Provider Connections Newsletter - Winter/Spring 2013

1199SEIU PROVIDER

Connections

Your Key to the 1199SEIU Benefit Funds

Winter/Spring Winter/Sprin ng 2013

Messagee from from the Exe Executive ecutive ecutive

Director Dirrector

As our vvarious ar ious healthcare healthcare plans for our hospital, tal,, nursing nursing home and home care car are member memberss that w ere oncee so similar become more more differ rent,, w understand that sta ayingg up to were different, wee understand staying date on yyour our 1199SEIU 199SEIU patients’ coverage coverage can n be challeng ing. That is wh hy w emain challenging. why wee rremain committed to kkeeping eeping you you informed infor med about any an ny plan and administrati ve changes nges to our administrative 1199SEIU Benefit nefit Fund plans.

In this issue off Provider Connections s, yyou ou will lear earn about impor tant changes to our Connections, learn important pr escr iption drug drrug pr ogram,, new new co vered benefits efits for some of our members, members,, lower lower prescription program, covered co-pa ayments for or other s,, news new ws on our Funds’’ policies, p , steps to mak our ur claims co-payments others, makee sur suree yyour ar processed quickly and accurately, accuratelyy, and mor re. aree processed more.

As al lways,, w h yyou ou find this newsletter newsletter useful. If yyou ou ha ave any an ny questions, s,, yyour our always, wee hope have dedicated Pr ovider v Representative is always alw ways aavailable vailable to help, help, or you you can contact ntact our Provider Representative Pr ovider Services Services ces Call Center at (646) 473-7160.

160. We We look forward forw ward to w orking ing with Provider working yyou ou in 2013 to o keep keep our member health hy. memberss healthy.

Mitra Behr oozzi,, Executive Executive Dir ector Behroozi, Director 1199SEIU Ben nefit and Pension Pension Funds Benefit

We look forward to We working wo orking with you in 2013 2013 to keep our members me embers healthy. healthy.

Help Y Your our Patients Patients Avoid Unnecessary Unnec cessary Costs:

Refer Refe er In-Network Keep Y Your our o Information n Up to Date – and a Keep 1 199SEIU Patient ts Coming Y ourr W ay 1199SEIU Patients Your Way As the healthcar healthcare are industry industry transitions to toward ward mor moree patient-center patient-centered, ed,, coordinated coordinated nated care, care, w know that many many practices and institutionss ar ing or chang ing ownership. owner nership. That’ wee know aree merg merging changing That’ss wh hy it is mor important than ever ever to mak ssuree your your provider prrovider infor mation n is cur rent. why moree important makee sur information current.

K eeping your your name, name, addr ess,, telephone number, number berr, National Provider Provider Identifierr (NPI) n umberr, Keeping address, number, specialty and type ype of practice up to date with the Funds ensur es that your your current cur urrent and new new ensures 1199SEIU patients ients can locate yyour our practice and nd check whether your your areas areas of exper tise fit expertise their needs.

Please tak m your practice ctice information infor mation in our Provider Prrovider der Dir ectory is takee a moment to check that your Directory up to date bbyy visiting v www w.1199SEIUFunds.org orgg and clicking on the “Find a Pr ovider”” tab www.1199SEIUFunds.org Provider” tab..

JJust ust choose a Fund und and click on the 1199SEIU U Member Choice & Panel Panel Providers Provider oviders list. If an ny any of the infor mation ion is outdated,, simply complete and return return a Provider Prrovider Demo graphic phic Infor mation information Demographic Information Change Requ est F or m,, which can be foundd at www.1199SEIUFunds.org/Providers. www w.1199SEIUFunds.org/Pr g/Providers. If Request Form, yyou ou need assistance, assisttance, there’s there’s a handy guide on nline to help yyou ou complete thee form, for m,, or you you online can call our Pr rovider Relations representatives representatives at (646) 473-7160.

Provider

If yyour our 1199SEIU patient needs to see a specialist or rreceive eceive lab, lab, radiolo gyy or other ancillary ancillary services, services, radiology be suree you you send them to an 1199SEIU IU par ticipating pro ovider. participating provider.

This helps ps our member memberss get the high-quality ality car they need from froom caree they cr edentialed aled providers providers while credentialed aavoiding voidingg high out-of-pocket out-of-pocket costs.

F or a complete mplete list of participating participating For PR OVVIDERRS n SEARCHABLE SEARCHABLE BY

BY SPECIALTY

SPECIALTYY

PROVIDERS LOCATION OR HOSPITAL NETW ORK n AS WELL WELL NETWORK as an updated dated dire dir ectory of preferred preeferreed directory labs,, visitt www.1199SEIUFunds.org. www w.1199SEIUFunds.org. .1199SEIUFunds.org Remember mber,, before before ord der ing an ny Remember, ordering any test,, procedure prrocedur cedure or tr eatment for yyour our treatment 1199SEIU IU patients,, you you should also vverify er ify that hat the Benefit Fund covers covers that serv v and whether a pr vice ior service prior author ization zation is required. required. authorization

All Funds Update

Your 1199SEIU patients belong to three different Benefit Funds: the National Benefit Fund, the Greater New York Benefit Fund and the Home Care Benefit Fund. We have made it easier for you to stay informed.

Please make sure that you know which changes apply to which Funds.

Eligibility and Claims Status Is Just a Click or Phone Call Away Remember to Update Your Provider Credentials Most of our providers are already saving valuable time by verifying their 1199SEIU patients’ eligibility and checking claims status automatically, 24 hours a day, 7 days a week THROUGH OUR )NTERACTIVE 6OICE 2ESPONSE )62 SYSTEM .OW we’ve added a new feature: check-cashed dates, helping you manage your accounts receivable for 1199SEIU claims by verifying when checks issued to you from the Funds have been cashed or cleared. Just call (888) 819-1199 and enter your Taxpayer Identification Number (TIN), your patient’s member ID number and the date of birth.

You can also verify your 1199SEIU patients’ eligibility online by using NaviNet, the nation’s largest healthcare communications network. NaviNet gives you real-time access to benefits and claim information, including duplicate Explanation of Payment forms, in a single, secure location. If you already use NaviNet, log in at www.NaviNet.net. If you haven’t signed up for the service yet, registration is easy and free. For more information and a link to NaviNet’s registration page, please visit our website at www.1199SEIUFunds.org/Providers.

Reminder: Express Scripts and Medco Have Merged -EDCO (EALTH 3OLUTIONS n THE 3%)5 "ENElT &UNDS PHARMACY BENElT MANAGER n HAS BEEN ACQUIRED BY %XPRESS Scripts in a deal approved by federal regulators last year. The change did not affect your 1199SEIU patients, who still have access to the same medications and pharmacies with no changes in their prescription coverage.You may also continue to use the same Medco prescription processes and contact information you’ve used in the past. The Fund will keep you and our members updated if any changes are necessary in the future.

Nuclear Cardiology Services Require Radiology Review The Funds’ Radiology Review program requires referring physicians to obtain prior authorization from Care to Care for outpatient advanced diagnostic imaging services, including MRI, MRA, CT, CTA, PET and PET/CT scans. Effective November 1, 2012, providers will also need prior authorization for nuclear cardiology procedures. (For a full list of Care to Care’s Imaging Criteria, please visit www.caretocare.com/ clinicalcriteria.) If your 1199SEIU patient requires one of these procedures, contact Care to Care at (888) 910-1199 for authorization.

To provide our members with access to the strongest provider network, participating providers are required to update their credentials every three years. If you receive a re-credentialing application from the Funds, please return it within 15 business days. Our Provider Representatives will follow-up if we don’t receive your form, but returning your updated application quickly is the best way to avoid losing your status as a participating provider. If you are a member of the Council FOR !FFORDABLE 1UALITY (EALTHCARE #!1( n WITH A CURRENT PROVIDER ATTESTATION ON lLE n YOU NO LONGER NEED TO COMPLETE A SEPARATE PROVIDER APPLICATION 3IMPLY ADD YOUR #!1( identification number to the application you receive in the mail.

Return your re-credentialing application to: 1199SEIU Benefit Funds Provider Relations Department Contracting and Network Management 330 West 42nd Street, 29th Floor New York, NY 10036-6977 Fax: (646) 473-7213 | Email: Providers@1199Funds.org

Are You Using 2013 CPT Codes?

Avoid having a patient’s claim denied or your payment delayed by using the 2013 Current Procedural Terminology (CPT) codes on all your claim submissions. If you have any questions, please contact our Provider Services Call Center at (646) 473-7160.

The Benefit Funds Review Hospital Readmissions As a reminder, your contract provides that if your 1199SEIU patient is readmitted to the same hospital within 30 days of a prior hospital admission for a clinically related condition or PROCEDURE THE READMISSION WILL BE SUBJECT TO MEDICAL REVIEW If the physician reviewer determines that the services could or should have been provided during the earlier inpatient stay, the Fund may deny payment for the readmission. The review is not for medical necessity. When readmissions are denied on this basis, providers will receive a notification and may appeal all ADVERSE DETERMINATIONS AS DESCRIBED IN THE 0ROVIDER (ANDBOOK For more information about this program, or if you have any questions, please contact our Care Management Department at (646) 473-7446.

National Benefit Fund News

Effective January 1, National Benefit Fund Patients No Longer Have Co-Pays or Benefit Limits for Mental Health Services Your 1199SEIU patients in the National Benefit Fund (NBF) WHOSE BENElT LEVEL IS EITHER 7AGE #LASS ) OR 7AGE #LASS ))

and their covered family members receive comprehensive coverage for mental health services with no co-payments or benefit limits, although prior authorization is required for inpatient services. To check your patients’ Fund or benefit LEVEL YOU CAN EITHER LOOK AT THEIR (EALTH "ENElTS )$ #ARD OR verify their eligibility for services by phone and online at (888) 819-1199 or www.1199SEIUFunds.org/Providers. * Wage Class III members are only eligible for inpatient mental health services.

Greater New York Benefit Fund News

Lower Co-Payments for Greater New York Benefit Fund Members As of March 1, 2013, many of your patients enrolled in the 1199SEIU Greater New York Benefit Fund have lower copayments for office visits and specialist visits. Co-payments for primary care office visits have been reduced from $10 to $5, and specialist visit co-payments have been reduced from $15 to $10. Please check your 3%)5 PATIENTS (EALTH "ENElTS )$ #ARD TO DETERMINE Eligibility Class. We recently notified affected members about THESE CHANGES AND ARE ISSUING THEM NEW (EALTH "ENElTS )$ Cards with updated co-payment information.

Please remember that these co-payments apply only to patients covered by the Greater New York Benefit Fund, not to those covered by the 1199SEIU National Benefit Fund.

Greater New York Benefit Fund Members Now Covered for Lactation Services As required by the Affordable Care Act, your 1199SEIU patients in the Greater New York Benefit Fund are now covered for lactation services. Effective January 1, 2013, these patients can receive up to three sessions of post-partum lactation consulting from a participating IBCLC-certified provider with no out-of-pocket costs. They can also receive breast pumps and supplies from a participating DME provider such as Landauer Metropolitan and Better Living Now. Please note that these changes affect only your patients covered

BY THE 'REATER .EW 9ORK "ENElT &UND n NOT THOSE COVERED by the 1199SEIU National Benefit Fund or 1199SEIU (OME #ARE "ENElT &UND )F YOU ARE NOT SURE WHICH &UND covers your 1199SEIU patients, you can check the front of THEIR 3%)5 (EALTH "ENElTS )$ #ARD CALL THE &UNDS automated eligibility system at (888) 819-1199 or log onto www.NaviNet.net if you are a NaviNet user.

1199SEIU Ben Benefit efit and Pension Funds West 330 W est 42nd Street New York, York, NY Y 10036-6977

Non-Profit U.S. Postage PAID PAID New York, York,, NY Permit No. 3700

ADDRESS SERVICE SERV VICE REQUESTED

www.1199SEIUBenefits.org www .11 199SEIUBenefits.org

Five New Drug Classes Added to Preferred Drug List Our clinical pharmacists are constantly reviewing our Preferred Drug List to help ensure that the most cost- and clinically effective medications are available to our members. Effective January 1, 2013, the Benefit Funds added five new drug classes to our Preferred Drug List (PDL): s !CTINIC +ERATOSES s ( 0YLORI !GENTS s )NJECTABLE (YPOGLYCEMIC !GENTS s 0ANCREATIC %NZYMES s 6ITAMIN $ !NALOGS There have also been changes to four additional drug classes, including: s %STROGENS s )NHALED #APSULE #/0$ s )NHALED #ORTICOSTEROID s -ISC 0ULMONARY #OMBINATION (Corticosteroid/Beta-Agonist) Inhalers Before prescribing medications for your 1199SEIU patients, please consult the most up-to-date version of the PDL at www.1199SEIUFunds.org/Providers.

Seven New Drugs Added to Specialty Care Pharmacy Accredo, the Benefit Funds’ specialty care pharmacy, has added seven new drugs to its list of available medications, including drugs for multiple sclerosis, metastatic colorectal cancer and chronic weight management. If you are prescribing any medication that requires refrigeration or other specialty handling, they must be prescribed through Accredo. Please call Accredo at (800) 987-4904 and provide them with the patient’s 1199SEIU Member ID number. The Accredo specialty pharmacist will arrange for the medication to be delivered directly to your patient. For prescriptions that require prior authorization, please call Express Scripts’ (formerly Medco’s) Prior Authorization Department at (800) 753-2851.

Effective December 1, 2012, the new specialty medications are: s !UBAGIO n MULTIPLE SCLEROSIS s "OSULIF n CHRONIC MYELOGENOUS LEUKEMIA s 0ERJETA n METASTATIC BREAST CANCER s 1SYMIA n CHRONIC WEIGHT MANAGEMENT s 3TIVARGA n METASTATIC COLORECTAL CANCER s 8TANDI n PROSTATE CANCER s :ALTRAP n METASTATIC COLORECTAL CANCER A full list of specialty care drugs is available at www.1199SEIUFunds.org/Providers.

For additional information about the Fund’s prescription drug benefit plan, please call Express Scripts at (800) 211-1456 from 8:00 am to 6:00 pm, Monday *Medication requires prior authorization. through Friday.