HEALTH CHOICE ®
Leading the Way to Quality Care
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A Provider’s Link to the Prestige Health Plan
2015 Issue 3
Pharmacy
News
Pharmacy Benefit Appeals Process Update
Prestige Health Choice will now fax providers a copy of
our member's pharmacy notice of action letters on prior
authorization requests. Our intent is to better inform you
on the Prestige appeals process. Appeals must be initiated
by members or authorized representatives with the
member's consent.
Additional information submitted by providers, without
member consent, will be deemed a reconsideration and
processed under our normal prior authorization request
procedures.
Contraceptive Update
Liletta, a new intra-uterine contraceptive device, is now covered by
Florida Medicaid. This device contains the same main ingredient
as Mirena (levonorgestrel). Both products have been assigned the
same HCPC code, J7302. For this reason, a modifier will be used to
distinguish Liletta from Mirena. When billing for Liletta, use J7302
and modifier SC. When billing for Mirena, continue to use J7302.
Pharmacy Network
As of August 15, 2015, CVS pharmacy will no longer be part of the
Prestige pharmacy network. Patients that use CVS pharmacy to fill
their prescriptions will need to select a new pharmacy. Prestige
has more than 8,300 retail pharmacies in our current network
including Walgreens, Walmart, Target, Publix, Winn-Dixie, and others. Please use our list of participating pharmacies on our site.
To assist with the transition, your patients will be able to continue
filling prescriptions for sixty (60) days after August 15th, as part of
continuity of care.
Connections
A Provider’s Link to the Prestige Health Choice Health Plan
Adverse Incident Reporting
An Adverse Incident is a critical event that negatively impacts the health, safety, or
welfare of Prestige members. Adverse incidents may include events involving abuse,
neglect, exploitation, major illness or injury, involvement with law enforcement,
elopement/missing, or major medication incidents. These are incidents over which
health care personnel could exercise control and which are associated in whole or in
part with medical intervention, rather than the condition for which such intervention
occurred and which:
1. Result in one of the following injuries:
a. Death
b. Brain or spinal damage;
c. Permanent disfigurement;
d. Fracture or dislocation of bones or joints;
e. A resulting limitation of neurological, physical, or sensory function
which continues after discharge from the facility;
f. Any condition that required specialized medical attention or surgical
intervention resulting from nonemergency medical intervention,
other than an emergency medical condition, to which the member
has not given his or her informed consent;
g. Any condition that required the transfer of the member, within
or outside the facility, to a unit providing a more acute level of care
due to the adverse incident, rather than the Prestige member’s
condition prior to the adverse incident; or
2. Were the performance of a surgical procedure on the wrong patient, a wrong
surgical procedure, a wrong-site surgical procedure, or a surgical procedure
otherwise unrelated to the Prestige member’s diagnosis or medical condition; or
3. Required the surgical repair of damage resulting to a Prestige member from a
planned surgical procedure, where the damage was not a recognized specific
risk, as disclosed to the Prestige member and documented through the
informed-consent process; or
4. Were a procedure to remove unplanned foreign objects remaining from a
surgical procedure.
Florida Statutes and Provider Agreements require participating and delegated
providers of Prestige to report all adverse incidents affecting Prestige members to
AHCA via the Critical Incident and Code 15 Reporting System.
Any of the above listed adverse incidents, whether occurring in a licensed facility, or
arising from health care prior to admission in a licensed facility, shall be reported by
the facility to the Agency within 15 calendar days after its occurrence (Code 15). The
electronically submitted report should be printed and faxed to Prestige immediately,
and no later than 24 hours after the incident occurred to 1-305-436-7485.
When reporting describe the incident carefully, indicating the injury site (i.e., arm,
leg, hand, etc.) and extent of injury. Be brief, but include important information,
including who, what, when, where, and how. Report any follow-up planned or
pertinent action taken as a result of the incident to prevent recurrence. Include the
name and contact information of any witnesses, including employees. Sign and date
the report. Include title/designation and contact phone number.
Connections
A Provider’s Link to the Prestige Health Choice Health Plan
Billing Practice Reminder
Please take a moment to re-familiarize yourself with the below excerpt from the Florida Medicaid Practitioner
Services Coverage and Limitations Handbook dated April 2014 (Pages 1-7: Chapter 1 – Qualifications, Enrollment, and
Requirements: Personal Supervision).
“Services provided by an ARNP or a PA under the personal supervision of a physician may be billed by the physician
instead of the ARNP or PA.”
Personal supervision pursuant to Rule 59G-1.010(276), F.A.C., means that the services are furnished while the
supervising practitioner is in the building and that the supervising practitioner signs and dates the medical records
(chart) within 24 hours of the provision of the service.
Exceptions are deliveries, psychiatric services, and Child Health Check-Up screenings. The ARNP or PA who provides these
services must bill using their own Medicaid ID number as the rendering provider number.” Please note that the above
listed exceptions require you to credential your ARNPs and PAs to provide these services to Prestige members.
Have any questions? Contact your Provider Account Executive for further clarification.
ICD-10 Preparation for October 1st Transition
The ICD-10 transition takes planning, preparation, and time, so medical practices should continue working toward
compliance. The following quick checklist will assist you with planning steps:
• Identify your current systems and work processes that use ICD-9 codes. This could include your clinical
documentation, encounter forms/superbills, practice management system, electronic health record system,
contracts, and public health and quality reporting protocols. It is likely that wherever ICD-9 codes now appear, ICD-10
codes will take their place.
• Talk with your practice management system vendor about accommodations for ICD-10 codes.
• Discuss implementation plans with all your clearinghouses, billing services, and payers to ensure a smooth transition.
• Talk with your payers about how ICD-10 implementation might affect your contracts. Because ICD-10 codes are much
more specific than ICD-9 codes, payers may modify terms of contracts, payment schedules, or reimbursement.
• Identify potential changes to work flow and business processes. Consider changes to existing processes including
clinical documentation, encounter forms, and quality and public health reporting.
• Assess staff training needs. Identify the staff in your office who code, or have a need to know the new codes.
• Budget for time and costs related to ICD-10 implementation, including expenses for system changes, resource
materials, and training.
• Testing is critical. You will need to test claims containing ICD-10 codes to make sure they are being successfully
transmitted and received by your payers and billing service or clearinghouse.
Prestige is offering ICD-10 educational webinars to help with your transition to ICD-10. To register, please visit
http://www.prestigehealthchoice.com/provider/itn/training-and-education/index.aspx .
Source: http://cms.gov
Connections
A Provider’s Link to the Prestige Health Choice Health Plan
HE ALTH CHOICE ®
Leading the Way to Quality Care
9250 NW 36th St
5th Floor
Doral, FL 33178
The Prestige Provider Manual has been
updated and posted online!
The provider manual is current as of July 2015. All claims
information is fully included in the provider manual;
therefore, there is no longer an independent claims
manual. The provider manual reflects current policies,
procedures and applicable changes to Medicaid.
Please visit www.prestigehealthchoice.com for the
provider manual. Also, feel free to call Provider Services
if you have any questions at 1-800-617-5727.
© 2015 Prestige Health Choice, Inc.
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