Transcription
Medicare and Medicaid Provider Newsletter December 2012In This IssueGeneral InfoNew Member ID CardsReferral RemindersAuthorization GridChangesIncompletePreauthorization andReferral ProcessPharmacy UpdatesPharmacy and ClaimsSubmission GuidesMedicare InfoAIM Specialty Health forMedicare Plans2013 PacificSourceMedicare Advantage PlanChangesMedicare Expansion inOregon and IdahoMedicare Provider ManualMedicaid InfoCoordinated CareOrganizations (CCOs) inCentral Oregon and theMid-Columbia GorgeIntroductionCommunityCare was developed to help furnish our providerswith faster and easier access to the information you need. Thisnewsletter highlights information specific to PacificSourceMedicare and PacificSource Community Solutions (Medicaid)lines of business. CommunityCare is separate from our ProviderBulletin, currently in production for our Commercial products.PacificSource Community Solutions is our Coordinated CareOrganization (CCO) plan serving the Central Oregon and MidColumbia Gorge Oregon Medicaid population. PacificSourceMedicare is our Medicare Advantage plan serving counties inOregon and Idaho. Issues of this newsletter will be available onour website under the Partners/For Providers section atwww.Medicare.PacificSource.com andwww.CommunitySolutions.PacificSource.com.Your feedback is welcome and appreciated, please e-mail anycomments and suggestions about this publication toproviderservicerep@pacificsource.com.
Medicare and Medicaid Provider Newsletter December 2012Quick LinksMedicare InfoInTouch LoginMedicareProvider DirectoryFormularyNotices &Updates AuthorizationGridCoverage PolicyClaims BillingDocuments & FormsMedicaid InfoCIM LoginGeneral InformationNew Member ID CardsWe will mail new ID cards with 2013 planinformation to PacificSourceMedicare and PacificSource CommunitySolutions members the last two weeks inDecember. New cards are effective January 1,2013. Please see sample ID cards below.PacificSource Medicare ID Cards:On the front of the cardUnder the pharmacy section, changes include new Rx Bin, PCN,and Group numbers.On the back of the cardPlease note the new claims mailing address city and zip codechanges - from Eugene 97401 to Springfield 97475.Provider DirectoryFormularyNotices & UpdatesPreapproval GridCoverage PolicyClaims BillingDocuments & FormsContact UsE-mail2
Medicare and Medicaid Provider Newsletter December 2012PacificSource Community Solutions ID Card:On the front of the cardUnder the pharmacy section, changes include new Rx Bin, PCN,and Group numbers.Referral Reminders for Medicare and MedicaidPlansPrimary care provider (PCP) referrals arerequired for all PacificSource CommunitySolutions (Medicaid) members in Oregon exceptfor Exceptional Needs Care Coordination (ENCC)members. Referrals are also required forPacificSource Medicare Essentials HMO membersin Idaho and in Lane, Coos, and Curry counties inOregon.For your convenience, you may submit referrals for Medicaremembers online through InTouch and for Medicaid membersonline using CIM. If you have questions, please contact yourPacificSource Provider Service Representative.3
Medicare and Medicaid Provider Newsletter December 2012Medicare and Medicaid AuthorizationGrid ChangesNotifications of changes to PacificSourceMedicare and PacificSource Community Solutionsauthorization grids for 2013 were mailedNovember 30. You can view the 2013Authorization Grid online atwww.Medicare.PacificSource.com andwww.CommunitySolutions.PacificSource.com.Did you know you can submit preauthorization requests online?Online submission can reduce processing time. You can submitrequests online via InTouch for PacificSource Medicare membersand through CIM for PacificSource Community Solutionsmembers. If you need assistance with InTouch or CIM, pleasecontact your PacificSource Provider Service Representative.Incomplete Preauthorization and ReferralProcessWe will change our process for incompletepreauthorization and referrals in 2013 forPacificSource Medicare and PacificSourceCommunity Solutions (Medicaid) plans. Thecurrent process for incomplete requests requirespending the request while obtaining missinginformation. This causes delays to coveragedeterminations and increases turnaround time.Beginning January 1, 2013, we will deny incompletepreauthorization and referral requests for Medicare and Medicaidplans. An incomplete request may be missing information suchas supporting documentation, member information, CPT/HCPC ordiagnosis codes, provider specialty, or facility name.Please note: There is no change to the submissionprocess.You will find preauthorization requirements and forms on ourwebsites at www.Medicare.PacificSource.com (Medicare) id). If you have questions, please contact yourPacificSource Provider Service Representative at (800) 624-6052ext. 2580 or by email at providerservicerep@pacificsource.com.4
Medicare and Medicaid Provider Newsletter December 2012PacificSource Medicare and PacificSourceCommunity Solutions Pharmacy UpdatesNew Pharmacy Benefit Manager (PBM) EffectiveJanuary 1, 2013:January 1, 2013, the PacificSource Medicare andPacificSource Community Solutions pharmacybenefit manager (PBM) will transition fromExpress Scripts (ESI) to CVS Caremark. CVSCaremark is the current PBM for our commercialline of business. This transition will help lowertotal drug costs for our members. CVS Caremarkhas 63,000 network pharmacies nationwide andincludes most local pharmacies and major chains, includingWalgreens.Our specialty pharmacy vendor will also be changing fromCurascript to CVS Caremark Specialty Pharmacy. Memberscurrently obtaining prescriptions from Curascript must obtain anew script for refills on or after January 1, 2013. Newprescriptions should be sent to CVS Caremark SpecialtyPharmacy by calling (800) 237-2767.Members currently receiving prescriptions from Express Scriptsmail order must obtain a new script for refills they may need onor after January 1, 2013. Members may use Wellpartner orCaremark Prescription Services for mail order services.2013 Medicare Formulary changes:Effective January 1, 2013, some medications will move to adifferent tier (i.e. Crestor and Symbicort will be nonpreferred brands). In addition, we will be removing somemedications from our formulary because of safety concerns forcertain populations (i.e. certain muscle relaxants).These changes will impact approximately 4,500 PacificSourceMedicare members and 600 prescribers. We mailed notificationletters to prescribing providers at the end of October and tomembers in early November. Provider notifications included a listof their affected members and suggested formulary alternatives.Members are allowed a one-time transition fill for coverage ofPart D drugs not included on the 2013 Formulary. The transitionfill provides a 30-day supply of a non-formulary, Part D covereddrug. A member, member representative, or provider mayrequest to have a non-formulary, Part D drug covered.If you have questions or would like more information regardingour pharmacy benefit manager or formulary changes, you cancontact our Pharmacy Services Department directly at5
Medicare and Medicaid Provider Newsletter December 2012(541) 330-4999 or toll-free at (888) 437-7728. Our hours are7:00 a.m. to 6:00 p.m. PST, Monday through Friday. Or, youcan call Customer Service toll-free at (888) 863-3637. Chartnotes for formulary exceptions may be faxed to the pharmacyservices department at (866) 805-5750.Pharmacy and Claims Submission GuidesPacificSource is committed to excellent service.As you know, PacificSource has grown. We nowserve members through PacificSource HealthPlans, PacificSource Community Health Plans(marketed as PacificSource Medicare), andPacificSource Community Solutions. While theselines of business have PacificSource in common,they offer different plans, and have differentclaims, authorization, and service numbers.To assist you, we have direct pharmacy service and customerservice numbers for each line of business. To ensure the fastestservice for you and your patients, it is important to use thecorrect contact information for each line of business. To help, wehave put together a Pharmacy Provider Guide and a CustomerService/Claims Submission Guide for your office to use as ahandy reference. You can find these guides under Resources inthe Provider section our websites atwww.Medicare.PacificSource.com re SpecificAIM Specialty Health for Medicare PlansPacificSource will begin utilizing AIM SpecialtyHealth for Medicare Advantage plans effectiveJanuary 1, 2013. Our commercial plans currentlyuse AIM for preauthorization of nonemergencyadvanced diagnostic imaging services performedin an outpatient setting. Implementation of AIMfor Medicare plans will allow consistency acrossour commercial and Medicare lines of business.For procedures scheduled on or after January 1, 2013, youmust submit to AIM for preauthorization. BeginningDecember 17, 2012, AIM will accept requests for PacificSourceMedicare members.6
Medicare and Medicaid Provider Newsletter December 2012To submit a preauthorization request, go to the AIM portal atwww.AmericanImaging.net. If you are not currently enrolledwith AIM, you can sign up at www.AmericanImaging.net/goweb.Access is available 24 to 48 hours after completing yourregistration. If you have questions, you can reach them byphone at (877) 291-0510.Modalities and locations covered under this program include: Imaging Serviceso Computer Tomography Scans (CT/CTA)o Magnetic Resonance Imaging(MRI/MRA/MRS/MRM/fMRI)o Nuclear Cardiologyo Positron Emission TomographyLocationso Freestanding Imaging Centerso Outpatient Hospitalo In-office use of physician-owned equipmentImaging services performed in the locations listed below do notrequire preauthorization: Exclusionso Emergency room serviceso Inpatient hospitalizationo Outpatient surgery (Hospitals and free standingsurgery centers)o Hospital observationOutpatient studies performed for urgent or emergent conditionswill be subject to a retrospective clinical claims review byPacificSource.A complete list of services that require preauthorization isavailable on our website at www.Medicare.PacificSource.com.Services requiring AIM authorization are identified on the grid inthe description field.2013 PacificSource Medicare Advantage PlanChangesChanges to PacificSource Medicare plans will beeffective January 1, 2013. We notified membersof their plan changes in their Annual Notificationof Change (ANOCs) letter at the end ofSeptember. Generally, members have anopportunity to change plans each year during theMedicare Annual Enrollment Period from October15 through December 7.7
Medicare and Medicaid Provider Newsletter December 2012For 2013, our product development goals were to keep choicessimple by simplifying our plan options, service area, andprovider network. In Central Oregon we simplified our planoptions by eliminating the Premier HMO-POS plans, reducing thenumber of plans in Central Oregon from six to four. Unlessmembers in these HMO-POS plans elected to change plans, theywill automatically be moved to the following plans: Premier Rx 7 plan members will automatically move intothe Essentials Rx 6 HMO plan. Premier 1 plan members will automatically move into theEssentials 2 HMO plan.Our plan options in both Lane county and Idaho did not changefor 2013, however the plans did have benefit changes.You can view a complete list of benefit changes by plan. To dothis, please refer to the ANOC available by plan name on ourwebsite at www.Medicare.PacificSource.com. If you have anyquestions, please contact your Provider Service Representativeat (800) 624-6052 ext. 2580 or by email atproviderservicerep@pacificsource.com.Medicare Expansion in Oregon and IdahoIn 2013, our PacificSource Medicare plans are expanding inOregon and Idaho. We believe we will retain and grow ourmembership with competitive plans in both our current and newservice areas. Throughout all our service areas, we offer twotypes of plans with and without prescription drug coverage. Essentials is our HMO plan.Explorer is our PPO plan.OREGON: Our Medicare Advantage plans will be available in Coosand Curry counties.We have expanded our Explorer PPO plans in CentralOregon and the Mid-Columbia Gorge.PERS plan is now available in Coos, Crook, Curry, andLane counties.In 2013, we will serve the following counties in Oregon: Central, Eastern, and Mid-Columbia Gorge: Crook,Deschutes, Grant, Hood River, Jefferson, Sherman,Wasco, Wheeler, and northern parts of Klamath and LakecountiesLane countyCoos and Curry counties8
Medicare and Medicaid Provider Newsletter December 2012IDAHO:We added plans in 14 new counties in northern, southeastern,and southwestern Idaho.In 2013, we will serve the following counties in Idaho: Southwest: Ada, Blaine, Boise, Camas, Canyon, Cassia,Elmore, Gem, Gooding, Jerome, Lincoln, Minidoka,Owyhee, Payette, Twin Falls, Valley, and WashingtoncountiesNorthern: Bonner, Boundary, and Kootenai countiesEastern: Bannock, Bingham, Bonneville, Jefferson, andMadison countiesMedicare Provider ManualA lot of work has gone into updating the MedicareProvider Manual. The Medicare Provider Manualoutlines requirements for becoming a provider,rules, and guidelines for completing claims,appeals, referrals, authorization, and a wealth ofother information, including tips and tools. Wehope you will find useful. You will find it atwww.Medicare.PacificSource.com under the"Partners/For Providers" section of our Medicarewebsite in January 2013. The link to open the Provider Manualwill be in the Documents and Forms section on the left side ofthe page. If you have questions or suggestion about thismanual, please contact your Provider Service Representative at(800) 624-6052 ext. 2580 or emailproviderservicerep@pacificsource.com.Medicaid SpecificMedicaid Coordinated Care Organizations(CCOs) in Central Oregon and the Mid-ColumbiaGorgePacificSource Community Solutions is proud to bethe Coordinated Care Organization (CCO) planserving Central Oregon and the Mid-ColumbiaGorge Medicaid population. CCOs are designed towork with the Oregon Health Authority to helpimprove and better manage the health care of9
Medicare and Medicaid Provider Newsletter December 2012our Medicaid population and to reduce current health care costsand administrative expenses.What is a Coordinated Care Organization (CCO)?The Oregon Health Authority (OHA) contracts with CoordinatedCare Organizations (CCOs), like PacificSource CommunitySolutions, to provide health care to people covered bythe Oregon Health Plan (OHP). These CCOs will coordinate all ofthe member's health care needs, including medical, dental,mental health care, and drug and alcohol abuse treatment.CCOs have a centralized governance comprised of providers,community members, and stakeholders who are accountable forthe health outcomes of the population they serve. The CCOincludes representation from the Consumer Advisory Councilwhich includes health care consumer representatives from eachcounty in the service area. The advisory council is responsiblefor ensuring the CCO work plan addresses health disparitiesidentified in the Community Health Assessment.CCOs have the flexibility to support new patient-centered andteam-focused models of care to help reduce health disparitiesand gaps in health care. CCOs are able to better coordinateservices and focus on prevention, chronic illness management,and person-centered care. Our objective is to meet the TripleAim goals of better health, better care, and lower costs.Members Transitioning to CCOsPacificSource Community Solutions CCO is available in thefollowing counties in Oregon: Central Oregon (Crook, Deschutes, Jefferson, andnorthern Klamath counties)Mid-Columbia Gorge (Wasco and Hood River counties)All PacificSource Community Solutions managed care membersand fee-for-service or "open card" Medicaid members residing inthe above counties have transitioned into our CCO. Membersoutside our CCO service areas have transitioned to another CCOin their community or remained with their current managed careorganization.As of November 1, 2012, all new OHP members will beautomatically enrolled into a CCO if available in their community.If no CCO is available, members may select an existing managedcare organization (MCO).10
Medicare and Medicaid Provider Newsletter December 2012You will find more information about our CCO and partnersonline at: www.CommunitySolutions.PacificSource.com (CentralOregon and Mid-Columbia Gorge CCO information)www.Health.Oregon.gov (we have a contract with theOregon Health Authoritywww.COHealthCouncil.org (Central Oregon HealthCouncil).www.ColumbiaGorgeCCO.com (Columbia Gorge HealthCouncil)Contact UsProvider NetworkPlease feel free to contact a Provider Service Representative at(800) 385-53624-6052 ext. 2580 he Provider Network DepartmentPacificSource Community Health Plans, Inc.PacificSource Community Solutions, Inc.PacificSource Community Health Plans, Inc. is a health plan witha Medicare Contract.Y0021 MISC1760 Plan Approved 1214201211
Coordinated Care Organizations (CCOs) in Central Oregon and the Mid-Columbia Gorge Introduction CommunityCare was developed to help furnish our providers with faster and easier access to the information you need. This newsletter highlights information specific to PacificSource Medicare and PacificSource Community Solutions (Medicaid) lines of business. CommunityCare is separate from our .
