CareAffiliate is Coming!
GE Modifier for Resident Performing Services
J-Codes to be Audited for Quantity Limitations
HEDIS
®
Measure Reminder
Member Eligibility Application – Enhancements for Vision Providers
Benefit Administration Manual Updates
City of Dearborn – New Self-Funded Group
Lab Services
Genetic Testing Requires Prior Authorization
Admissions and Observation Stay Process Change Reminder
ICD-10 Webinars Continue
Utilization Management Staff Availability
CareCore National and Medsolutions Announce Name Change
Prior Authorization for In-Home and Facility-Based Sleep Studies Programs
Prior Authorizations from CareCore National
Reminder: Change in Process for Claims Adjustments
Provider Questions About HAP?
On July 13, 2015 CareAffiliate will be live! This new platform is replacing what you know today as IRA and OAA. Some of the benefits include:

Quicker approvals for prior authorization requests that meet evidenced-based criteria when submitted online with CareAffiliate

Pre-populated authorization requests resulting in less data entry

Ability to attach clinical documentation when submitting an authorization (leading to decreased phone calls)

Expanded character limitations within each text box to capture more information needed to submit an authorization
Changes you can expect with the Implementation of CareAffiliate

Prior authorization is not required for:

OB delivery - C-section

OB delivery - Normal vaginal delivery

Observation post surgical

HAP will be using InterQual 2015 and the HAP revised InterQual (see article on page 6 -
Admissions and Observation Stay Process Change Reminder.
Missed Training?
If you missed training, you can watch our training video. Log in at hap.org
and select the
CareAffiliate link under Quick Links . You will find the video, training manuals and other helpful resources.
1

The Evaluation and Management services outlined below must be billed with a GE modifier, which means that they can be performed by a resident without the presence of a teaching physician under the primary care exception.

99201

G0344

99202

G0402

99203

G0438

99211

G0439

99212

99213
Effective September 1, 2015, the J-codes identified below will have a maximum unit amount.
Units billed beyond the customary usage on a single date of service will require medical notes for payment.
Procedure
Code
Billable Unit
Limit Value
J2505
J9305
J0178
J9306
J9041
J2778
J9171
J9033
J9019
1
130
2
840
35
5
220
275
55
®
Below is an important reminder for a HEDIS measure.
PPC - Postpartum Care: Postpartum visits to an OB/GYN practitioner or midwife, family practitioner or other PCP on or between 21 and 56 days after delivery.
The patient’s medical record must have documentation indicating the date when a postpartum visit occurred and one of the following:

Pelvic exam

Evaluation of weight, BP, breasts and abdomen
- Notation of breastfeeding is acceptable for the “evaluation of breasts” component

Notation of postpartum care, including, but not limited to:
- Notation of postpartum care, PP care, PP check, 6-week check
- A preprinted Postpartum Care form showing that information was documented during the visit
2

There were changes made to the Member Eligibility Application (MEA) that will simplify vision benefits for your HAP patients. The following changes were made to the screen:
Under Coinsurance & Copay :

A Preventive row was added and the mouse over text (?) reads “routine eye exam.”

The Medical Office Visit/Eye Exam rows were combined

Mouse over text (?) was added to Glasses and Contact Lenses and reads: “review more detailed Summary of Benefits and Coverage for information on benefit limits.
”
Under Vision Information

Removed the benefit descriptions for office visit and medical eye exams

Added a new benefit description for hardware benefit maximum
Below are examples of the MEA Detail screen prior to the change and the screen that you see today.
Prior to the changes After the changes
For a brief description of each policy update or change, log in at hap.org
and select Benefit
Administration Manual (BAM), Recent Changes.
Effective July 1, 2015

Ambulatory blood pressure monitoring

Benign skin lesion removal

Deluxe items and items not primarily medical in nature

Gene-based testing for prostate cancer screening, detection and disease monitoring

Genetic Testing for Von Hippel-Lindau syndrome

Genetic Testing panels

Insulin infusion pump and supplies

Pediatric intensive feeding programs

Pharmacogenetic testing

Varicose Vein Treatment for other than Senior Plus and Alliance Medicare PPO Member
3

As of July 1, the City of Dearborn is participating with HAP’s Administrative Services Only (ASO) product. This self-funded plan is similar to our HMO product and will be administered by Alliance
Health and Life Insurance Company (AHLIC), a wholly owned subsidiary of HAP and licensed third party administrator (TPA).
Network/Participating Providers
The ASO self-funded network is comprised of providers in our current HMO network.
Fee Schedule and Reimbursement
To the extent possible, this ASO self-funded plan will function like our fully insured HMO plans.
You will be reimbursed according to the HAP HMO fee schedule.
Remittance Advice (RA)
You will receive a separate RA for payment on these claims. It will not be included with your RA for HMO claims. (Note: the RA will indicate City of Dearborn at the top.)
Authorizations and Referrals
The same authorization rules and policies/procedures you follow for HAP HMO apply to this
ASO self-funded plan.
ID Card
Members with this plan will carry the ID card below. The City of Dearborn logo will be in the upper right hand corner.
4

Specific lab tests can be performed in the physician’s office. Any lab tests not performed in the
PCP or specialist’s office must be sent to a Joint Venture Hospital Laboratory (JVHL) with the exception of tests for:

Members assigned to the Henry Ford Medical Group

Members seeking services at the University of Michigan
Important
 JVHL participates in all of HAP’s product lines, including HAP, HAP Preferred, Inc., and
Alliance Health and Life Insurance Company, along with HAP Medicare Advantage plans.

JVHL is the exclusive capitated HMO laboratory for HAP products.

Capitation applies to Commercial HMO, Medicare Advantage and POS products.

The capitation agreement includes outpatient and reference laboratory services.

JVHL does not participate in the following laboratory categories (the servicing provider must bill HAP directly):
Professional pathology
Blood products/transfusion
RSD
To find a list of approved in-office lab codes for PCPs and specialists, log in at hap.org
, then
Procedure Reference Lists under Quick Links .
Providers are responsible to obtain prior authorization for certain lab services. Please check the
Procedure Reference List when you log in at hap.org
. Failure to obtain prior authorization may result in claims denial.
To locate a list of JVHL service centers, please visit www.jvhl.org
or call (800) 445-7979.
Genetic Testing
HAP requires prior authorization for genetic testing. For all genetic tests, HAP assesses the strength of the medical evidence and recommendations from professional organizations such as the National Comprehensive Cancer Network (NCCN), the American Society of Clinical
Oncology (ASCO), the American College of Obstetricians and Gynecologists (ACOG) and others to develop criteria.
Genetic Counseling
HAP requires counseling prior to all genetic testing. Appropriate genetic counseling is a critical component of this process and should be performed before undertaking any genetic test.
Patients need to understand the implications of the test and how the results will be used to make future decisions.
Ensuring appropriate testing
There has been significant growth in both the number of genetic tests and the volume of these tests being ordered by physicians. The rapid advances in genetics and the ease with which these tests move into the marketplace make it important for physicians to order such tests wisely. Avoiding unnecessary testing not only reduces health care costs but improves quality of care.
5

On June 1, 2015, HAP nurses began utilizing HAP-specific UM criteria instead of standard
InterQual

UM criteria to review requests for observation stays and inpatient admissions for the following set of diagnoses:

Acute kidney injury

Abdominal pain

Anemia

Atrial Fibrillation

Cellulitis

COPD

Deep vein thrombosis

DKA

Hyperglycemia

Hypertension

Infection

Nephrolithiasis

Osteomyelitis

Sepsis and SIRS

Syncope

Vaginal bleeding
InterQual criteria is updated on a periodic basis. However, when HAP believes InterQual criteria can be modified to better align with available evidence, we adjust our criteria. McKesson invites feedback from users, and we will share our feedback for their consideration on future releases of InterQual criteria. You will find that HAP-specific UM criteria closely align with InterQual criteria. Details of the changes, including reference to the specific InterQual sections affected, are attached in the HAP Nurse Review Requirements .
Please note: if a nurse documents that a case is not meeting InterQual or HAP-specific criteria, the nurse must refer the case to a HAP medical director for further review.
If you have any questions, please contact our Admissions and Transfers team at
(313) 664-8833, option 3.
A Payers Collaboration consisting of HAP, Blue Cross Blue Shield, Humana, Priority Health and
UnitedHealthcare are working together to provide valuable information to the provider community about transitioning to ICD-10.
The Payers Collaboration will host a series of hour-long webinars by specialty on Thursdays at noon (Eastern Standard Time). Some of the benefits of these webinars include:

Drill down into diagnosis codes common to specialties and see how they are affected by
ICD-10

Suggested transition checklists help minimize disruption in the move to ICD-10

Free ICD-10 testing options offered to help assess coding proficiency

Confidence that the payers will be prepared to handle ICD-10 coded claims and encounters on Oct. 1, 2015
CME credits are not offered for these webinars.
Webinar Schedule
Information on webinars can be found when you log in at hap.org and select ICD-10
Compliance under Quick Links.
6

For utilization management (UM) inquiries, HAP staff is available by telephone as follows:
HAP
Department
Hours and
Contact Number For

Admissions

Transfers

Inpatient Review

Skilled Nursing Facility

Rehab

Outpatient authorizations and Services

DME

Homecare

Home Infusion

Hospice
Case management
Admissions Team
Referral Management Team
Case Management
24/7; 7 days per week
(313) 664-8833
Monday – Friday
8:00 a.m. – 4:30 p.m.
(313) 664-8950
Monday – Friday
8 a.m.
– 5 p.m.
Pharmacy Services Pharmacy
(313) 664-8476
Monday – Friday
8:00 a.m. – 4:30 p.m.
Behavioral Health Services Coordinated Behavioral
Health Management (CBHM)
(313) 664-8940
Monday – Friday
8 a.m. – 5 p.m.
(800) 444-5755
In December 2014, CareCore and Medsolutions announced their merger which would allow the delivery of innovative medical benefits management solutions designed to bring better outcomes to everyone involved in the healthcare system: patients, providers and payers alike.
In June they announced the launch of a new name and brand —eviCore healthcare— that will help advance the company’s commitment to containing healthcare costs and achieving quality medical outcomes.
What Changes for You?
Nothing. You will continue submitting requests for in-home and facility-based sleep studies programs and cardiac imaging, musculoskeletal procedures, radiation therapy and high-tech radiology services as outlined below. Over the next few months you will notice the transition to eviCore on their website, provider portal and letters.
7

HAP requires providers to request prior authorization for in-home and facility-based sleep studies through MedSolutions for HAP HMO, HAP POS, Alliance Health and Life Insurance
Company, and Medicare Advantage members. (Note: Genesys-assigned HAP HMO and POS members are excluded from this process).
Requesting a prior authorization
Both ordering physicians and rendering facilities can initiate a prior authorization request from
MedSolutions. In-office procedures are not allowed. Ordering physicians may request studies to be performed only at HAP-contracted sleep study provider offices/facilities.
There are three ways to request an authorization:

Fax : (888) 693-3210. MedSolutions fax forms are available online or by calling the number below. Only MedSolutions fax forms are accepted.

Phone : (855) 736-6284 Monday through Friday, 8 a.m. to 9 p.m. (EST).

Online : medsolutionsonline.com
Decisions on a routine prior authorization request will be processed within three (3) business days after receipt of the necessary information.
Resources and Questions
MedSolutions’ criteria and request forms are available at medsolutionsonline.com. If you have any questions or need additional information, please contact the MedSolutions Customer
Service department at (855) 736-6284.
8

Cardiac imaging, musculoskeletal procedures, radiation therapy and high-tech radiology services require clinical review and prior authorization from CareCore National (CareCore).
Prior authorization is not required for:

Echocardiography, echo stress tests, radiation oncology and radiation therapy for HAP members who are under 18 years of age. Please see the Services that Require Prior
Authorization List when you log in at hap.org
. A signifier of “AGE” will be next to the code.

Certain add-on codes found in the cardiology, musculoskeletal management and radiation therapy programs. See the Services that Require Prior Authorization List for updates when you log in at hap.org
.
Requesting Prior Authorization
The most efficient way to obtain authorization from CareCore is at www.carecorenational.com
. It’s important to have the patient’s chart available so that you can easily provide the following:

Insurance information

Member information (name, ID number, DOB)

Ordering physician information (name, address, TIN/NPI)

Servicing provider information (name, address where test is to be performed)

CPT and ICD-9 codes

Symptoms

Results of previous studies

Complete clinical information. This will minimize the need for further review by a CareCore clinical nurse or medical director.
You can also obtain prior authorization by phone at (800) 420-3471, option 2.
Initial requests for authorization are no longer accepted by fax.
Following this process will help ensure efficient and timely processing of your prior authorization requests.
9

Use HAP’s online claims application for claims adjustments. Simply:
1. Log in at hap.org
2. Select Claims
3. Search for the claim(s) that you wish to appeal
4. Select from one of three options
Option Use when
Appeal-referral appeal
Payment Amount-Underpayment
Payment Amount-Overpayment
Claims and authorizations do not match
You think HAP did not pay the appropriate amount for a claim based on your contracted rates
You think HAP paid you too much for a claim per your contracted rates
Note:

For any appeals that do not fall into one of the options above, please select option 2 —Payment Amount-Underpayment
 If “Ineligible” displays in the column “Request Appeal,” contact Provider Inquiry at
(866) 766-4661
5. Include the required information in the notes section:

Reason for submitting appeal/adjustment request

Contact name

Phone number

Email address (add this in the notes field)
Step-by-step instructions can be found in the Billing Manual and on the Claims application under
Need Help.
We appreciate your cooperation in adhering to this new process. We are confident this will eliminate duplication and ensure a more efficient, timely means of resolution.
P
You can always call us at (866) 766-4708 for more information. We also have the following information posted online at hap.org. If you prefer a hard copy, call the number listed above and we will mail it to you.

Pharmacy facts: formulary list

Covered and non-covered benefits

Evaluation of medical technology

Privacy and HIPAA information

Network limits

Disease management services

Utilization management criteria

Affirmative statement about UM incentives

Quality management program

Complex case management

Credentialing information

Clinical practice guidelines updates
 HAP’s policy for making an appropriate
 practitioner reviewer available to discuss any utilization management denial decision and how to contact a reviewer
Member rights and responsibilities
10