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Your Key to the 1199SEIU Benefit Funds

Fall/Winter 2013

Message from the Executive


Here at the 1199SEIU Benefit Funds, we share a mission with our participating providers – ensuring that our members, your patients, receive quality healthcare. We know that a critical part of that shared mission is making sure you have access to the patient information you need, when you need it. That is why we were pleased to find that over 90 percent of the providers who responded to our recent survey said they were happy with NaviNet, the online service we now use to provide you with access to real-time eligibility, claims and benefit records. In this issue of Provider Connections, you will read more about those survey results and find out how we are making it easier for you to process your claims, submit a claim review and request prior authorization. We have also included information on important upcoming changes to our claims system, our prior authorization procedures and our specialty care pharmacy. As partners in our members’ care, we appreciate your feedback. If you ever have any questions, concerns or suggestions, do not hesitate to contact your dedicated Provider Representative or call our Provider Relations Call Center at (646) 473-7160.

Mitra Behroozi, Executive Director 1199SEIU Benefit and Pension Funds

We know that a critical part of our shared mission is making sure you have access to the patient information you need, when you need it.

Survey Finds 90 Percent Satisfaction with NaviNet Last year, in response to your requests for easier access to member information, we introduced an online, real-time portal through NaviNet. We recently surveyed our providers on your satisfaction with the system. More than 1,000 of you responded, and 90 percent of you told us you are satisfied with the electronic access to patient information; eligibility, benefit and claims status and the accuracy of information that NaviNet provides. Of course, we’re always looking for ways to improve our service. Since many of you told us you would use additional features if they were available, we will be using the survey findings to expand the services that NaviNet offers in the future. For instance, some providers told us that they sometimes call us after using NaviNet because they need additional claims details (33 percent) or additional eligibility and benefit details (28 percent). If you haven’t signed up for NaviNet yet, registration is easy and free. For more information and a link to NaviNet’s registration page, please visit

Benefit Funds Will Move to ICD-10 in 2014 Like all healthcare payers, the Funds are required to transition to the ICD-10 system for diagnosis coding and inpatient hospital procedures on October 1, 2014. Please check our website – – in the coming months for information as we prepare to upgrade to the new codes. We will post instructions on how and when to submit claims using ICD-10 as soon as they become available.

New CMS 1500 Claim Forms The National Uniform Claim Committee has already made several revisions to the CMS-1500 claim form to accommodate ICD-10. At this point, there are two versions of the form. We will accept both versions until further notice.

Quick and Easy Electronic Payments Are on the Way On January 1, 2014, we will begin offering providers the option to be paid using electronic funds transfers, as the Affordable Care Act requires. Details will be available soon.

We Are Making Claims Reviews Easier We have made it easier to inquire about your medical claims or to request a review if a claim is denied. Simply use the new Claim Reconsideration Form, which is available at can email, fax or mail the completed form and all supporting documents to the Benefit Funds’ Medical Claims Department: •


Fax: (646) 473-7088

Mail: Benefit Funds’ Medical Claims Department, P.O. Box 717, New York, NY 10108-0717

We must receive your request within 180 days of the initial claim processing date.

Prior Authorization Now Required for Skin Substitute and Implant Procedures As of July 1, 2013, providers must request prior authorization for the following knee cartilage repair and skin substitute procedures: • • • • • • •

J7330 – Autologous chondrocyte implant Q4100 – Skin substitute, nos Q4101 – Apligraf Q4102 – Oasis wound matrix Q4106 – Dermagraft Q4107 – GraftJacket Q4124 – Oasis ultra tri-layer wound matrix

These procedures should be performed in an ambulatory surgical center, office or outpatient facility. Please note that the Funds do not cover other Q coded skin substitute procedures, as they are considered experimental and unproven. To request prior authorization, contact our Prior Authorization Call Center at (646) 473-7446 or complete the request form found on our website at and fax it to (646) 473-7447.

NEW: Prior Authorization Process for Specialty Drugs As of January 1, 2014, the Benefit Funds will use Care Continuum, a subsidiary of Express Scripts, Inc., to streamline the prior authorization process for specialty drugs. You can find the full list of specialty drugs requiring prior authorization at The new Medical Benefit Management Specialty Drug List is also available on our website. Make sure you avoid having your claim denied by requesting authorization before administering these drugs to your 1199SEIU patients.

Register Now with Care Continuum’s ExpressPAth Online Portal Registering for an ExpressPAth Portal account is quick and easy, and speeds up the authorization process.You will receive notice right away if the request is approved. And, if necessary, you can appeal denied requests online. Just go to Providers/Forms-for-Providers and download the ExpressPAth Quick Start Guide to get started. We will also be offering three webinars on how to use the ExpressPAth Portal. Keep an eye out for details.

New Specialty Drugs Available through Accredo Specialty Care Pharmacy Drug Name Classification Cancer

Three Simple Ways to Request Prior Authorization When Submitting Medical Claims for Specialty Drug Reimbursement •

Go to Care Continuum’s ExpressPAth Portal at

Call Care Continuum at (877) 273-2122, Monday through Friday, 8:00 am to 7:00 pm, EST

Fax Care Continuum at (877) 814-4047. Download a drug-specific request form at

Please indicate if your request is urgent so it will receive priority handling.

Decitabine Gilotrif Iclusig Kadcyla Mekinist Pomalyst Synribo Tafinlar Temozolomide

Immune Deficiency

Bivigam Cinryze Kalbitor

Metabolic Disorder

Procysbi Ravicti Zavesca

Multiple Sclerosis






Clinical Program Rule

Prior Authorization Required Prior Authorization Required Prior Authorization Required Prior Authorization Required Prior Authorization Required Prior Authorization Required Prior Authorization Required Prior Authorization Required Prior Authorization Required

Prior Authorization Required/ Quantity Duration Prior Authorization Required

Quantity Duration

Other Specialty Gattex Agents Kynamro Signifor

For Prior Authorization through the Accredo Specialty Care Pharmacy Program, call (800) 803-2523, 8:00 am to 8:00 pm, EST.

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

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Provider Connections Newsletter - Fall/Winter 2013