Plan and Program News
Claims News
A Message from Our Chief Medical Officer:
Dr. Van H. Dunn Partnership with eviCore healthcare Is Expanded To help ensure your 1199SEIU patients receive the highest, most consistent standard of cancer treatment, the 1199SEIU Benefit Funds have expanded our partnership with eviCore healthcare, effective April 1, 2016. Using established, evidencebased clinical pathways, eviCore supports clinicians in pursuing the most effective course of action for medical oncology treatment by reviewing pre-service elective radiation therapy and medical oncology services, as well as outpatient hightech radiology and nuclear cardiology studies. This expanded partnership will help maintain consistency in diagnoses and treatment methodology, and reduce disparities in treatment and outcomes for 1199SEIU cancer patients. The partnership and prior authorization process will also help limit patients’ exposure to potentially harmful treatments and encourage a more holistic and patient-centered approach to healthcare delivery. For more information, visit www.1199SEIUFunds.org.
In my first message to you, our participating providers, let me begin by saying that I am honored to serve as the Chief Medical Officer of the 1199SEIU Benefit Funds. The Benefit Funds administer healthcare coverage to our members and their families in a manner that not only helps ensure they receive quality care but also helps them avoid unnecessary out-of-pocket costs. Removing financial barriers to medical care is integral to our mission of providing our more than 400,000 covered lives with the care they need when they need it, and I applaud the role you play in delivering that care. All health plans have rules that their covered participants need to follow, but at the Funds we have developed our rules and programs with these two objectives in mind: providing quality care while minimizing members’ out-of-pocket costs. When our members follow plan rules, with your support, they may have no cost at all. So when you read about plan requirements in Provider Connections, such as adhering to the Preferred Drug List (PDL) or obtaining prior authorization for medical oncology, we hope you will see the benefit to our members. We value our partnership with you, and we appreciate your professionalism and dedication to our shared mission. I look forward to working with you and building a relationship that will continue to support our members’ health and well-being.
Do Not Use Unlisted Billing Codes When a Valid CPT Code Exists Please avoid submitting claims with unlisted billing codes unless you are certain a corresponding Current Procedural Terminology (CPT) code is not available. Using unlisted codes will delay the processing of your claim and may result in a denial of payment. If you have questions about which CPT billing code to file with your claim, please call (646) 473-7160, and a Provider Relations Representative will assist you.
Prescription Drug Coverage News
New Diabetes Drug Class Added to Preferred Drug List Our clinical pharmacists regularly review our Preferred Drug List (PDL) to help ensure that our members have access to the most cost-effective and clinically proven medications. Effective July 1, 2016, the Benefit Funds have added a new PDL class for diabetes drugs: •
Basal insulin
We have also made changes to eight additional drug classes: • DPP-4 inhibitors • GLP-1 receptor agonists • SGLT2 inhibitors • Blood glucose test strips • Antipsychotics • Hyaluronic acid derivatives • Ulcerative colitis agents • Testosterone replacement agents
Sincerely, Dr. Van H. Dunn Chief Medical Officer
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Provider Connections
Summer/Fall 2016
Before prescribing medications for your 1199SEIU patients, please review the most recent PDL, effective July 1, 2016, at www.1199SEIUFunds.org/Providers.
Reminder: Electronic Prescribing of Medications Is Mandatory in New York If you provide medical care in New York State, remember to submit prescriptions for your 1199SEIU patients electronically. Effective March 27, 2016, the state began requiring that providers electronically send prescriptions for both controlled and non-controlled substances directly to pharmacies, with limited exceptions. The law is aimed at reducing fraud, improving efficiency, limiting dispensing errors by avoiding illegible handwriting and promoting greater accountability of provider prescribing habits. The mandate is an extension of the state’s Internet System for Tracking Over-Prescribing Act (I-STOP), enacted in 2013, which required all New York prescribers to consult the Prescription Monitoring Program Registry when writing a prescription for a Schedule II, III, IV or V controlled substance. For more information, please visit www.health.ny.gov/professionals/narcotic/electronic_ prescribing/docs/epcs_faqs.pdf.
Provider Connections
Summer/Fall 2016
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