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January 2019Provider RelationsNewsletterINSIDE THIS ISSUE:1NEW Community Health Directwebsite1ePower1New Provider Credentialing1New Providers, effective1/1/20191Termed Providers2ProHealth name change3EncoreCombined - Tier 242019 Access90 Program4MDwise CHN terming5-7Payor Highlights8CHD 2019 PA Quick Ref Guide9CHD Peer to Peer Review10Provider Relations StaffDirectoryCommunity Health Direct has a NEW and improved website with valuable info for members & providers! Visit usat: ePower Provider Portal:Look up member claims, eligibility and more onCommunity Health Direct’s ePower (Provider Portal) ntialing of New Providers:*PLEASE NOTE* Credentialing through Community Health Direct forALL new providers can take anywhere from 90-120days from notification to completion. The Credentialing fee has increased to 200 for ALLnew providers wishing to join the Community/ProHealth network, effective 11/1/2016.Community Health DirectProvider Relations Manager:Jenny BouckJBouck@ecommunity.comPhone#: (317)621-7547Contracting and Credentialing Corner: NEW Providers Joining ProHealth - Click HERE TERMED ProHealth Providers - Click HERE1
New name. New look. Same great product.ProHealth, the network that administers health insurance to thousands ofCommunity Health Network employees and their families, is getting afacelift. Effective January 1, 2019, the product will be renamedCommunity Health Direct and will feature a new logo design along withtargeted marketing support and strategic consumer education. Theseenhancements reflect our efforts to improve support to our partners in anevolving healthcare environment.The reimagining of ProHealth will not impact the provider network for the Gold and Silverplans. Those providers will continue to participate as part of the Community Health Directbrand. However, all references to ProHealth will be replaced with Community Health Directon all print and digital communications. Likewise, Gold and Silver insurance cards issued for2019 will feature the new Community Health Direct logo.The emergence of direct-to-employer health insurance management arrangements haschanged the spirit of what it truly means to provide exceptional service to customers.Likewise, the ProHealth network of high quality, high demand products and services hasexpanded beyond Community Health Network into entities and organizations such as theCity of Fishers, Primaria and Encore. In 2019, continuing to offer our very best products,services and support to our partners is our top priority.What does this mean for you, your providers and staff? The rebranding of ProHealth will not impact the provider network for the Gold and Silverplans. Those providers will continue to participate as part of the Community Health Directbrand. The Epic payer/plan that you use for ProHealth will be updated, effective January 1, 2019. Community Gold and Silver PlansThere will be a new website in 2019 for Community Health Direct. It will be located atwww.ecommunity.com/community-health-direct2
Community Health DIrect Tier2 Changes for Community Gold & Silver Plans:Beginning 1/1/2019, Encore Combined will become the Tier 2 network for the Community Goldand Silver Plans (see chart below).3
Community Health Direct - Health Plan Pharmacy Benefit Update 2019Mandatory 90 supply fill for maintenance medications (Access90 Program)As of January 1, 2019 Community Health Network, in partnership with Walgreens pharmacies andExpress Scripts Home Delivery, is implementing the Access90 Maintenance Medication Program. Applies only to maintenance mediations— List will be available at: www.ecommunity.com/community-health-direct under MemberArea, Gold and Silver Plan, Pharmacy This is a mandatory program for both Community Gold and Silver members Members must fill a 90 day supply of their maintenance medications at Walgreens or ExpressScripts Home Delivery.— Members currently on a maintenance medications that are included in the Access90program: Members can get up to 2 courtesy fills of 30 day supplies at a 30 day copay ifneeded, then must fill a 90 day supply.— When a member is started on a new maintenance medication or new dosage and themedication is included in the Access90 program: The member should fill 1-2 (30day supply) fills to make sure they can tolerate thenew prescription and then fill a 90 day supply Members will only pay 2.5 times the copay instead of 3 copays for a 3 month supply Walgreens will still have the preferred copays for 90 day fillsIf you have any additional questions visit: www.ecommunity.com/community-health-direct underMember Area, Gold and Silver Plan, Pharmacy or call Community Health Direct at (317)621-7575option 2 then option 2.Changes to the MDWise Community Health Network Plans:MDwise Community Health Network HIP & HHW (Medicaid) plans will be terming, effective12/31/2018. MDwise is moving away from the delivery system model, and will be transitioningthese into the MDwise Excel and MDwise Excel HIP programs.If you have any questions regarding these changes, please feel free to reach out toGovernmental Program Manager Salena Woodson at SWoodson2@eCommunity.com or byphone at (317)621-7593.4
PAYOR HIGHLIGHTSEncore/Encircle Name Change:October 1, 2018 Encircle was rebranded to be calledEncoreCombined and has significant enhancementsto its provider participation and value for IndianaEmployers.Encore Health Network has been gradually expanding the provider participation of Encircle to includemost of Indiana. EncoreCombined will include 95% of the providers in the Encore Health Network servicearea.Hospitals participating in the EncoreCombined product agree to offer top tier pricing in an open accessproduct. Significant pricing upgrades have been made with many of the Hospitals in the EncoreCombinedproduct.United Healthcare Navigate plan: Navigate is a gated product and care is managed by the member selected PCP. The UnitedHealthcare logo, Navigate product name and PCP are listed on the front of the health care IDcard, bottom right hand corner. Plan benefits should be verified before provision of care to ensure the PCP and address match UHC records. Referrals are required for members to be seen by specialty physicians. All referrals must be generated via Link and referral submissions do not require submission of medicaldocumentation. Referrals are not necessary for other providers with the same TIN as the PCP. UHC’s authorization requirements are in addition to specialist referrals.General information: te/indiana-health-plans/in-commercial-plans.html, select UnitedHealthcare NavigateFAQ: Questions.pdfNavigate QRG: uide.pdfReferral submission QRG: orgue/referral/Referral-Guide.pdf5
PAYOR HIGHLIGHTS6
PAYOR HIGHLIGHTS7
Community Health DirectHRA Gold, HSA Silver Health Plans2019 Authorization Quick Reference GuideCommunity Health Direct supports the concept of the PCP as the “medical home” for its members.Services from Tier II and Tier III providers will only be considered for coverage at the Tier I level if those services are unavailablewith a Tier I provider.Please submit requests as soon as possible to allow time for review.Routine requests for authorizations are processed within 3 business days after receipt of all needed clinical information.Contact informationMedical Management: 317‐621‐7575Medical Management Fax: 317‐621‐7984Provider Relations: 317‐621‐7581Benefits/ Eligibility: 317‐621‐7565Authorizations RequiredNo Authorization RequiredStandard Authorization Requests Fax your request; include CPT and ICD‐10 codes and clinicaldocumentation with authorization request.Requests for Tier II and Tier III services at Tier I coverage:* Any requests for services not provided by the CommunityHealth Network or Tier I providers as listed in directoryDurable Medical EquipmentUrgent Care at Urgent Care Centers, such as Med Checkand Community Clinic at WalgreensLaboratory Genetic pre‐natal tests outlined in the American College ofObstetricians /Gynecologists (ACOG) guidelines, and surgi‐cal specimen testingDurable Medical EquipmentInpatient Notification Outpatient Durable medical purchases over 500 –this includes wheel‐chairs, CPAP (initial rental/purchase ONLY), hospital beds,insulin pump (initial purchase ONLY)ProstheticsCustom OrthoticsAll inpatient admissions, including clinical updates for con‐tinued stayRehabilitation facility admissionsSkilled nursing home facilitiesOutpatient Cosmetic/Aesthetic ProceduresTransplant RequestsGenetic testing (Excludes prenatal tests outlined in theAmerican College of Obstetricians /Gynecologists (ACOG)guidelines, and surgical specimen testing)Routine labs/genetics tests performed by non-Tier I labora‐toriesEndoscopy servicesColonoscopies for patients under the age of 50Investigational and experimental proceduresInfertilitySurgeries of the neck and backRhinoplasties and SeptoplastiesRadiology MRI‐ Spine (includes cervical)Non‐oncology related PET ScansMedical purchases less than 500Bilirubin blankets for newbornsNebulizersCPAP supplies after initial authorizationInsulin pump supplies after initial authorizationCathetersOther disposable supplies after initial authorization Colonoscopies for patients aged 50 or olderDialysis and Epogen administration with DialysisHome Health Care Home Health ServicesHospice Care (Outpatient and Inpatient)Total Parental Nutrition (TPN)Home oxygenRadiology All radiology services except MRI(s) Spine (includes cervical)Miscellaneous Services Sleep studies performed at in-network sleep labsSleep studies performed in home under the direction of anin-network sleep labBehavioral Health Neuropsychological testingApplied Behavior Analysis (ABA)Behavioral HealthOnly these services that are unavailable in-network are covered at Tier 1 without a prior authorization** Office visits and office based testing: All inpatient admissions for behavioral health treatment –this includes inpatient hospital and partial hospitalizations(PHP) for mental health and substance abuseIntensive outpatient (IOP) for mental health and substanceabuse Pediatric neurosurgery 15 years oldPediatric endocrinology 16 years old Members 18 years old - pediatric hematology/oncology,pediatric ophthalmology, pediatric pulmonology, pediatricurology, pediatric cardiology8
Peer-to-Peer Process for Community Health Direct Gold and Silver Plans:Effective June 8, 2018 Community Health Direct changed the peer to peer process to expeditethe turnaround time on adverse determinations. The changes include: Providers can call (317-621-7575, option 2) and schedule a peer to peer discussion as longas a prior authorization form with associated clinical records has previously beensubmitted; however once the denial letter is sent, Community Health Direct MedicalDirectors cannot overturn an adverse determination. Community Health Direct Utilization Management nurses will provide a potential verbaldenial on requests that do not meet medical necessity. In addition, the prior authorizationform that was submitted to Community Health Direct will be faxed back to the provider’soffice noting the reason criteria was not met on the form. Call back numbers will besupplied with both the potential verbal denial and the faxed prior authorization form toschedule a peer to peer discussion. Providers will have until 5pm the following business day to schedule a peer to peerdiscussion to provide additional information. If no response is received by 5pm the following business day, a denial letter will be sent toboth the provider and the member. Once the denial letter is sent, reconsideration will require that the member appeal thedenial (please note that members may designate their provider to appeal on their behalf).If you have any questions, please contact your local Provider Relations Analyst:Carol BoydCommunity Health DirectProvider Relations AnalystPhone#: (317)621-7923CBoyd@eCommunity.comDawn WidgeryCommunity Health DirectProvider Relations AnalystPhone#: (317)621-7462DWidgery@eCommunity.com9
Provider Relations Department6626 E. 75th St, #500Indianapolis, IN 46250Phone: ealth-directDepartment StaffManager Provider Relations:Jenny Bouck, jbouck@ecommunity.comBusiness Information Coordinator:Hollie Putzback, hputzback@ecommunity.comProvider Relations Analysts:Amanda Bobo, abobo@ecommunity.comCarol Boyd, cboyd@ecommunity.comDawn Widgery, dwidgery@ecommunity.comGovernmental Programs Manager:Lori White, lwhite4@ecommunity.comSalena Woodson, swoodson2@ecommunity.comSupervisor Provider Credentialing:Jenna White, jwhite2@ecommunity.comCredentialing Coordinators:Aletha Burnett, aburnett@ecommunity.comApril Woodruff, awoodruff@ecommunity.comAdrianne Stocks, astocks@ecommunity.comAmy Walls, awalls@ecommunity.comDenise Smith, dasmith6@ecommunity.comDianne Castillo, dcastillo@ecommunity.comJerrilyn Dixon, jdixon3@ecommmunity.comKim Tibbets, ktibbets@ecommunity.comLori Jones, ljones@ecommunity.comMelissa Baldwin, mscharfenberg@ecommunity.comMichael Starks, mstarks@ecommunity.com10
Encore Health Network has been gradually expanding the provider participation of Encircle to include most of Indiana. EncoreCombined will include 95% of the providers in the Encore Health Network service area. Hospitals participating in the EncoreCombined product agree to offer top tier pricing in an open access product.
