Joint Replacement ...................8

Referrals to Specialists .............9

Compliance Audit Requests ...9

National Correct Coding Initiative and Outpatient Coding Edits ............................10

Provider Performance Data ...10

Membership Cards and Verifying Eligibility .................11

Utilization Management-Authorization Review Process .....................................11

Paper Claims Address Reminder .................................12

Contact Us ...............................12

You Spoke, We Listened!Every year, MedStar Family Choice sends a Provider Satisfaction survey to a sample of in-network providers. The results are compiled and analyzed by the Quality Improvement department to determine areas of needed focus. Over the past year, MedStar Family Choice has been working on ways to improve our operations based on your feedback. We focused on five main areas based on the survey results to better your experience as providers. As a result, we:

1. Improved our paid claims rate to 97% within 30 days and reduced turnaround times to two days or less.

2. Added nurses to our Case Management, Disease Managemen, and Transition Care Programs to help you coordinate the care your members need.

3. Added outreach staff to help close gaps in care by working closely with members and offices to help schedule appointments and to decrease the “no-show” rate by MedStar Family Choice members.

4. Improved the prior authorization grid to reduce the number of services requiring authorization to allow you and your office staff more time to focus on your patients.

5. Continuously updated our formulary based on your suggestions and recommendations. (A current copy is available on our website.)

MedStar Family Choice always welcomes your feedback as we continue to work toward making your experience a positive one. If you have any suggestions or recommendations, please feel free to reach out to our Provider Relations department 800-906-1722, option 5.

2016 Consumer Report CardThe Department of Health and Mental Hygiene (DHMH) created a report card to assist enrollees in choosing a managed care organization (MCO) based on quality scores. The DHMH evaluates the activities of all MCOs contracted with the state of Maryland that provide care to medical assistance recipients in the HealthChoice program. The consumer report card has been developed from HEDIS® scores, encounter data and member satisfaction survey data. Please refer to the MedStar Family Choice website at MedStarFamilyChoice.com to view the 2016 report card and all other report cards from previous years.

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Report Fraud and AbuseMedStar Family Choice and MedStar Health have comprehensive compliance programs in place to monitor and detect fraud and abuse. Fraud and abuse could be committed by a provider, member or even an employee of the managed care organization. As a MedStar Family Choice provider, it is your responsibility to report fraud and abuse. Providers report fraud by calling the MedStar Family Choice compliance director at 410-933-2283 or the MedStar Health Integrity Hotline at 877-811-3411. You may also email ocbi@medstar.net.

A strict non-retaliation policy is in place for reporting suspected fraud and abuse. Some common examples of fraud and abuse are:

• Billing for a service that was never performed

• Unbundling of procedures

• Up-coding

• Performing unnecessary procedures

• Altering or forging a prescription

• Allowing others to use a member’s ID card for care

Most billing errors are oversights and not indicators of fraudulent activity. However, fraud and abuse does occurand MedStar Family Choice is responsible for monitoring, identifying and deterring these types of activities. As a result, we regularly monitor and audit claims submissions and encounter data. In addition, MedStar Family Choice performs routine and random chart audits as a part of the compliance program. Providers are subject to comply with these audits. If overpayments related to fraudulent or abusive billing have been identified, we may retract those payments made to providers. MedStar Family Choice may be required to notify the Department of Health and Mental Hygiene (DHMH) Office of Inspector General and Medicaid Fraud Control Unit (MFCU) of the retraction. DHMH or the MFCU may perform its own investigation. Penalties such as fines, loss of licensure or imprisonment can occur for providers found guilty of fraudulent activity.

Please note: When in the course of regular business, as part of an internal compliance program, or as a result of a self-audit a provider determines that payments made to the provider were in excess of the amount due from MedStar Family Choice, the provider is obligated to report and return the improper amounts.

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MedStar Safety Moment Quality and Safety are areas of focus in every corner of MedStar Health. ‘Safety Moments’ are now part of meetings at every level of MedStar Health, and in that spirit MedStar Family Choice will be including a safety moment in its newsletters.

Here is a “good catch” from the Precertification area at MedStar Family Choice:

A request for Dilaudid 2 milligrams # 60 10 days supply and Morphine 30 milligrams #60 15 days supply came into the nurse for a member. The nurse thought that this request for two powerful short acting narcotics was unusual. Rather than just process the request, she contacted the prescribing physician for confirmation. Sure enough, there was an error. The doctor forgot to include ‘ER’ (extended release) on the morphine prescription and so it was interpreted as short acting morphine. The oversight was corrected and because of the actions of our nurse a possible overdose and death was avoided.

This case should remind us all that even though electronic prescribing has helped a great deal with bad penmanship, we still need to carefully review prescriptions for potential errors that could have catastrophic consequences for our members.

Screening for HypertensionHypertension is a recognized global disease and affects patients of every demographic. Therefore, we encourage all practices, regardless of specialty, to check each patient’s blood pressure during an office visit with their provider, even if the patient has no prior history of high blood pressure. Many factors may increase a patient’s blood pressure and it is recommended that members with a high blood pressure reading be asked if they are under treatment for hypertension. If they are not, the patient should be encouraged to schedule an appointment with his or her primary care provider to screen for potential disease.

Providers performing blood pressure checks on each patient at every office visit ensures that diseases, like hypertension, do not pass undetected and improves the chances for successful treatment. Together, the medical community can reduce the growing effects of hypertension on the patient population.

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CAHPS® 2016 Final ReportThe Consumer Assessment of Healthcare Providers and Systems (CAHPS®) is a standardized survey that asks our members to evaluate and rate their experiences with their health care, their personal doctor and their health plan. The HealthChoice program contracts an independent vendor to conduct a member satisfaction survey once a year for MedStar Family Choice. The surveyed members are randomly chosen from three different population groups: adults, children and children with special needs/chronic conditions. The members are asked to rate their satisfaction on the following measures:

• How Well Doctors Communicate• Shared Decision Making• Getting Care Quickly• Coordination of Care• Getting Needed Care• Customer Service• Health Promotion and Education

The adult composite measures, when compared to the Medicaid MCO aggregate for MCOs operating in Maryland, concluded that MedStar Family Choice scored above the HealthChoice aggregate for all seven measures. When compared to the previous year’s results, improvement was documented in all areas except Coordination of Care. Therefore, it is evident that the focus MedStar Family Choice has placed on customer service in the past few years has been beneficial and according to our analysis, customer service has become a driving strength.

Similar to the adult survey, the 2016 child survey for the general population uses the same seven composite measures. When comparing the scores for 2016 to 2015, the following composite measures either increased or stayed the same in ratings: How Well Doctors Communicate, Getting Needed Care, Getting Care Quickly, and Health Promotion and Education. In fact, Getting Care Quickly showed statistically significant improvement from the previous year. MedStar Family Choice decreased slightly in the other three categories. When compared to national benchmarks set by NCQA, MedStar Family Choice scored above or equal to the benchmarks in all of the composite measures except Shared Decision-Making.

The same 2016 child survey contains a section that is specific to children with chronic conditions (CCC). As compared to the scores from the previous year, MedStar Family Choice met or exceeded the ratings in How Well Doctors Communicate, Getting Needed Care, Getting Care Quickly, Health Promotion and Education and Coordination of Care.

MedStar Family Choice fell slightly below the ratings from the previous year in the other categories. The survey for the CCC population also includes five additional measures, which are:

• Access to Prescription Medication• Access to Specialized Services• Personal Doctor Who Knows Your Child• Getting Needed Information• Coordination of Care for Children with

Chronic Conditions

In these categories, MedStar Family Choice met or exceeded the ratings from the previous year in all categories except Getting Needed Information, which fell by approximately 3%.

As a result of this year’s scores for the adult and child surveys, MedStar Family Choice has planned several interventions for 2017 in an effort to raise the ratings of several categories. These include joint training sessions with MedStar Family Choice vendors, additional member survey questions, silent monitoring programs, various marketing campaigns and additional newsletter articles. However, when viewing the surveys overall, MedStar Family Choice is pleased with the results.

Coordinating an Organ Transplant Getting ready for a transplant procedure takes a big commitment from the member and the member’s family. As a result, we have an organ transplant coordinator who becomes the member’s MedStar Family Choice case manager and helps them to coordinate care with the transplant team. The organ transplant coordinator begins the process by contacting the member to record detailed medical and social history and explain the program. They make sure the member knows what to expect and answers questions regarding provider appointments, what labs to expect, how long the process may take, and discusses any addiction conditions and counsels on healthy food options. The coordinator stays involved with the member and the provider office the entire time.

Providers are encouraged to keep in touch with our organ transplant coordinator since prior authorization is needed for all transplant specialty appointments. The referring physician is responsible for sending all clinical documentation to MedStar Family Choice, as well as the documentation of the facility where the transplant will take place. Both members and providers can contact our Organ Transplant Coordinator, Deborah Lucas, RN, BS, at 410-933-3022 regarding this program. Authorization request including ICD-10® codes and documents supporting medical necessity should be sent via fax to 410-933-2205 or 410-933-2209.

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EPSDT Changes and Program Key Areas New Requirements for Early Periodic Screening, Diagnosis, and Treatment (EPSDT) screening criteria updates for CY 2017 include:

• Annual screening for depression with the PHQ-9 Modified or other tools available in the GLAD-PC toolkit for children beginning at 11 years of age

• Annual screening for Substance Use with a validated substance use tool (CRAFFT is recommended) for children beginning at 11 years of age, or younger if indicated

• Annual STI Risk Assessment beginning at 11 years of age

• Assessment of nutritional status of a child includes documented assessment of “typical’ diet by specifying food groups or completion of nutritional questionnaire

• Objective assessment for vision and hearing for additional ages (3, 8 and 10 years of age)

• Annual Anemia Risk Assessment beginning at 11 years of age

• Dyslipidemial lab tests: first test between 9 to 11 years of age and second test between 18 to 21 years of age

• 3 Doses of HPV from 11 to18 years of age in girls

The Healthy Kids EPSDT program focuses on five key areas:

1. Health and developmental history (assessing both mental and physical development)

2. Comprehensive physical exam

3. Laboratory tests and at risk screenings

4. Immunizations

5. Health education and anticipatory guidance

It is important to indicate:

• The head circumference measurement at each visit from ages 0 to 2 years

• A distinct or graphed BMI percentile at each visit from ages 2 to 21 years

Please note that BMI alone does not represent the progress of a growing child; percentiles are necessary.

• TB screenings starting at 6 months

• Autism screening

• Depression screening

• Continued education

• Developmental screening tools

• A dental referral starting at 12 months

It is important to remember that the Delmarva Foundation may come on site to conduct EPSDT chart audit reviews for primary care providers. By following all EPSDT guidelines with supportive documentation, your office will receive great results. Visit the Maryland Department of Health and Mental Hygiene Healthy Kids website at MMCP.DHMH.Maryland.gov/EPSDT/Pages/Home.aspx to obtain the latest copies of EPSDT encounter visit forms, Healthy Kids Preventative schedule or to access the EPDST provider manual.

HIPAA Notice of Privacy Practices All new members receive a copy of our Notice of Privacy Practices upon joining MedStar Family Choice. The Notice of Privacy Practices outlines how MedStar Family Choice may use and disclose our member’s information, as well as when authorization for use and disclosure is required. Policies and procedures are also in place to make sure that our member , written and electronic protected health information, including portable electronic devices. Therefore, to ensure the privacy and security of its members’ medical information, MedStar Family Choice requires its providers to abide by a number of medical record documentation standards. These standards include provisions such as:

• Providing a Notice of Privacy Practices to members

• Complying with all federal, state and local regulations pertaining to medical records

• Securing both paper and electronic medical records

• Ensuring the confidentiality of member information through creation of standards

• Releasing of information only to authorized staff, including those from DHMH, DOH and HHS for quality assurance and auditing purposes

• Reporting to MedStar Family Choice in a timeframe required by law

Breaches of the HIPAA privacy rules as they relate to MedStar Family Choice members and cooperation with MedStar Family Choice in the remediation of such breaches, providers must immediately report privacy breaches related to MedStar Family Choice members in accordance with the provider agreement by calling the MedStar Health Privacy Office at 877-811-3411 (toll free) or email us at privacyofficer@MedStar.net. A copy of the notice is available on our website at MedStarFamilyChoice.com and hard copies can be provided upon request by calling Provider Relations.

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Requirements Pertaining to False Claims and Statements This is intended to provide you with information on laws pertaining to the prevention and detection of fraud, waste and abuse, in accordance with the requirements of the Federal Deficit Reduction Act of 2005. In addition, this article describes the procedures in place within MedStar Health and MedStar Family Choice for detecting and preventing fraud, waste and abuse. The MedStar Office of Corporate Business Integrity provides all MedStar Health facilities with compliance oversight, billing integrity support, occurrence reporting and resolution, and training and education. MedStar’s Internal Audit department conducts routine, independent audits of business practices, and all financial managers are required to attend training on the financial manager’s code of ethics and reporting obligations.

Employees, physicians, contractors, and patients are encouraged to report privacy, financial reporting, human resources, and other compliance concerns by making an anonymous and confidential call to the MedStar Integrity Hotline by calling 877-811-3411, toll-free. The hotline is available 24 hours a day Employees, physicians, contractors, and patients can also email the compliance officer at ocbi@medstar.net. Any person reporting fraud and abuse may also contact the MedStar Family Choice Maryland Medicaid compliance director at 410-933-2283. Retaliation for reporting in good faith, an actual or potential violation or problem, or for cooperating in a compliance legal or human resources investigation is expressly prohibited by MedStar policy. If overpayments related to fraudulent or abusive billing have been identified, we may retract these payments made to providers. In addition, under certain circumstances (Maryland Medicaid MCO Transmittal No. 82), MedStar Family Choice may be required to notify the Department of Health and Mental Hygiene (DHMH) OIG and Medicaid Fraud Unit (MCFU) and/or the Department of Health Care Finance (DHCF). These entities may perform their own investigation. Penalties such as fines, loss of licensure or imprisonment can occur for providers found guilty of fraudulent activity.

Federal False Claims Act

The Federal False Claims Act, 31 U.S.C. §§ 3729-3733, applies to persons or entities that knowingly and willfully submit, cause to be submitted or conspire to submit a false or fraudulent claim, or that use a false record or statement in support of a claim for payment to a federally funded program. The phrase “knowingly and willfully” means that the person or entity had actual knowledge of the falsity of the claim, or acted with deliberate ignorance or reckless disregard for the truth or falsity of the claim. Persons

or entities that violate the Federal False Claims Act are subject to civil monetary penalties (42 U.S.C. § 1320a-7a) and payment of damages due to the federal government. Under the False Claims Act, those who knowingly submit, or cause another person or entity to submit, false claims for payment of government funds are liable for three times the government’s damages plus civil penalties of $5,500 to $11,000 per false claim. The Federal False Claims Act provides that any person with actual knowledge of false claims or statements submitted to the federal government may bring a False Claims Act action in the government’s name against the person or entity that submitted the false claim. This is known as the False Claims Act’s “qui tam” or whistleblower provision. Depending on the outcome of the case, a whistleblower may be entitled to a portion of the judgment or settlement. The Federal False Claims Act provides protection to whistleblowers that are retaliated against by an employer for investigating, filing or participating in a False Claims Act lawsuit.

State False Claims Acts

A number of states have enacted false claims acts in an attempt to prevent the filing of fraudulent claims to state funded programs. The District of Columbia has established such an Act under Title 2, Chapter 3 of the District of Columbia Code. The District of Columbia law provides that any person who knowingly presents, or causes to be presented, a false claim, record or statement for payment by the District, or conspires to defraud the District by getting a false claim paid can be liable to the District for penalties and damages. District of Columbia law allows whistleblowers to bring claims under certain circumstances and protects whistleblowers from retaliation by employers. Virginia has a similar law, known as the Taxpayers Against Fraud Act, established under Chapter 3 of Title 8.01 of the Virginia Code. Virginia’s law also permits whistleblowers to bring actions in the name of the Commonwealth of Virginia and protects whistleblowers from discrimination by employers.

Maryland has a similar law, titled the Maryland False Health Claims Act of 2010, originally enacted as Maryland Senate Bill 279. The Maryland law prohibits actions constituting false claims against state health plans or programs, permits whistleblowers to bring actions under the law and provides protection for whistleblowers from retaliation. In Maryland, the civil penalty can be up to $10,000 for each violation. There can be an additional penalty of up to three times the amount of the damages that the state sustains. Depending on the outcome, the whistleblower may be entitled to a portion of the judgment or settlement.

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Clinical Practice GuidelinesClinical Practice Guidelines (CPG) are available through MedStarFamilyChoice.com. Click on the appropriate MedStar Family Choice Plan, there will be a link to the currently approved CPGs.

These guidelines include:

• 2017 Preventive Screening Recommended Guidelines• 2017 CDC Recommended Immunization Schedule • Community Acquired Pneumonia-Adults• Community Acquired Pneumonia-Pediatric• The Assessment and Prevention of Falls in the Elderly• Management of Adult Diabetes Mellitus• Guidelines for the Diagnosis and Management of Asthma• Management of Hypercholesterolemia• Identification and Management of Clinical Depression

in Adults• Management of Hyperbilirubinemia in the Healthy Term

Newborn• Management of Hypertension in Adults Age 18 Years

and Older• Identification, Evaluation, and Treatment of Overweight

and Obese in Adults• Expert Committee Recommendations Regarding the

Prevention, Assessment and Treatment of Child and Adolescent Overweight and Obesity: Summary

• Management of Osteoporosis• Managing Otitis Media in Children Ages 6 months -

12 years• Cervical Cancer Screening for the Primary Care Physician• Diagnosis and Management of Acute Group A Pharyngitis • Management of Pediatric ADHD• Treating Acute Asthma Exacerbations in Adults and Children• Management of Acute Low Back Pain in Adults• Management of Bronchiolitis in Pediatrics• Management of Bronchitis in Adults• Management of Bronchitis in Children and Adolescents• Diagnosis, Management and Prevention of COPD• Outpatient Treatment of DVT with LMWH• Prescribing Naloxone in the Outpatient Setting• Opioids For Pain Management• Guideline for Perinatal Care• Outpatient Use of Proton Pump Inhibitors• Management of Sinusitis in Adults• Management of Sinusitis in Children Ages 1 to 18• Outpatient Management of Pediatric Urinary Tract Infection

Pass-through Billing MedStar Family Choice and DHMH prohibit pass-through billing. Pass-through billing occurs when the ordering provider requests and bills for a service, but the service is not performed by the ordering provider or those under their direct employ. If you are a physician, practitioner or medical group, you must only bill for services that you or your staff perform. The performing provider should bill for these services unless otherwise approved by MedStar Family Choice.

“Per limitations provided in COMAR I 0.09.02.04, providers may only bill Medicaid for services they or their employees have actually performed when billing for a service that includes both a technical and a professional component. Providers may not bill for services they have subcontracted to be performed by a third party. For example, a Dr. Smith enters into an agreement to pay ABC Consultants directly to interpret ultrasounds that Dr. Smith has performed. The agreement does not establish an employer employee relationship. In this case, Dr. Smith would bill for the service using a modifier TC to indicate that he only performed the technical component of the service. Even though Dr. Smith has an arrangement where he has paid ABC Consultants to perform the professional component, Dr. Smith may not bill for the professional component because neither he nor his employees have performed the service. ABC Consultants would bill the Program for the professional component only using the modifier 26.”1 1. Per DHMH Transmittal Number 80, Published June 23, 2015, and COMAR 10.09.02.04.

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Case Management for Total Joint ReplacementThe MedStar Family Choice Case Management department has a program in place to help coordinate education efforts and discharge planning for our members who are candidates for total hip and knee replacements.

Our case manager contacts the member soon after they are pre-certified for surgery. This ensures the member is provided with a smooth transition through the continuum of care. At this time, our case manager will encourage member attendance at the total joint replacement education programs in participating hospitals. If a member declines the formal class, they are encouraged to review the online education available through Medstar Orthopedics or Medstar Family Choice Healthly Life Portal.

If needed, options for home care, physical therapy, equipment, and short-term skilled nursing home care are discussed with the member including network providers. An assessment that includes basic support information and the member’s desired discharge plan is then completed and faxed to the hospital’s orthopaedic case manager. Any pertinent information from assessment is also faxed to doctor’s office, if needed. Even though our case manager will actively work with the member, facilities and providers, we ask that the orthopedic physicians and/or office staff assist members in enrolling in pre-operative classes. Please be sure to make us aware of pending surgeries as early as possible.

Once aware of the surgery, we can begin our process with the member. It is important to keep in mind that discharge plans may change based on the clinical condition of the member and, in our experience, patients who are well prepared have better outcomes.

You can contact our MedStar Family Choice Case Management department at 800-905-1722, option 2, or fax the request with clinical information to 410-933-2274.

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MedStar Family Choice Provider Health Education Survey 2016 Summary The MedStar Family Choice Education Survey is sent to practitioners annually for feedback related to educational programs offered within MedStar Health. The feedback we receive from providers is evaluated on areas of program success related to educational outreach and case management activities in regards to target populations. The goal of offering these classes free of charge to MedStar Family Choice members is to eliminate the financial barrier and encourage members to participate in the health education opportunities via health fairs, screenings, classes, and support groups. As a result, we are able to identify new areas of informing physicians as to the availability of classes and educational topics of interest for their patients. At the beginning of December 2016, primary care physicians (PCPs) and specialists were sent a request to return a health education survey to Provider Relations for analysis. As per the results, PCPs and specialists reported that they received a copy of the health education schedule via the MedStar Family Choice website, electronically (by email or fax), U.S. mail, or another resource. After review of the answers, more PCPs referred members to classes than specialists. Providers who did not refer members to classes continued to indicate that there was (1) no need; (2) the provider did not know about the classes; or (3) the provider left referrals to the PCP. In addition, this year some providers indicated that they provided the necessary education within their own office. All providers who indicated that they referred members to educational classes referred to diabetes education, nutritional education, prenatal health classes, stop smoking classes, weight loss programs, cardiac health programs, prejoint replacement programs, arthritis lectures, exercise programs, and first aid/CPR for infants and children. Education for our members is an essential function for all areas of the MedStar Family Choice team. We continue community outreach efforts to members related to health education through fairs located where most MedStar Family Choice members reside, incentive programs, and by posting the schedule on the MedStar Family Choice website. The Provider Relations team continues to alert all providers of the existence and importance of these classes. Educational material is included in provider education sessions. It is also available through a specific MedStar Family Choice department program, which is often featured in the provider newsletter. In addition, the classes are sent to the providers through U.S. mail, email or MedStar Family Choice website posting. All departments will continue to educate members and providers through these avenues.

for members over the age of 21 years for up to 30 visits (the state manages patients under the age of 21 for physical therapy, occupational therapy and speech therapy). Prior authorization is required for more than 30 visits in a calendar year. Please note: Physical therapy services provided by a chiropractor are not covered and must be directed to an in-network PT provider. All providers are encouraged to use the MedStar Family Choice “Find a Doc” feature on our website at MedStarFamilyChoice.com in order to receive assistance in finding in-network specialists, laboratories and radiology providers. Please note, all referrals to out-of-network providers requires a prior authorization. Please send all questions or queries regarding referrals to MedStar Family Choice Provider Relations to mfc-providerrelations2@medstar.net. Telephone assistance is available for Maryland providers by calling 800-905-1722, options 5.

Referrals to SpecialistsReferrals to an In-network Provider

Primary Care Providers (PCP) should use the Uniform Referral form to refer members to a specialist. Other referral forms generated by a provider’s electronic medical record (EMR) system are accepted as long as all information that is on the Maryland Uniform Referral form is represented on the referral form that the PCP is generating. If a referral is requested by a specialist on the day of a member’s visit but the referral is not ready, PCPs may give the specialist verbal consent to see that patient on the date of service. Verbal consent will permit the member’s treatment while the referral is completed by the PCP. If the specialist does not obtain verbal approval from the PCP, then the specialist can see the member once without the referral. The office notes should then be sent to the PCP for the member’s chart.

Referrals from Specialist

Specialists can refer to other specialists if they receive written or verbal approval from the PCP (follow the documentation steps outlined above). Providers should use the Uniform Referral form to refer members to a specialist. Other referral forms generated by a provider’s electronic medical record (EMR) system are accepted as long as all information that is on the Maryland Uniform Referral form is represented on the referral form that the specialist is generating. If a referral is requested by a specialist on the day of a member’s visit but the referral is not ready, the referring provider may give the specialist a verbal consent to see that patient on the date of service. Verbal consent will permit the member’s treatment while the referral is completed by the referring provider. Document the verbal approval in the patient’s medical chart. If the specialist does not obtain verbal approval from a referring provider or PCP, then the specialist can see the member once without the referral. The office notes should then be sent to the PCP for the member’s chart.

Referrals for Lab and Radiology Services

PCPs and specialists are to directly refer their MedStar Family Choice patients for lab and radiology services to in-network free-standing locations and facilities. Specialists should not send their members back to the PCP for a referral. All providers should use a Lab Requisition form for labs, but providers can either use a Uniform Referral form and/or their EMR Referral form or write a script for radiology requests.

Referrals to Physical Therapy, Occupational Therapy and Speech Therapy

Both PCPs and specialists can refer to physical therapy, occupational therapy and speech therapy. Providers are to follow the process outlined within this article for referrals

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Compliance Audit Requests MedStar Family Choice conducts a number of audits throughout the year. If your office is selected, our compliance audits review the following:

• Documentation: i.e. documentation supports the code(s) billed, is legible and is signed and dated by the provider who rendered the services

• Billing: i.e. overpayments, overusage, pass-through billing

• Coding guidelines: i.e. upcoding, unbundling and correct use of codes

• Authorizations: Please be sure that what is authorized is what is billed

Once all of the requested documentation is received and reviewed by our compliance department, we will notify you of our findings. If fraud or improper coding is identified, MedStar Family Choice has the right to recoup payments in accordance with State law. If you have any questions regarding an audit, please contact Provider Relations at 800-905-1722, option 5.

Please note that our audits are based on current CPT® and ICD-10® guidelines in conjunction with the current CMS and the Maryland Medicaid guidelines as applicable. CMS guidelines can be reviewed at CMS.gov and on the HealthChoice website at mmcp.dhmh.maryland.gov/Pages/home.aspx.

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The National Correct Coding Initiative (NCCI) is a program developed by the Center for Medicare and Medicaid Services (CMS) that consists of coding policies and edits. NCCI edits address correct coding combinations submitted by a provider for multiple services in regards to the same patient, on the same anatomic site and on the same date of service. There are two types of edits: procedure-to-procedure edits and medically unlikely edits (MUEs). Procedure-to-procedure edits make certain that CPT and/or HCPCS codes billed together are eligible for separate reimbursement and medically unlikely edits (MUEs) ensure that the appropriate number of units for a particular service were billed.

MedStar Family Choice claims processing center utilizes nationally recognized vendor CCI edit software so that providers are reimbursed for services in accordance with the NCCI procedure to-procedure edits. Also contained in our existing NCCI edits are the Medicaid MUE’s for professional claims and some types of outpatient facility claims. This logic includes a maximum number of units of service for each HCPCS/CPT code. Claims that do not meet criteria set in the CCI edit software are denied. Instances when a claim is denied because of NCCI procedure-to-procedure edits include, but are not limited to:

• Mutually exclusive codes that cannot be reported together were billed

• Unbundling of codes when a single comprehensive CPT code is available. Since 2010, MedStar Family Choice has been using the NCCI methodologies in place for Medicare Part B because these methodologies are compatible with methodologies for Medicaid claims.

Since July 5, 2015, MedStar Family Choice has incorporated CMS/Medicaid MUEs into our policies. Therefore, additional MUEs that are compatible with Medicaid will be applied even though they are not applied by Medicare. Please keep in mind that many procedure codes have CCI edits associated with them. Providers should use applicable modifiers when services are in fact separate and independent from each other in order for claims to be processed and paid as separate procedures. Since modifiers can be used to bypass CCI edits, MedStar Family Choice monitors their use. Therefore, if a modifier is to be used to bypass CCI edits, it is imperative that providers clearly

document and explain the circumstances of the services that were provided in the member’s chart. The documentation must clearly show that the procedure code and modifier met the conditions for separate billing.

At this time, coding edits affect professional and outpatient claims submitted on CMS-1500 forms, as well as outpatient facility claims submitted on UB-04 (CMS-r1450) forms. For Maryland Health Choice providers, it was determined by the Department of Health and Mental Hygiene (DHMH), in conjunction with CMS, that procedure-to-procedure edits for outpatient hospital claims regulated by the Health Services Cost Review Commission are not permissible.

The DHMH clarified that the only outpatient coding edits that must be implemented for regulated outpatient hospital claims are a subset of edits identified under the CMS Integrated Outpatient Coding Edits (I/OCE). Visit CMS.gov/OutpatientCodeEdit for more detailed information.

If you need more information regarding NCCI methodologies and the appropriate usage of modifiers, you can go to the Centers for Medicare and Medicaid Services website at CMS.gov for the National Correct Coding Initiative Policy Manual, as well as the Medicaid National Correct Coding Initiative Edit Design Manual at bit.ly/1TJpygm.

National Correct Coding Initiative and Outpatient Coding Edits

Provider Performance Data MedStar Family Choice may utilize a provider’s performance data in numerous ways, including but not limited to:

• Recredentialing

• Pay for performance

• Quality improvement activities

• Public reporting to consumers

• Preferred status designation in the network (using tiers) for narrow networks

• Reduced member cost sharing

• Other quality activities

Please contact Provider Relations at 855-210-6203, option 5, with any questions and or concerns.

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MedStar Family Choice Membership Cards and Verifying EligibilityMedStar Family Choice does not deny claims when a member presents an ID card that does not reflect your office as the primary care provider (PCP). This is to prevent participating PCP offices from turning members away when they are active MedStar Family Choice members on the date of service (DOS). PLEASE DO NOT TURN MEMBERS AWAY! When this happens, please ask members to update their ID card information prior to their next appointment. Changing a PCP is relatively simple. Please follow these instructions if your office is not printed on the card as the member’s PCP:

• Always verify through IVR that the member is an eligible MedStar Family Choice member on the DOS by calling 866-710-1447

• See the patient if they are active. Do not reschedule the appointment

• Ask the member to call Member Services at 888-404-3549 to request a new member card reflecting their correct PCP name prior to the next scheduled appointment. You may allow the patient to call from your office while they are waiting to be seen. (You can also utilize the PCP change request located on the MedStar Family Choice website.)

• Follow current authorization procedures, if applicable. A list of services requiring prior authorization is available at MedStarFamilyChoice.com or can be obtained by calling Provider Relations

Please keep in mind the importance of current PCP information in regards to member ID cards. This information is used to create member rosters that are mailed monthly to PCP offices. These rosters are used by MedStar Family Choice to send member information to provider offices and when making outreach attempts for members. If the roster is inaccurate, the PCP on file may consequently receive member mailings that go into the member’s chart, as well as telephone calls regarding the specific member that is not actively under their care. MedStar Family Choice rosters are also used by Vaccines For Children (VFC) nurses who supply vaccines to pediatric offices for members enrolled in the HealthChoice program. As a result, pediatric offices may not be adequately stocked with vaccines for their members. If you need further assistance regarding the member’s benefits and eligibility, call our Provider Services Call Center at 800-261-3371.

Utilization Management-Authorization Review ProcessTo ensure that members receive proper health care, MedStar Family Choice follows a basic pre-authorization process. To request pre-authorization, all appropriate ICD-10s/CPT/HCPCS and supporting clinical information must be included with the provider’s request. Requests for authorization can be included on the Maryland Uniform Consultation Referral Form or the MedStar Family Choice Prior Authorization (Non-Pharmacy) Request Form with clinical information attached. Our experienced clinical staff reviews all requests, and pre-authorization decisions are based on nationally recognized criteria, such as Inter-Qual and Medicare guidelines. Additional authorization criteria utilized by MedStar Family Choice can be found at MedStarFamilyChoice.com in our utilization management (UM) process policy.

Member needs that fall outside of standard criteria are reviewed by our physician staff for plan coverage and medical necessity. We do not specifically reward practitioners or other individuals for issuing denials of coverage of care. UM decision-making is based only on appropriateness of care and services and existence of coverage. In addition, there are no financial incentives for UM decision-makers that would encourage decisions that result in underutilization. Providers may request a written copy of the criteria used in the decision making process by contacting the UM department at 800-905-1722, option 2, Monday through Friday, from 8:30 a.m. to 5 p.m. Authorization requests should be made no less than five to seven business days in advance of the service.

Please allow up to two business days for MedStar Family Choice to process a complete authorization request. Requests are considered complete when all necessary clinical information has been received from the provider.

The final decision is made within seven days, whether or not all clinical information has been received. For members with urgent authorization needs, physicians or a physician’s staff member should contact MedStar Family Choice Care Management at 410-933-2200 or 800-905-1722, option 2. If MedStar Family Choice denies the pre-authorization request, the provider and member will receive a copy of the denial. In addition, the denial letter will indicate that the treating provider may contact the MedStar Family Choice physician advisor to discuss the case by calling 800-905-1722, option 2.

Paper Claims Address Reminder All claims and overpayment refunds should only be mailed to the new address at:

MedStar Family Choice Maryland Claims PO Box 2189 Milwaukee, WI 53201 800-261-3371

MedStar Family Choice accepts electronic claims submissions for both professional claims and institutional claims. Claims can be submitted using the following online services:

Professional Claims

• Capario (formerly Medavant ProxyMed) - Payer ID 00243

• Healthcare (formerly Emdeon) - Payer ID 39190

• Relay Health (aka McKesson) - Payer ID 4775

Facility Claims

• Payerpath (aka Allscripts) - Payer ID 521995799

• Healthcare (formerly Emdeon) - Payer ID 39190

• Relay Health (aka McKesson) - Payer ID 3614

• XactiMed (Aka MedAssets) - Payer ID 521995799

Claims are also accepted directly via 837 and online claims submissions.

95223 King Ave., Suite 400 Baltimore, MD 21237 888-404-3549 PHONE

The MedStar Family Choice Newsletter is a publication of MedStar Family Choice.

Submit new items for the next issue to MedStar Family Choice at mfc-providerrelations2@medstar.net.

Kenneth A. Samet, FACHE President and CEO, MedStar Health

David Finkel President, MedStar Family Choice

Margo Briscoe Managing Editor, Health Plan

MedStarFamilyChoice.com

Contact UsEach participating MedStar Family Choice provider is assigned a provider representative to assist offices with questions regarding provider contracts and the MedStar Family Choice health plan. Your representative is assigned to you according to the ZIP code of your office. If you are not certain who your provider representative is, please call or email MedStar Family Choice Provider Relations, and we can assist you.

Provider relations main telephone number:

800-905-1722, option 5

855-600-3077 FAX

mfc-providerrelations2@medstar.net EMAIL

You may contact MedStar Family Choice, Monday through Friday, between 8:30 a.m. and 5 p.m. Providers have the option to leave a message or send a fax or email after normal business hours. However, any calls, faxes and emails received after hours will be addressed the next business day

Please call 800-905-1722:

Option 1 for Outreach, transportation and eligibility verifications

Option 2 for Pharmacy, pre-authorizations, inpatient reviews and case management

Option 3 for Member Services or denials and appeals

Option 4 for Claims.

Please listen for further options.

17-MFCMD-3001.071717