the point for martin’s point health care network providers/media/files/mpdotorg... · for...

The

Po

int

New

slet

ter f

or

Mar

tin

’s P

oin

t H

ealt

h C

are

Net

wo

rk P

rovi

der

s

S U M M E R 2 0 1 4

Inside: • Provider Profile: Douglas Couper, MD, FACP

• Electronic Claim Adjustment Requests

• ICD-10 Update

• Medication Pre-Authorization

• Electronic Prescriptions

•Telehealth

Strong mentorship seems critical to remaining competitive in health care. How do you find time to share knowledge and skills with other clinicians?

Making time to give and receive mentorship is challenging for practicing physicians because we are so busy, but it is also key to the evolution of medical practice. It’s important to keep up with medical research

and literature, but interpersonal guidance, discussion and shared experiences are crucial.

We spend most of our time in exam rooms with patients and it’s easy to become isolated. So, I appreciate organizations like the ACP that connect me with other internists and medical groups within my state and across the nation. For example, I might strike up a conversation with an internist from the Mid-west at an ACP

Provider Profile

Name: Douglas Couper, MD, FACP

Specialty: Internal Medicine

Practicing Since: 1987

Qualifications: • MD, Boston University School of

Medicine; Internal Medicine Residency and Internship, Baystate Medical Center, Springfield, Massachusetts

Professional Organizations: • Board Certified by the American

Board of Internal Medicine; Fellow, American College of Physicians

The American College of Physicians (ACP) recently honored internal medicine specialist Dr. Douglas Couper with advancement to Mastership at their annual convocation ceremony in Florida. Election to Mastership recognizes outstanding career accomplishments and notable contributions to medicine such as teaching, work in clinical medicine (research or practice), preventive medicine, improvements in the delivery of health care, and/or contributions to medical literature.

In her commencement speech, ACP President Dr. Molly Cooke said, “Mastership is conferred only on a select number of worthy candidates who are deemed distinguished through the practice of our specialty of internal medicine.

The Awards Committee considered our ideal candidate and found that the qualities of such an individual include strength of character, integrity, bravery, perseverance, compassion, devotion, and steadiness, as well as clinical competence. Emphasis was placed on service as a mentor, advocacy for quality in internal medicine, a commitment to social justice, deep interest in people, and the creation of communities of medicine. Ideal candidates are ‘citizen physicians,’ educational innovators, humanists, and learner-teachers who inspire others to seek high standards and excellence in our cherished specialty of internal medicine.” In light of this recent award, we asked Dr. Couper to share his thoughts on mentorship in the practice.

PROVIDER NEWSLETTER SUMMER 2014 PROVIDER NEWSLETTER SUMMER 2014

meeting in Florida and gain new insights into my profession from him or her. Those opportunities are so important.

How do you coach and mentor newer physicians to higher performance?

I do a lot of mentoring of younger physicians through the ACP. It’s more than just, “This is how you handle condition X, Y, and Z.” It’s explaining how to find answers on your own, or discussing how to balance work and family life. I participate in breakfast and dinner meetings with residents and with medical students where we meet, talk, and address whatever aspect of the profession they may have questions about. This type of interaction can be invaluable for a mentee. And it also prompts me, as a mentor, to look at my knowledge base, to think about the way I function and maintain balance. Each question affords me the opportunity to really consider how I do things. So, it’s a good platform for self-reflection.

Did you have a mentor who inspired, steered or challenged you?

I’ve had several mentors over the years. One was the clinic director during my residency. He was so passionate about his profession, and always available to talk. We had many meetings and discussions, both formal and informal. I

still remember many of the quotes and quips he used to say, such as, “When you have a hammer, everything looks like a nail.” This was in the context of patient referrals. For example, if you are thinking about referring a patient to a cardiologist, remember that you may be setting up your patient for a cardiac catheterization. The lesson was to think carefully about the specialists to whom you refer patients, because they have a predilection to use the tools they

have at hand, as do we all. Another provider who I met through the ACP was a strong influence and taught me a lot about mentorship in and of itself. He really set a good example for being a good example. I deeply appreciate the confidence that he instilled in me.

What advice would you give to physicians who

want to offer constructive feedback to their colleagues? It seems like this could be tricky.

I think the key is to maintain ongoing dialogues and positive working relationships that build a reservoir of goodwill. That way, when a difficult conversation needs to happen, it’s easier because it’s in the context of established trust and open lines of communication.

Often, mentorship and constructive feedback are given by a senior practitioner to a junior practitioner. But peer-to-peer discussion and co-evolution are also an important form of mentorship. In my practice, colleagues often run cases by me and I do the same. We all have different areas of expertise. We read each other’s notes, confer, learn from each other, and grow together. It’s truly inspiring to have the opportunity to collaborate with my talented peers and work together to continually raise the bar in our practice.

“ Making time to give and receive mentorship is challenging for practicing physicians because we are so busy, but it is key to the evolution of medical practice.”


ClaimsAttention Billing Staff! Effective July 1, 2014, Martin’s Point US Family Health Plan and Generations Advantage claim adjustment requests can be submitted electronically.

Electronic Submission Requirements for Adjusted and Void Claims:

EDI/837 - CMS/HCFA-1500 or UB-04 Claim Loop 2300

CLM05-1: Patient Control Number

• Must contain the patient control number from the original claim. Example: CLM*A37YH566*500***11::7*Y*A*Y*Y*C~

CLM05-3: Claim Frequency Code

• Must include the number ‘7’ if you want to adjust the original claim. Example: CLM*A37YH566*500***11::7*Y*A*Y*Y*C~

• Must include the number ‘8’ if you want to void the original claim. Example: CLM*A37YH566*500***11::8*Y*A*Y*Y*C~

A new REF segment which contains a REF01 must contain the value ‘F8’ and REF02

• Must contain the Martin’s Point claim number from the original claim. Example: REF*F8*12345E06789~

REF Payer Claim Control Number 1 S 2300

REF01 Reference Identification Qualifier ID 2-3 R F8

REF02 Claim Original Reference Number AN 1-50 R

To adjust a claim, add a new segment: NTE*ADD*Adjusted Claim—Reason for Claim Adjustment. Examples:

1. NTE*ADD*Adjusted Claim—CPT Code change from 93010 to 99284~

2. NTE*ADD*Adjusted Claim—Added 3 new Service Lines and Charges~

3. NTE*ADD*Adjusted Claim—Removed service line~

4. NTE*ADD*Adjusted Claim—Modifier GF added to CPT Code 99284~

To void a claim, add a new segment: NTE*ADD*VOIDED CLAIM.


Paper Submission Requirements for Adjusted and Void Claims:

CMS/HCFA-1500 Claims UB-04 Claims

Box 22: RESUBMISSION CODE (Claim Frequency Code) • Enter ‘7’ if you want to adjust

the original claim • Enter ‘8’ if you want to void

the original claim

Box 22: ORIGINAL REF. NO. (Original Reference Number)• Must contain the Martin’s Point claim

number from the original claim.

Box 26: PATIENT’S ACCOUNT NO. (Patient Account Number)• Must contain the patient account


Box 3a: PAT CNTL # (Patient Control Number)• Must contain the patient control


Box 4: TYPE OF BILL • Last digit must be ‘7’ to adjust

the original claim • Last digit must be ‘8’ to void

the original claim

Box 64—DOCUMENT CONTROL NUMBER • Must contain the Martin’s Point claim


Please Note!

• Requests for claim adjustment may be filed as long as the original claim has been finalized (paid or denied). Electronic submission is preferred.

• Exception! To process claim adjustments pertaining to COB, EOB, timely filing and medical documentation, we must have both a completed Claim Adjustment Form (online at https://martinspoint.org/for-providers/claims) showing the original claim number and a paper copy of your adjusted claim with the corrected and/or additional information.

• When submitting a request for claim adjustment, be sure to include all lines from the original claim that are still correct, not just the new or corrected lines. Please keep in mind that the adjusted claim will replace the original claim in its entirety. All payments on the original claim will be reversed and only those lines included on the adjusted claim will be reviewed for payment.

• Returned claims that do not include a Martin’s Point claim identification number cannot be adjudicated and therefore, are not entered into our claim system. If you

wish to resubmit a returned claim, do not submit a request for claim adjustment. Please submit an entirely new claim and do not use the words “Corrected,” “Replacement” or “Adjusted” anywhere on the claim.

• Timely Filing: Both participating and non-participating providers must file requests for claim adjustment within 120 days from the remittance date.

• Electronic claim submission allows for quicker processing and payments. We offer three Electronic Data Interchange (EDI) options.

• Emdeon Business Services: Call 1-800-845-6592 to enroll. Martin’s Point Payor ID: 53275

• Office Ally: Call 1-866-575-4120 and select option 3 to enroll. Martin’s Point Payor ID: MPHC1

• Relay Health: New users should call 1-866-735-2963 to enroll. Current users should call 1-800-527-8133. Martin’s Point Payor ID: MPHC2

Questions? Please visit www.MartinsPoint.org/for-providers/claims or call 1-888-732-7364.


ICD-10 UpdateOn April 1, 2014, the Protecting Access to Medicare Act (PAMA) was signed into law. This legislation requires the federal government to delay adoption of ICD-10 codes until at least October 1, 2015, one year later than the previous ICD-10 implementation date.

On May 1, 2014, the Centers for Medicare and Medicare Services (CMS) released a statement that sets the deadline for ICD-10 implementation at October 1, 2015—the

earliest possible date set by the Protecting Access to Medicare Act of 2014.

Based on these recent developments, Martin’s Point has decided to align our transition plan with the October 1, 2015 implementation date. We have revised our timeline, but will continue to prioritize ICD-10 remediation efforts and encourage providers to do the same.


ICD-10 Protocol ReminderSITUATION ICD-9 OR ICD-10?

Pre-authorization requests for services/discharges expected to occur prior to October 1, 2015

ICD-9

Retrospective authorization requests for services/discharges that occurred prior to October 1, 2015

ICD-9

Pre-authorization requests submitted on or after September 1, 2015, for services/discharges that are expected to occur on or after October 1, 2015

ICD-10

Pre-authorization requests submitted prior to September 1, 2015, for services/discharges that are expected to occur on or after October 1, 2015

Not allowed

Pre-authorization requests that cover multiple visits expected to occur both prior to October 1, 2015, and on or after October 1, 2015

Both ICD-9 and ICD-10 codes will need to be submitted: one for ICD-9 coding, and one for ICD-10 coding.

Authorization extensions for services/discharges that were expected to occur prior to, but actually occurred on or after October 1, 2015

Provider should resubmit the authorization request using ICD-10 codes.

We will continue to update you on our ICD-10 progress throughout 2014 and 2015. If you have any questions, please call our Provider Inquiry team at 1-888-732-7364, send an e-mail to [email protected] or visit http://cms.gov/Medicare/Coding/ICD10.


Medication Pre-Authorization Our health plan formularies are frequently updated to keep pace with new clinical data and evolving drug classes. Our goal is to maintain clinically sound, broad formularies that help drive generic utilization that lowers pharmacy costs for your patients.

As with most health plans, certain drugs require formal pre-authorization of medical necessity before the prescription is filled to guarantee coverage. Step therapy is also used in drug categories that have multiple agents with comparable therapeutic efficacy. This means that these medications are only covered if the member has already tried certain therapeutically-equivalent medications that did not work.

For certain drugs, we may also limit the amount of the drug that we will cover. These limits do not prevent you from prescribing larger quantities, but we will require pre-authorization before covering quantities that exceed the established limit. Following is an overview of our drug pre-authorization process and online tools:

1. Before writing a prescription for one of our US Family Health Plan or Generations Advantage members, please visit https://martinspoint.org/for-providers/pharmacy to review:

• Our latest drug pre-authorization requirements

• Links to the complete formulary for each plan

• Important pre-authorization forms and instructions

These formularies are revised periodically to accommodate new brand-name drugs and generic alternatives. For this reason, it is important to re-visit this page often.

2. PLEASE NOTE! Be sure to include complete medical documentation with your drug pre-authorization request. We cannot process your request without this required information. Missing information may delay delivery of important care to your patient. Please help us avoid these unnecessary delays by providing the information we need to process your request, up front, every time.


3. For US Family Health Plan members, we have specific drug pre-authorization forms and step-therapy questionnaires posted online at https://martinspoint.org/for-providers/pharmacy. The forms are listed alphabetically by drug name and category. You may also request drug pre-authorizations by calling our Provider Inquiry team at 1-888-732-7364.

4. For Generations Advantage members, there are several ways to request a drug coverage determination or exception:

• You or your patient may call 1-888-296-6961.

• You or your patient may fax a written request to our secure fax line at 1-855-633-7673.

• You or your patient may send a written request via U.S. Mail to: Caremark, LLC Clinical Prior Authorization Department 1300 E. Campbell Rd. Richardson, TX 75081

• You or your patient may request a coverage determination, exception, or appeal via our website:

• Generations Advantage members may request prescription pre-authorizations at https://medicare.MartinsPoint.org/secure-requests

• Generations Advantage members and providers may initiate coverage determination requests here: https://cdrd.cvscaremarkmyd.com/CoverageDetermination.aspx?ClientID=9

• Providers may send an email to: [email protected] to request drug pre-authorization forms. PLEASE NOTE: Your request should include the prescribing provider name, email address, phone number, and office contact name. This is not a secure email box so please do not include any patient information. We will respond securely via email or phone. Thank you!

Updated Clinical Guidelines At Martin’s Point, we believe that great medical care is based on scientific evidence published in peer-reviewed medical literature that is generally recognized by the medical community. This ensures that our members receive consistent, high quality care, while avoiding inappropriate or unnecessary procedures, services, and expense. For the latest list of medical guidelines that Martin’s Point has adopted, please visit https://MartinsPoint.org/for-providers/health-management.


US Family Health Plan Formulary UpdatesDRUG NAME FORMULARY STATUS COVERED ALTERNATIVE

Symbicort® Requires pre-authorization and tier 3 copay effective July 9, 2014

Advair HFA®

Breo Ellipta® Requires pre-authorization and tier 3 copay effective July 9, 2014

Advair HFA®

Dulera® Requires pre-authorization and tier 3 copay effective July 9, 2014

Advair HFA®

Mybetriq® Requires pre-authorization effective July 9, 2014

Detrol LA®, oxybutinin, trospium IR

Pentasa® Tier 3 copay effective August 6, 2014 sulfasalazine, mesalamine, balsalazide

Asacol HD® Tier 3 copay effective August 6, 2014 sulfasalazine, mesalamine, balsalazide

Khedezla Requires pre-authorization and tier 3 copay effective August 6, 2014

venlafaxine IR or ER

Electronic PrescriptionsMartin’s Point pharmacies now accept electronic prescriptions! Search for us under the following names from within your Electronic Medical Records (EMR) system:

• “Martins Pt. Mail Order Pharmacy Maine” (for US Family Healthy Plan members ONLY)

• “Martins Pt. Portland Clinic Maine Pharmacy”

• “Martins Pt. Portsmouth Clinic New Hampshire Pharmacy”

If you are unable to find the Martin’s Point pharmacy names as listed above, please contact your EMR system administrator and request a download of the latest list of e-prescribing pharmacies from Surescripts.® Effective December 11, 2013, the State of Maine

allows electronic prescriptions for controlled substances. EMR software companies must take additional security and technology steps

to comply with the Drug Enforcement Administration’s Interim Final Rule.

Please confirm with your software vendor that they are certified by the DEA before transmitting prescriptions for controlled substances.

New York state providers, please be sure to select “Martins Pt. Mail

Order Pharmacy Maine” within your EMR system rather than our Portland, ME or Portsmouth, NH clinic pharmacies when sending prescriptions for US Family Health plan members. This will prevent delays in the delivery of their medication. Thank you!


Generations Advantage Formulary Updates DRUG NAME FORMULARY STATUS

(All effective July 1, 2014)COVERED ALTERNATIVE

eszopiclone Added to formulary: tier 2 copay, quantity limit: 30 tablets /30 days

Pilopine HS® 4% gel Removed from the formulary Azopt®, Travatan Z®, Combigan®

Invokana® 100 mg Added to formulary: tier 3 copay, quantity limit: 90 tablets /30 days

Invokana® 30 mg Added to formulary: tier 3 copay, quantity limit: 30 tablets /30 days

omega-3 capsules Added to formulary: tier 2 copay

PegIntron® kit 80 mg Added to formulary: tier 5 copay



Pertussis, Tdap and Shingles Vaccine Claims for Generations Advantage Members

As you may already know, certain prescription drugs and vaccines covered under the Medicare Part D benefit cannot be paid under the medical (Part B) portion of a Medicare Advantage health plan benefit. For example, the Pertussis, Tdap and shingles vaccines are not covered by Medicare Part B, so claims for these services should not be sent to Martin’s Point. Vaccine service fees and/or associated administration costs for any Part D vaccine administered to Generations Advantage members should be billed on a HCFA 1500 claim form and sent to the following address:

CVS/Caremark Medicare Vaccine Processing Dept PO Box 52136 Phoenix, AZ 85072-2136

Providers will be paid for these claims by CVS/Caremark on an out-of-network basis, with the exception of participating CVS/Caremark pharmacies. Patient balance billing is allowed in this situation. This means that Generations Advantage members will have a lower cost-share if they receive these services at an in-network pharmacy.

If you have any questions about Part D claims for services rendered to a Martin’s Point Generations Advantage member, please call CVS/Caremark at: 1-888-296-6992.


NONPROFIT ORGUS POSTAGE

PAIDPERMIT #186PORTLAND, ME

PO Box 9746Portland, Maine 04104–5040www.MartinsPoint.org

TelehealthMartin’s Point is partnering with Cardiocom, a remote telehealth vendor, to provide home tele-monitoring services to high-risk heart failure patients. This portion of our Living Healthy program utilizes an in-home device that allows registered nurses to remotely monitor patient symptoms and biometric data. This proactive daily management may improve your patient’s quality of life, slow disease progression, and prevent hospitalizations.

Patients use the home monitoring device daily to answer a series of questions about their current symptoms and to measure their biometric data. The device is easy to use, even by patients with limited mobility and technical skills.

Patient health data will be automatically transmitted to, and reviewed by, registered nurses. If there are any biometric measurements

outside the patient’s predetermined parameters or any symptom scores above a set threshold, the nurse will contact the patient to verify the data and fax a detailed exception report to your office. At that point, you determine the best course of treatment and contact the patient directly with any care instructions. Patients will also have the opportunity to work with a Cardiocom nurse on behavior change and self-management of their condition.

We look forward to working with you in the care of your patients through telehealth. If you have any questions, please call 1-855-335-8951, Monday through Friday between 9 am and 5:30 pm EST.

InsideProvider Profile: Douglas Couper, MD, FACP

Electronic Claim Adjustment Requests

ICD-10 Update

Medication Pre-Authorization

Electronic Prescriptions

Formulary Updates

Telehealth

Please visit https://MartinsPoint.org/for-providers for more information on the topics covered in this newsletter and to review the Martin’s Point provider manual. You may also call 1-888-732-7364 with any questions or to request paper copies of any of the information on our website.

the point for martin’s point health care network providers/media/files/mpdotorg... · for...

Documents