provider - php · 2017-01-04 · 4 provider connection electronic funds transfer! php has had...

A health plan that works for you.

THIRD QUARTER 2016

Provider

Connection

In this issueHEDIS Corner ..............................................2

Snort Sniffle Sneeze ..................................... 3

2016 MAHP Pinnacle Award ......................... 3

Medication Fill History Report COMING SOON ...........................................4

Electronic Funds Transfer .............................4

Epinephrine Auto-injectors .......................... 5

Meningitis B Vaccines 2016 ........................... 5

Flu Shot .......................................................6

Provider Satisfaction Survey 2016 .................6

Pharmacy Department News and Updates .... 7

Physician Health Plan Supports Boys and Girls Club ........................8

2016 TAIP Measure ..................................... 10

Holiday Hours ............................................ 10

Provider Connection2

What is HEDIS? » Healthcare Effectiveness Data and Information Set

(HEDIS) is a tool used by the managed care industry to compare health plan performance across plans and against benchmarks.

Why are scorings important? » Performance scores provide comparative data that is

used to focus on quality improvement efforts.

» Increasing performance scores result in better quality outcomes for our membership.

How is this done? » Medical records are requested and reviewed for

services rendered for the measure being reviewed. Administrative data is collected though claims.

Medication Management for People With Asthma (MMA) HEDIS measure of focus.

» This measure assesses the percentage of members 5–85 years of age during the measurement year who were identified as having persistent asthma and dispensed appropriate medications that they remained on during the treatment period.

» Physicians Health Plan supports and follows the Michigan Quality Improvement Consortium (MQIC) guidelines which are based on national sources. Evidence-based clinical practice guidelines for Asthma can be found at MQIC.org.

» General principles for the diagnosis and management of asthma cover:

» Assessment and monitoring

» Education

» Control environmental factors and co-morbid conditions

» Medication treatment

» Physicians Health Plan’s AsthmaWatch program emphasizes asthma control through preventive treatment and educational assistance. Educational assistance includes identifying asthma triggers, stressing the importance of staying on all

medications and following an asthma action plan.

» Together we can strive to ensure the best possible outcomes for our members.

Antibiotic utilization HEDIS measures of focus.

» Appropriate Treatment for Children With Upper Respiratory Infection (URI): The percentage of children 3 months to 18 years of age who were given a diagnosis of upper respiratory infection (URI) and were not dispensed an antibiotic prescription.

» Appropriate Testing for Children With Pharyngitis (CWP): The percentage of children 3–18 years of age who were diagnosed with pharyngitis, dispensed an antibiotic and received a group A streptococcus (strep) test for the episode. A higher rate represents better performance (i.e., appropriate testing).

» Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis (AAB): The percentage of adults 18–64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription.

» Antibiotic Utilization (ABX) Antibiotic utilization: This measure summarizes data on outpatient utilization of drug prescriptions, stratified by age, and evaluates many factors, including total number of antibiotic prescriptions, average number of prescriptions per year, and use of antibiotics of concern.

» Antibiotic resistance is one of the world’s major public health challenges, according to the Centers for Disease Control and Prevention (CDC). It is time for everyone to preserve the power of antibiotics by understanding when they work and when they do not. Physicians Health Plan is here to assist you with patient education for the reduction of overuse of antibiotics.

» PHP is offering free posters for your office. Available sizes are 8x10 or 16x20. See samples on the next page. If you are interested in a poster, contact your Provider Relations Team at [email protected] with the quantity and size (8x10 or 16x20).

HEDIS Corner

Provider Connection 3

Sample 2Sample 1

The annual Get Smart about Antibiotics Week is Nov. 14-20, 2016.

PHP awarded a 2016 MAHP Pinnacle AwardEleven Michigan Health plans from across the state submitted 31 groundbreaking programs to the Michigan Association of Health Plans Annual Pinnacle Awards on Tuesday, Sept. 13, showing entrepreneurial spirt as they increased efficiency and improved Patient healthcare to lower costs and increase services to Michigan citizens.

This year the Commercial Clinical Service Improvement Award was given to Physicians Health Plan (PHP) for “Closing Gaps in Care and Promoting Member Safety.” To combat adverse drug interactions, PHP contracted with Express Scripts for an evidence-based safety program that uses medical, pharmacy, and lab test data to prevent adverse drug events and find gaps in care. The extensive algorithm detects potential safety and health risks, and generates alerts for Pharmacists and Physicians. In two years, the program has generated more than 10,000 alerts.

MAHP is an industry voice for 14 healthcare plans, covering over 2.5 million Michigan residents, and 50 businesses affiliated with the healthcare industry. MAHP facilitates communication among members, government, and the industry regarding healthcare issues of common concern. The mission of the MAHP is to provide leadership for the promotion and advocacy of high quality, affordable, accessible healthcare for the citizens of Michigan.

Treat colds and flu with care. Talk to your healthcare provider.As a parent, you want to help your child feel better. But antibiotics

aren’t always the answer. They don’t fight the viruses that cause

colds and flu. What will? Fluids and plenty of rest are best. Talk to

your healthcare provider. Find out when antibiotics work—and

when they don’t. The best care is the right care.

For more information, please call 1-800-CDC-INFO

or visit www.cdc.gov/getsmart.CS121386























Electronic Funds Transfer!PHP has had Electronic Funds Transfers (EFT) available now for several months and our providers are very pleased with the results. Now that PHP is doing two check writes, Monday and Thursday nights, our providers are getting paid faster and more often. If you are interested in the new EFT process please see the requirements below to get started today!

Requirements for receiving your payments electronically include:

» Receive your ERA electronically via the 835 files

» Be a participating provider with PHP

» Obtain your unique ID number from PHP

» Register with PNC Bank: PNC Remittance Advantage website at rad.pnc.com

If your office is not yet receiving an ERA via the 835 file

» Contact your claims clearinghouse and explain that you would like to be set up on an 835 file with PHP. Your clearinghouse will need your National Provider ID (NPI), Tax ID (TIN) as well as a physical address (not a P.O. Box).

» The set-up time typically takes two to three weeks.

» First-time providers receiving 835 and EFT files will receive the paper EOP for 31 days following the initial registration. After the 31-day period, the paper EOP will be discontinued.

EOP information can be obtained using PHP’s Web Portal, HealthWeb®. If you require additional information or training with HealthWeb®, please email your Provider Relations Team at [email protected]

Receiving electronic payments is fast and easy. Contact your Provider Relations Team today to get started by calling 517.364.8323 or 517.364.8316.

Medication Fill History Report COMING SOON!The treatment of chronic illness commonly includes the long-term use of pharmacotherapy. Although medications are effective in combatting disease, the full benefit is often not realized. Approximately 50 percent of Patients do not take their medication as prescribed. Poor adherence to medication leads to increased morbidity and death and can incur costs estimated at approximately $100 billion per year. Factors contributing to poor medication adherence are numerous.

PHP has created a bi-annual Medication Fill History report identifying Patients with a specific chronic illness and filling a specific medication. The report will include the prescription fill history based on pharmacy claims data. The goal is to provide Physicians with information we have available regarding fill history patterns. The Medication

Fill History report is informational only and provided as an option for Physicians to initiate conversations with Patients on the importance of taking their medications as prescribed and the complications that could arise from not taking them according to doctor’s orders. (If a Patient fills their prescription at a pharmacy that has a free medication program or has dual pharmacy insurance coverage, the medication fill information may not be available.)

PHPs first Medication Fill History Report will include Patients with the primary diagnosis of diabetes and high blood pressure who are filling an Ace inhibitor (ACE) and Angiotensin-receptor blocker (ARB) prescription. If you have Patients that meet these criteria, watch for a report to arrive soon. (Mayo Clinic Proceedings v.86(4):304-314)


Bexsero and Trumenba now covered by PHP without authorizationPHP Pharmacy Department, August 2016

» Meningitis is a bacterial or viral infection that affects the lining of the brain and spinal cord. One of the bacteria that can cause meningitis is Neisseria meningitidis, of which there are different strains, or serogroups, such as A, B, C, W, and Y.

» As part of the standard Advisory Committee on Immunization Practices (ACIP) recommended vaccination schedule, meningococcal vaccines cover serogroups A, C, Y, and W, under the brand names of Menactra®, Menomune®, and Menveo®. As of 2015, new add-on vaccines were introduced that also cover serogroup B.

» Current ACIP recommendations state that persons age 10–25 may receive the serogroup B vaccination in addition to the standard meningitis vaccine, although they are not part of the standard vaccination schedule. There are two meningococcal serogroup B vaccines available: Bexsero® and Trumenba®.

» As of Aug. 1, 2016, the agents Bexsero and Trumenba no longer require prior authorization.

Epinephrine Auto-injectors The dramatic increase in the price of EpiPens has been a recent focus in the media. EpiPen, a brand name product, is not the only epinephrine product available. Multiple companies manufacture epinephrine pens, most of which are more cost-effective than EpiPen.

How to get your Patients the medicine they need:

» Generic epinephrine auto injectors are Tier 1 for all PHP plans. EpiPens are a Tier 1 drug product for Patients with the PHP SPHN benefit plan and Tier 2 for all other PHP benefit plans.

» Prescribing a generic epinephrine auto injector will save the Patient money and will lower costs for the health plan - which could mean lower premiums for Patients.

» PHP covers three 2-packs (or six pens total) of epinephrine pen injectors per year. If your Patient requires more than six pens in a 365-day period, submit a Prior Authorization Request Form requesting additional pens indicating the location at which each pen will be stored (school, daycare, home, etc.).

It is extremely important to note that EpiPen (and all epinephrine auto injectors) are sensitive to light and must be stored in the carrier tube provided by the manufacturer. It is also important to remember extreme temperatures (below 59 degrees and above 86 degrees Fahrenheit) can compromise the medication’s potency and efficacy.


Flu ShotThe timing of influenza season is often unpredictable. Flu outbreaks can occur as early as October and continue until as late as May. A flu shot is the safest, most effective way to protect our region against the flu. Encourage your Patients to get vaccinated today.

PHP members with a Pharmacy benefit plan can go to any Network Pharmacy to have the Injectable Flu Vaccine, Pneumonia Vaccine or the Shingles Vaccine* administered at no charge. The Pharmacy must be able to administer the medication on-site. Pharmacies will be reimbursed for the vaccine and the administration fee.

*Shingles Vaccine is only covered for members that are 50 years of age and older

Provider Satisfaction Survey 2016PHP would like to thank the providers that have returned the annual Provider Satisfaction Survey. The feedback we receive is used to assist us in developing enhancements to existing programs and processes and to improve our services for you. Based on feedback and comments from previous surveys, we have been able to implement changes that have benefited both our members and our network. Your feedback will ensure that we continue to work as a collaborative partnership. PHP Network Services encourages you to take a few minutes to let us know how we are doing, if you received the survey and have not returned it, you still have time. Either enter your responses online or mail in your responses today. If you have an immediate concern or a question, please contact us directly at [email protected].


Pharmacy Department News and UpdatesAugust 2016PHP’s Prescription Drug List (PDL) is available online. Please visit PHPMichigan.com/providers and select “General Forms and Information” to find the current drug list.

Criteria for medications requiring prior authorization are also available online by selecting “Pharmacy Prior Authorization Criteria.” The Medication Prior Authorization Formcan be found here too under Prior Authorization Forms. Please use this when submitting a request for medications requiring prior authorization.

If you have any pharmacy questions, please call the Pharmacy Department at 517.364.8545 or email us at [email protected].

Below is a list of recent changes made to the PHP Prescription Drug List:

Changes to the PDL:

Drug Action Implementation Date

Jayln (Brand and Generic)

Removing PA 10/1/16

Orenitram ER Add to PDL with PA 9/1/16

Velphoro Add to PDL with PA 9/1/16

Pennsaid Adding PA 8/12/16

Alocortin A, MuGard, Gelclair

Excluding from PDL 9/1/16

Genova Removing PA 7/15/16

Arestin Add to PDL with PA 10/18/16

Dovonex Qty limit – 120gm/month 10/18/16

Taclonex

Delzicol Qty limit – 6 tabs/day 10/18/16

Denavir Adding PA 10/18/16

Edecrin Adding PA 10/18/16

Lidocaine OintmentQty limit – max 120gm/

month10/18/16

Metformin ER Osmotic (Fortamet)

Moving to Tier 3 10/18/16

Dyrenium Add to PDL with PA 10/18/16

SantylQty limit – max 90gm/

month10/18/16

Oseni Adding PA 10/18/16

Zyflo/Zyflo CR Adding PA 10/18/16

Viberzi Adding PA 10/18/16

Amrix Adding PA 11/1/16

Fetzima Adding PA 11/1/16

Gelnique Adding PA 11/1/16

Colcrys/ColchicineAdding quantity limit –

10 tabs/30 days11/1/16

Physicians Health Plan Supports Boys and Girls Club of LansingPHP Caregivers donate school supplies annually to Lansing-area groups. This year’s recipient was the Boys and Girls Club of Lansing. The Boys and Girls Club of Lansing has been serving the Lansing area since 1964, providing area youth with physical fitness, recreational, and educational activities. PHP Caregivers donated a total of $1,077.33 in school supplies and cash, along with an additional $400 in office supplies.



2016 TAIP Measure: Extended Office HoursPhysicians Health Plan (PHP) added a new measure in 2016 to our Triple Aim Incentive Program (TAIP) giving providers an opportunity to earn an incentive when expanding access to care for our members.

Ensuring that our members are able to access necessary and superior healthcare is a priority. This incentive is available to offices who provide hours outside of the normal 8 a.m. to 5 p.m. office schedule. If your office provides this service, it is very easy to receive the credit for the incentive. When you provide services for a member prior to 8 a.m. or after 5 p.m., make sure to apply the correct coding to the claim. Claims for services received during the extended office hours should contain either CPT code 99050 or 99051. Eligible TAIP Physicians will receive a $40 credit each visit per Patient for services provided during extended office hours. If you have any questions about this measure, or any of the measures listed in our TAIP, please contact your Provider Relations Coordinator.

Holiday HoursPhysicians Health Plan will be closed Nov. 24-25, 2016, Dec. 23 and Dec. 26, 2016 and Jan. 2, 2017 in observation of the upcoming holidays. If you have an issue that requires immediate assistance, our answering service will be available to assist you.

1400 E. Michigan Avenue P.O. Box 30377Lansing, MI 48909-7877

A health plan that works for you.

517.364.8484 PHPMichigan.com















provider - php · 2017-01-04 · 4 provider connection electronic funds transfer! php has had...

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