Provider Connections Newsletter - Fall 2012

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1199SEIU Benefit and Pension Funds 330 West 42nd Street New York, NY 10036-6977

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

ADDRESS SERVICE REQUESTED

1199SEIU PROVIDER

Connections

Your Key to the 1199SEIU Benefit Funds

Summer/Fall 2012

Message from the

www.1199SEIUBenefits.org

Refer your 1199SEIU Patients to Our Health Coaching Service If your 1199SEIU patients are struggling to lose weight or quit smoking, the Benefit Funds can offer support to supplement your care.

Through our telephonic health coaching service, at (866) 935-1199, we offer intensive weight management and smoking cessation programs, which can help your patients improve their chances of maintaining a healthy weight and staying smoke-free for good.

According to a recent study in the American Journal of Public Health, six months into a telephone weight-loss coaching intervention program, participants, on average, lost more weight, lowered their blood triglycerides and were eating less fat and more fruits and vegetables. And similar telephone interventions have been used successfully to spread lifestyle messages related to hypertension, high cholesterol and smoking.

Our professionally trained health coaches will support the care you provide with extra, one-on-one coaching for your 1199SEIU patients. In addition to a weight management program, our health coaching service can also provide your patients with education and support to help them manage two of our members’ other top health concerns – diabetes and heart disease. And our smoking cessation program offers members free nicotine replacement patches or gum so they can choose the method that works best for them. If your 1199SEIU patients need a smoking cessation medication, you can prescribe one from the Funds’ Preferred Drug List.

Executive Director

We value our relationship with you and continually strive to support you in providing the highestquality care to our members, your 1199SEIU patients. In this issue of Provider Connections, we share with you some of the latest technologies we are using to help streamline claims processes, which not only facilitate prompt payment but also reduce unnecessary administrative work for your staff, freeing them to focus on providing support to you and better serving your patients.

Of course, our successful partnership depends on you as well, and one of the most important ways you can help is by providing us with your most accurate, up-to-date contact information. By making sure your information on our website is accurate, you are giving our members easy and reliable access to the care they need.

We have also listed changes to our Preferred Drug List (PDL), including our Specialty Care Pharmacy.

Please be sure to refer to the PDL whenever you’re prescribing medications for your 1199SEIU patients to help them avoid unnecessary out-ofpocket costs and assure that they are receiving the best, most cost-effective treatment.

As always, we hope you find the information in this newsletter helpful. If you have any questions or concerns, we encourage you to contact your Provider Representative or our Provider Relations Call Center at (646) 473-7160.

Refer Your 1199SEIU Patients to Our 24-Hour Nurse Helpline During Your Off-Hours Of course, our 24-Hour Nurse Helpline is always available to answer health-related questions – 24 hours a day, 7 days a week. So if your 1199SEIU patients need additional support in any of these areas, or access to a 24-hour nurse who can answer their questions, please encourage them to call (866) 935-1199.

Mitra Behroozi, Executive Director 1199SEIU Benefit and Pension Funds

We value our relationship with you and continually strive to support you in providing the highest-quality care to our members, your 1199SEIU patients.

Here to Help – Our Provider Relations Call Center Our Provider Relations Call Center is staffed with trained representatives who are ready to answer your questions promptly and professionally.Whether you have a routine request or you are trying to sort out a complicated case, you can call (646) 473-7160 every Monday through Friday, from 8:00 am to 6:00 pm, and a Provider Relations staff member will be happy to help you.

ClaimCheck Software Updated On July 1, 2012, we updated ClaimCheck, the comprehensive claims auditing software used by the Funds. Utilizing the updated version – Knowledge Base 49 with National Correct Coding Initiative (NCCI) version 18.2 – encourages consistent, correct coding and ensures services are reported accurately. As we have previously communicated, the Benefit Funds also adhere to the NCCI guidelines, developed by the Centers for Medicare & Medicaid Services to promote correct coding methodologies and limit improper coding and related inappropriate payments. Please make sure to submit your claims using the CMS correct coding guidelines, which can be found by visiting www.cms.gov/NationalCorrectCodInitEd.

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Make Sure Your Provider Information Is Up to Date Keeping our Provider Directory listings current allows prospective 1199SEIU patients to quickly and easily locate your practice and find the services they need. But the task has become more challenging in the last few years as changes in the healthcare industry have been accompanied by an increase in mergers, acquisitions and closures of some institutions. Please help us ensure that all your information – including provider name, specialty, type of practice, address and telephone number – is up to date by taking a few moments to visit our website at www.1199SEIUFunds.org and reviewing the information about your practice by clicking on the “Find a Provider” tab on our homepage. If anything needs updating, please complete and return a Provider Demographic Information Change Request Form, which can be found at www.1199SEIUFunds.org/Providers.

Please be sure to review the Provider Demographic Information Change Request Form Guide, which will assist you in completing the form.

New Technology Streamlines Claims Submission Process

Verify Your 1199SEIU Patients’ Eligibility Online or By Phone Check your 1199SEIU patients’ eligibility for services or the status of a claim online through NaviNet to save time and help ensure that you are providing covered services.

The nation’s largest real-time healthcare communications network, NaviNet gives you real-time access to benefits and claim information, including duplicate Explanation of Payments, on a single, secure website. If you are already a NaviNet user, simply log in at www.navinet.net, and you’ll find the most up-to-date eligibility and claims information for all your 1199SEIU patients. If you haven’t signed up for the service, registration is free. For more information and a link to NaviNet’s registration page, visit www.1199SEIUFunds.org/Providers.

Remember that you can also check your 1199SEIU patients’ eligibility for service or the status of a claim 24 hours a day, 7 days a week, with our Interactive Voice Response (IVR) system.The automated system allows you to check patient eligibility and claims status an unlimited number of times by calling (888) 819-1199 and entering your Taxpayer Identification Number (TIN) and your patient’s Member ID number and date of birth. If you have trouble accessing the system, please call a Provider Relations representative at (646) 473-7160. For more information, visit our website at www.1199SEIUFunds.org/Providers.

As the use of electronic health records systems (EHR) becomes more the rule than the exception, we are working hard to streamline the claims process. But for providers who have not yet transitioned to electronic billing, we have adopted an Optical Character Recognition (OCR) system.The OCR technology converts your paper claim into an electronic data interchange (EDI) – text that is “readable” by electronic claims processing systems.We use this EDI file to process your paper claim electronically, speeding the process by which you get paid. When the OCR system detects any missing or incorrect data, you will receive a notice from Emdeon, one of our clearinghouses, instructing you to revise and resubmit the claim. Should you receive one of these notices, we urge you to please resubmit the claim electronically – using the Funds’ electronic claims payer ID #13162 – after the completed and/or corrected information is submitted and processed. If you need help resubmitting your claim electronically, please contact Emdeon directly at (800) 845-6592 or visit www.emdeon.com.

And remember, the Centers for Medicare & Medicaid Services (CMS) now requires providers that file claims electronically to use version 5010 of the standard electronic Health Insurance Portability and Accountability Act (HIPAA) transaction. So to avoid delayed payments and make sure your remittance is processed correctly, please submit your claims using the Funds’ electronic claims payer ID #13162, the updated 5010 system format and the current procedure codes, which can be found on our website at www.1199SEIUFunds.org/Providers. If you need further assistance, please call our Provider Relations Department at (646) 473-7160.

New Drug Class and Step Therapy Added to Our Preferred Drug List Effective June 1, 2012, we have added a new step therapy for the treatment of pulmonary arterial hypertension (PAH) and a new Preferred Drug List (PDL) drug class for treating Type 2 diabetes.

According to the Oral PAH Drug Class Step Therapy Guidelines, as of June 1, 2012, if you intend to prescribe Letairis for the first time to any of your 1199SEIU patients with PAH, they must first try Tracleer.

Revatio (a specialty drug that requires prior authorization) is another available option for treating PAH that is covered by the Benefit Funds.

The new PDL drug class for Type 2 diabetes – DPP-4 Inhibitors – includes: • • • •

Januvia Janumet Kombiglyze XR Onglyza

Remember to visit www.1199SEIUFunds.org/Providers regularly to review the most up-to-date Preferred Drug List.

Nine New Drugs Added to Specialty Care Pharmacy Our specialty care pharmacy, Accredo, has added nine new drugs to its list of available medicines. If you are prescribing any of these drugs to one of your 1199SEIU patients, 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 Medco’s Prior Authorization Department at (800) 753-2851.

Effective April 1, 2012, the new specialty medications are: • • •

Erivedge* Eylea* Firazyr*

• • •

Inlyta* Jakafi* Kalydeco*

• • •

Nulojix Octagam Prialt

A full list of specialty care drugs is available at www.1199SEIUFunds.org/Providers. For additional information about the Funds’ prescription drug benefit plan, please call Medco’s Prescriber Service Center at (800) 211-1456 from 8:00 am to 6:00 pm, Monday through Friday. *Medication requires prior authorization.

Prior Authorization Not Required for Hearing Aids Remember, you no longer need prior authorization for hearing aids. Although certain medical devices – such as prosthetic devices or wheelchairs – do require a pre-authorization request, please let your 1199SEIU patients know that any prescription you write for a hearing aid can be filled directly.

If you have any questions, or if you need any additional information about devices, equipment or medications that require prior authorization, please visit www.1199SEIUFunds.org/Providers or call one of our Provider Services Representatives at (646) 473-7160.