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SUMMER 2008
Your Key to the 1199SEIU Benefit Funds
New Prior Authorization Process for Certain Drugs Begins August 1, 2008 Back in October of last year, the 1199SEIU Benefit Funds instituted a “Step Therapy” program for the medication Nexium, requiring members to try the less-costly omeprazole before using Nexium. Due to the success of this program, we will now be extending step therapy to other medications, which became effective Friday, August 1, 2008. Under the 1199SEIU Benefit Fund’s Step Therapy policy, our members must first try established, lower-cost, clinically appropriate medications before moving on to other, more costly medications such as preferred brand names. Of course, if the medication is not effective in treating the member’s condition, you can request authorization for the higher-cost medication.
Refer to Participating Providers So Your 1199SEIU Patients Don’t Pay the Bill When you refer your 1199SEIU patients to a specialist or a facility, radiology, lab services, or any other ancillary services, be sure to refer them to an 1199SEIU participating provider. Referring within our network of credentialed providers helps our members get the high quality care they are entitled to with no out-of-pocket costs. For a complete list of participating specialists, lab and radiology providers, visit our website at www.1199SEIUBenefits.org. • For radiology services: Medfocus (888) 910-1199 • For diagnostic testing: Laboratory Corporation of America (LabCorp) (800) 788-9091 • Quest Diagnostics (800) 877-7530 • Bendiner and Schlesinger (877) 240-0349 • Centralized Lab Services (718) 786-2300
This means that 1199SEIU providers must follow a new authorization process when prescribing certain medications. (Please see a list of medications in the chart below). In addition to the medications listed below, certain cancer therapy, Pulmonary Arterial Hypertension (PAH) and miscellaneous hormone drugs will also be included in this Step Therapy policy. A Medco representative will be in contact with you to advise of the affected medications and provide further details. To arrange an authorization review, call Medco toll-free at (800) 417-1764, 8:00 am to 9:00 pm, Monday through Friday. You will also need to submit the necessary clinical documentation to Medco. If you fail to do so, your 1199SEIU members’ prescriptions may be rejected or they may be subject to expensive out-of-pocket costs. Medications Subject to Step Therapy Prior Authorization Rules Step Therapy Category
Preferred Brand
Non-Preferred Brand
Anemia • Aranesp *Note: Patients who have been taking Procrit or Epogen for less than 8 weeks will be permitted to remain on the Non-Preferred Brand for 8 weeks. Proper documentation is still required.
• Procrit • Epogen
Hepatitis C • Peg Intron *Note: All patients who are taking Pegasys prior to August 1, 2008, will be allowed to remain on the Non-Preferred Brand medication and be “grandfathered” into the system. Proper documentation is still required.
• Pegasys
Growth Hormone
• Genotropin • Saizen • Omnitrope • Accretropin
• Norditropin • Humatrope • Nutropin • Tev Tropin
Message from the Executive Director At the 1199SEIU Benefit Fund, our members’ health is our top priority. So, we do all we can to give you the tools you need to provide our members with the best possible care. From our Provider Relations Department to our 24-hour automated system to check claims and eligibility status, we are providing services to help work hand in hand with you. Good patient care depends upon our members and providers understanding the scope of the benefits we provide, and how to access them. And that’s what you’ll read about inside this issue of 1199SEIU Provider Connections. Working together, we can ensure that our members – your patients – are receiving the quality care that they need.
Mitra Behroozi
There’s Still Time to Help Strengthen Our Network The 1199SEIU Benefit Fund Credentialing Committee is still in the process of re-credentialing our providers. If you are a board-certified participating provider, come join our Committee and help make our network the best it can be. As a peer reviewer, you have the chance to use your expertise to ensure that our providers are being credentialed accurately. To join the Committee, or for more information, please contact Stephanie Price at sprice@1199funds.org.
Check Eligibility and Claims Status 24 Hours a Day The 1199SEIU Benefit Fund now offers you an automated system to check the eligibility of National Benefit Fund and Greater New York members, as well as the status of your pending claims. You can also check eligibility and claims for 1199SEIU Home Care members for services rendered up to April 1, 2008. This service is available 24 hours a day, seven days a week. Just call (888) 819-1199 and have your tax ID number, member ID number and the member’s date of birth on hand.
Have Your Claims Processed Faster by Using Correct Billing Codes The more accurately you fill out your claims, the quicker the 1199SEIU Benefit Fund can process your claims. • Anesthesia Services: Bill for Anesthesia Services using a CPT Anesthesia Code from 00100 to 01999. Using CPT surgical codes should be limited to providing pain management services. • Radiology Services: When billing for radiology services involving both limbs, affix modifiers LT/RT to the CPT code and the number of units. If you use modifier 50 (bi-lateral procedure), do not add 2 units as the modifier 50 already applies 2 units to any CPT code. If the definition of a CPT code indicates multiple views, the claim line should be billed with one unit, unless the service is bilateral, in which case the modifiers LT/RT should be posted. If the CPT definition encompasses a number of items, only one unit should be billed. For example, use CPT code 11900 (intralesional injection) for up to and including 7 lesions, and CPT code 11901 (intralesional injection) for more than 7 lesions.
Refer 1199SEIU Members With Chronic Conditions to Our Health Coaching Service The 1199SEIU Benefit Fund has added health coaching by telephone to our suite of wellness services for 1199SEIU members. Now when you treat one of our members for asthma, diabetes or high blood pressure, you can also refer them directly to our Health Coaches, who can support your course of treatment and answer their questions even when they can’t visit the doctor. Over the past few months, our Health Coaches have been reaching out to members with a history of these conditions. But if you are seeing an 1199SEIU member who is newly diagnosed with diabetes, high blood pressure, asthma, or another chronic condition, let them know about this added support. It just takes one call to reach out to a Health Coach, and our coaches will follow up with ongoing support. Our Health Coaches are available around-the-clock, and there’s no limit to how many times a member can call. 1199SEIU members can call the Health Coach line toll-free at (866) 935-1199, at any time of the day or night, to reach a trained healthcare professional. Nurse Helpline Gives Members Access to Advice 24/7 In addition to health coaching, we also offer a 24-Hour Nurse Helpline. A trained professional is always on hand to answer members’ questions on any health topic at all – from the difference between two medications to quitting smoking to a child’s fever in the middle of the night. Refer your 1199SEIU patients to the 24-Hour Nurse Helpline at (866) 935-1199. Toll-Free 1199SEIU Health Coaching and 24-Hour Nurse Helpline: (866) 935-1199
