Your Key to the 1199SEIU Benefit Funds
Message from the Executive
We at the 1199SEIU Benefit Funds share a mission with our participating providers: to help ensure that our members have access to quality healthcare. We know that a critical part of our partnership is keeping you up to date on our plan policies and our members’ coverage. This issue of Provider Connections includes good news for your 1199SEIU patients who are covered by the Greater New York and Home Care Benefit Funds. First, Greater New York members no longer have co-payments for their prescription drugs. We have issued all affected members a new Health Benefits ID card, so please ask your patients for the updated card at each visit, and update your records. And starting in January 2016, our Home Care Benefit Fund will begin offering coverage to members’ children. Again, be sure to ask these patients for their new ID cards, and contact the Funds with any questions about a patient’s eligibility. We have included information about our partnership with Healthix, the downstate New York Regional Health Information Exchange, which is helping providers share information to better coordinate their patients’ care, and a new “Living Well Program” that we are offering to all 1199SEIU members who are facing painful and complex end-of-life issues. Living Well is a collaboration between the Funds and Vital Decisions, a healthcare counseling service designed to help patients and their families navigate difficult medical decisions. Finally, we update you on our successful transition to the new ICD-10 coding system, along with changes to our prescription drug coverage. We hope you find this edition of Provider Connections helpful and informative. If you have any comments, questions or concerns, please feel free to contact your designated Provider Representative or call our Provider Relations Call Center at (646) 473-7160, and a staff member will be happy to assist you.
We at the 1199SEIU Benefit Funds share a mission with our participating providers: to help ensure that our members have access to quality healthcare.
Mitra Behroozi, Executive Director 1199SEIU Benefit and Pension Funds
Plan and Program News Healthix Partnership Helps You Coordinate Your 1199SEIU Patients’ Care To better support and coordinate our members’ care, the 1199SEIU Benefit Funds have partnered with Healthix, the downstate New York Regional Health Information Organization (RHIO). Healthix enables hundreds of participating hospitals, clinics, nursing homes, home care agencies and other healthcare providers to exchange clinical information, communicating about consenting patients’ health to improve the quality, safety and efficiency of care. Healthix provides patient data from participating organizations in New York City and Long Island and now, through statewide patient record look-up, from across New York State. Healthix also facilitates care coordination through real-time clinical event notifications, informing providers when their patients are in the ER or have been admitted to the hospital. If your practice does not already participate with Healthix, we encourage you to join by emailing Info@Healthix.org. And if you do, please ask your 1199SEIU patients to give their written consent to share their health information through Healthix. More than 2 million patients in New York City and Long Island have already consented, and we have urged our members to allow their providers to share their records as well. To learn more, visit www.Healthix.org.
Benefit Funds Offer End-of-Life Care Counseling The 1199SEIU Benefit Funds launched a “Living Well Program” last spring for all of our members who are facing difficult end-of-life medical issues. In partnership with Vital Decisions, a healthcare counseling service, the Benefit Funds’ Care Management team has engaged more than half of the members facing these issues in making care decisions with the support of a trained counselor. The program’s counselors support healthcare providers, including doctors, nurses, care coordinators and family members, to implement a team-based approach while ensuring the full participation of the patient in his or her own healthcare planning and medical choices. If any of your 1199SEIU patients are dealing with difficult treatment choices for terminal medical conditions, please encourage them to visit www.VitalDecisions.net or call our Member Services Department at (646) 473-9200 for more information about this supportive resource.
How Can You Participate? If you would like more information on how your practice can participate in Healthix, call (877) 695-4749. You can also visit http://Healthix.org/contact to request a demonstration of the Healthix Clinical Message Center, Clinical Event Notifications, Patient Record System and other functionalities.
Coverage Changes for Greater New York Benefit Fund Patients Effective September 1, 2015, your 1199SEIU patients covered by the Greater New York Benefit Fund no longer have co-payments for their prescription drugs. Affected members —active workers who are Eligibility Class I, as well as retirees—received a new Health Benefits ID card in August. Please ask your 1199SEIU patients for Health Benefits I.D. Card this card at each visit, and update their information in your records. To verify eligibility, you can also call our Interactive Voice Response (IVR) system at (888) 819-1199 on the date of service, or contact our Provider Relations Call Center at (646) 473-7160, and a representative will be happy to assist you.
Home Care Benefit Fund to Add Dependent Coverage Starting January 1, 2016 The 1199SEIU Home Care Benefit Fund will begin offering health coverage to members’ dependent children on January 1, 2016. That means your 1199SEIU patients who are Home Care workers or Home Health Aides may have added their children to their benefit plan. These members received a new Health Benefits ID card, which you should ask for at every visit, and update your records. Please also remember to check your 1199SEIU patients’ Health Benefits ID card to verify whether they are enrolled in Plan A or Plan B. Those who are enrolled in Plan A have no co-payments for medical services or prescriptions when they use their Health Center; those enrolled in Plan B have co-payments for medical services and prescriptions ($5 for doctor visits and $25 for inpatient hospital admissions). To verify eligibility, you can also call our Interactive Voice Response (IVR) system at (888) 819-1199. For more information, visit www.1199SEIUFunds.org/Providers.
Claims News Benefit Funds’ ICD-10 Transition Continues to Move Forward After months of testing, the Benefit Funds have successfully transitioned to the ICD-10 diagnosis and outpatient hospital procedure coding system as of October 1, 2015, as mandated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). To date, our claims system has been processing ICD-10 coded claims accurately and efficiently. To help avoid disruptions in claims processing or payment and prior authorization processes, please remember that claims for services provided on or after October 1, 2015, must use ICD-10 codes, while claims for earlier services should continue to use ICD-9 codes. Remember, claims with ICD-10 codes must be submitted with ICD-10 qualifiers. For more information on the Benefit Funds’ transition to the ICD-10 coding system, including a list of Frequently Asked Questions, please visit www.1199SEIUFunds.org/Providers/ ICD-10. If you have any additional questions about the Funds’ ICD-10 transition, please email them to ICD10@1199Funds.org.
Cardiology Procedures Requiring Prior Authorization Reminder: The following CPT codes for cardiovascular procedures have been added to the list of inpatient and outpatient services that require prior authorization through our vendor, CareAllies: •
Percutaneous Transcatheter Procedures – codes 93582 and 93583
Biventricular Pacing – codes 33271, 33272 and 33273
Transcatheter Mitral Valve Repair – codes 33418 and 33419
Cardioverter Defibrillator Pulse Generators – codes 33230, 33231 and 33240
To request prior authorization for the above-listed cardiology procedures, you must download a CareAllies Initial Pre-Certification Request Form from www.1199SEIUFunds.org/Providers (scroll down to “Provider Resource Center,” and click on “Forms and Resources.” Then scroll down and click on “Forms for Authorization”). Please fax the completed form to CareAllies at (866) 535-8972. If your request is approved, an approval letter will be faxed to you. If your request is denied, the determination letter will be faxed to you and will include information on how to appeal the decision.
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Prescription Drug Coverage News Filling Long-Term Prescriptions for Your 1199SEIU Patients The Funds recently made changes to The 1199SEIU 90-Day Rx Solution program so that your 1199SEIU patients can more easily fill three-month prescription orders for long-term medications at their local Rite Aid pharmacies. In addition to filling prescriptions at Rite Aid, your 1199SEIU patients may also still use Express Scripts’ home delivery service. Please be reminded that after the same medication has been refilled twice in 30-day increments, it must be transferred to a 90-day supply.
One New Specialty Drug Class Added to the Specialty Medications List Accredo, the Benefit Funds’ specialty care pharmacy, has added a new specialty drug class, effective January 1, 2016, for the intrauterine device (or subdermal implant), with preferred drugs Liletta® and Nexplanon®. If you are prescribing any medications that require refrigeration or other specialty handling, you must prescribe them through Accredo. In these cases, please call Accredo at (800) 987-4904 and provide them with the patient’s 1199SEIU Member ID number. An Accredo specialty pharmacist will arrange for the medication to be delivered directly to your patient or your office.
Five New Drug Classes Added to the Benefit Funds’ Preferred Drug List Our clinical staff regularly review the 1199SEIU Benefit Funds’ Preferred Drug List (PDL) to help ensure our members have access to the most cost-effective and clinically proven medications. Effective January 1, 2016, the Benefit Funds added five new drug classes to the PDL: • • •
PCSK9 inhibitors – used to treat high cholesterol Alzheimer’s agents – used to treat Alzheimer’s disease and dementia Long-acting muscarinic antagonists (LAMAs)/ Long-acting beta agonists (LABAs) combination – used to treat asthma SGLT2 inhibitor/DPP4 inhibitor – used to treat Type 2 diabetes Weight loss agents – used to treat obesity
We have also made changes to four existing drug classes, including: • • •
Hepatitis C genotype 3 – Sovaldi® plus ribavirin therapy is now a non-preferred treatment Long-acting muscarinic antagonists (LAMAs) – Incruse® Ellipta® is now a non-preferred drug Irritable bowel syndrome with constipation (IBS-C) – Amitiza is now a non-preferred drug
Please note that Nexium 24-hour OTC is now a covered prescription benefit and should be prescribed as a preferred, brand-name drug. If your patient needs 40mg of Nexium daily, it is available as one package of 42 capsules (21-day supply). If you would like to prescribe an 84-day supply, then the prescription should be prepared as four packages of 42 capsules. Before prescribing medications for your 1199SEIU patients, please check the most up-to-date PDL, effective January 1, 2016, at www.1199SEIUFunds.org/Providers.