300 Hillmont Ave., Ventura, CA 93003 (805) 652-6165 or (805) 652-6000
Santa Paula Hospital A Campus of Ventura County Medical Center 825 N. 10th Street Santa Paula, CA 93060 (805) 933-8632 or (805) 933-8600
Ventura County Health Care Plan on call Administrator available 24 hours per day for emergency Providers (805) 981-5050 or (800) 600-8247
Available 24 hours a day, 7 days a week for Member questions regarding their medical status, about the health plan processes, or just general medical information.
There is also a link on the member website: vchealthcareplan.org/members/memberIndex.aspx that will take Members to a secured email where they may send an email directly to the advice line. The nurse advice line will respond within 24 hours.
To speak with VCHCP UM Staff, please call the Ventura County Health Care Plan at the numbers below:
QUESTIONS? CONTACT US:
MONDAY - FRIDAY, 8:30 a.m. to 4:30 p.m.
Phone: (805) 981-5050 or toll-free (800) 600-8247
FAX (805) 981-5051, vchealthcareplan.org
Phone: (805) 981-5050 or toll-free (800) 600-8247
FAX (805) 981-5051, vchealthcareplan.org
TDD to Voice: (800) 735-2929 Voice to TDD: (800) 735-2922
Ventura County Health Care Plan 24-hour Administrator access for emergency providers: (805) 981-5050 or (800) 600-8247
Language Assistance - Language Line Services: Phone (805) 981-5050 or toll-free (800) 600-8247
TIMELY ACCESS REQUIREMENTS
VCHCP adheres to patient care access and availability standards as required by the Department of Managed Health Care (DMHC). The DMHC implemented these standards to ensure that members can get an appointment for care on a timely basis, can reach a provider over the phone and can access interpreter services, if needed. Contracted providers are expected to comply with these appointments, telephone access, practitioner availability and linguistic service standards.
If a timely appointment is not available at any of our contracted clinics/facilities, then an out-of-network (OON) referral request should be sent by the referring provider to the Plan for authorization. The authorization request must include the details regarding the access issue and why an OON referral is required.
Note: The referring provider may allow for an appointment outside of the timely access requirements if it will not be harmful to the patient’s health. These instances must be documented in the patient’s chart and communicated to the patient.
Electronic Claim Submission
PROVIDERS: You can transmit your CMS-1500 and UB-04 claims electronically to Ventura County Health Care Plan through Office Ally. Office Ally offers the following services and benefits to Providers: No monthly fees, use your existing Practice Management Software, free set-up and training, 24/7 Customer Support, and other clearinghouse services.
Just think….no need for the “paper claim”.
Within 24 hours, your File Summary is ready. This report will list the status of all your claims received by Office Ally. This acts as your receipt that your claims have been entered into their system.
The File Summary reports all claims you’ve sent and are processed correctly; as well as keeping track of rejected claims that you may need to resubmit for processing.
Ready to make a change for the better???
CONTACT OFFICE ALLY AT: (360) 975-7000 or officeally.com
You can also reach out to us at VCHCP.ProviderServices@ventura.org for a copy of the Provider Welcome Packet.
Language and Communication Assistance
Good communication with VCHCP and with your providers is important. If English is not your first language, VCHCP provides interpretation services and translations of certain written materials.
• To ask for language services call VCHCP at (805) 981-5050 or (800) 600-8247. You may obtain language assistance services, including oral interpretation and translated written materials, free of charge and in a timely manner. You may obtain interpretation services free of charge in English and the top 15 languages spoken by limited-English proficient individuals in California as determined by the State of California Department of Health Services.
• If you are deaf, hard of hearing or have a speech impairment, you may also receive language assistance services by calling TDD/TTY at (800) 735-2929.
• If you have a preferred language, please notify us of your personal language needs by calling VCHCP at (805) 981-5050 or (800) 600-8247.
• Interpreter services will be provided to you, if requested and arranged in advance, at all medical appointments.
If you have a disability and need free auxiliary aids and services, including qualified interpreters for disabilities and information in alternate formats, including written information in other formats, you may request that they be provided to you free of charge and in a timely manner, when those aids and services are necessary to ensure an equal opportunity for you to participate.
Did you know?
DIRECT SPECIALTY REFERRAL
• Did you know that the direct specialty referral allows contracted Primary Care Physicians to directly refer members to certain contracted specialty providers for an initial consult and appropriate follow up visits without requiring a Treatment Authorization Request (TAR) submission and prior authorization from the Health Plan?
• Did you know that specialists can perform certain procedures during the initial consultation and follow up visits without prior authorization from the Health Plan? Also, any follow up visits will not require prior authorization as long as the member has seen the specialist within a rolling year and the visit is for the original problem.
45 DAY PEND PROCESS
• Did you know that Utilization Management Department’s Intake sends pend notes to requestor via Cerner (if VCMC provider) or place phone calls to requestor (if Non-VCMC provider)?
• Did you know that the Plan’s Medical Director reviews all pend and denial letters/determinations for appropriateness prior to sending to providers?
MEDICAL POLICIES
• Did you know that the Plan’s Medical Director continues to review existing medical policies and create new medical policies, if needed?
How to Find a Provider
The online Provider Directory is updated weekly thus providing the most accurate information available. This can be found in our website vchealthcareplan.org via the “Find a Provider” link. For a printed copy of the directory contact Member Services at (805) 981-5050 or (800) 600-8247 or email VCHCP.Memberservices@ventura.org.
Select your plan:
Select a provider type:
Select a specialty:
Select a city:
Select a language:
Select a gender:
Select Name of Clinic...
Select Name of Hospital...
TIP: When searching for a specialist, make sure to select a specialty but ensure that the provider type is set at “All Provider Types” as selecting a provider type will limit the options available.
UPDATING OFFICE INFORMATION
• Adding/terminating a provider or location
•
VCHCP Maternal Mental Health Program and Maternal Infant Health Program
Effective January 1, 2025, VCHCP’s existing maternal mental health program will cover at least one maternal mental health screening to be conducted during pregnancy, at least one additional screening to be conducted during the first six weeks of the postpartum period, and additional postpartum screenings, if determined to be medically necessary and clinically appropriate in the judgment of the treating provider. In compliance with the new legislation AB1936, VCHCP will incorporate the required maternal mental health screenings into its existing maternal mental health program by covering the screenings without prior authorization, without cost sharing and ensuring that the claims submitted for these screenings are paid.
Effective January 1, 2025 , VCHCP is implementing a maternal and infant equity program. This will be incorporated in the Plan’s existing maternal mental health programs. The maternal and infant equity program will address racial health disparities in maternal and infant health outcomes by offering Doula services.
✓ The Plan will use Prenatal and Post partum Care HEDIS measure to identify racial health disparities in maternal and infant health outcomes. Intervention will be implemented through the use Doulas on those races with low score on Prenatal and Postpartum HEDIS measure.
✓ The Plan will use its existing Prenatal Care and Post Partum Follow-Up Programs, to include Doulas as an activity. Races who are identified with low HEDIS scores will be targeted in the HEDIS quality intervention program such as outreach to members encouraging the use of Doulas.
✓ The Plan will use its Prenatal Care and Post Partum Follow-Up HEDIS measure to evaluate the effectiveness of the maternal and infant health program. Races who are identified with low HEDIS scores will be further targeted for doulas intervention.
✓ The Plan will ensure access to Doulas by covering Doula services during the member’s pregnancy including prenatal, perinatal and post-partum stages, with a direct referral from the member’s doctor. Doula Services will be added on the Plan’s Evidence of Coverage (EOC). Providers can also reference the Provider Operations Manual for doula services. Doula providers will be added to the Plan’s provider website (Provider Directory Find the Provider Hyperlink). Providers may call VCHCP provider services (805) 981 5050 for additional information on Doula services.
Doulas
A Doula is a trained and certified professional who can provide support before, during and after delivery. They do not deliver the member’s baby, but instead compliment the care they will receive from your healthcare team. Having a doula may provide a great experience during a major milestone in their lives. According to the American Pregnancy Association Doulas provide emotional, physical and educational support to a mother who is expecting, is experiencing labor or has recently given birth. The purpose of having a Doula is to help empower women to have a safe, memorable and empowering birth experience.
Types of Doulas:
• Birth Doula – Sometimes called birth companions or labor doulas. They prepare you for childbirth and ongoing support during labor.
• Antepartum Doula – Assists with pregnancy that require special attention such as high-risk pregnancies (i.e. bed rest or unmanageable symptoms).
• Post Partum Doula – Provides assistance after delivery. They assist in adjustment of life with an infant.
Doulas typically meet with women and their partner every few months throughout their pregnancy to build rapport and discuss their goals of birth. This can be beneficial to women who have limited support system and who might otherwise be alone during the later stage of their pregnancy and childbirth. Doulas serve as your advocate and can help facilitate a positive and safe birthing experience.
Ventura County Health Care Plan will now be covering Doula services effective January 1, 2025.
American Pregnancy Association. (2024). Having a Doula – What are the Benefits? americanpregnancy.org/healthy-pregnancy/labor-and-birth/having-a-doula/ Harvard Health Publishing. (2023). What does a birth Doula do? health.harvard.edu/blog/what-does-a-birth-doula-do-202311222995 Cleveland Clinic. (2022). Doula. my.clevelandclinic.org/health/articles/23075-doula
BIOMARKER TESTING
VCHCP covers biomarker testing and does not require prior authorization (as mandated by SB535) for an enrollee with advanced or metastatic stage 3 or 4 cancer; and cancer progression or recurrence in the enrollee with advanced or metastatic stage 3 or 4 cancer, effective July 1, 2022. VCHCP covers biomarker testing as mandated by SB496. This bill would require a health care service plans on or after July 1, 2024, to provide coverage for medically necessary biomarker testing, as prescribed, including whole genome sequencing, for the purposes of diagnosis, treatment, appropriate management, or ongoing monitoring of an enrollee’s disease or condition to guide treatment decisions. Prior authorization is required.
In accordance with Health and Safety Code Section 1367.665(b), the Plan will cover and will not require prior authorization for biomarker testing for enrollees with a cancer diagnosis. Personal history of cancer is covered and will not require prior authorization; however, providers must provide applicable cancer or personal history of cancer diagnosis codes at point of claims. Any diagnosis codes (ICD 10 codes) included in the diagnosis code group below do not require prior authorization.
• Cancer diagnosis codes: C00 through C96.Z
• History of cancer diagnosis code: Z85 through Z85.9
In accordance with Health and Safety Code Section 1367.667, the plan will cover biomarker testing for enrollees who does not have cancer diagnosis and personal history of cancer if it meets medical necessity criteria after utilization management review. Medical necessity will be determined using applicable VCHCP medical policies or Milliman Care Guidelines criteria. Any restricted or denied use of biomarker testing for the purpose of diagnosis, treatment, and ongoing monitoring of any other medical condition may be disputed through the Plan’s grievance and appeal processes.
The bill requires the Plans, on or after July 1, 2024, to cover biomarker tests that meet any of the following:
• A labeled indication for a test that has been approved and cleared by the FDA or is an indicated test for an FDA-approved drug.
• A national coverage determination made by the Centers for Medicare and Medicaid Services.
• A local coverage determination made by a Medicare Administrative Contractor for California.
• Evidence-based clinical practice guidelines, supported by peer-reviewed literature and peerreviewed scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff.
The bill requires the Plan to abide by the process described in Health and Safety Code Section 1363.5 to determine whether biomarker testing is medically necessary for the purposes of SB 496. Health and Safety Code Section 1363.5 involves the Plan’s disclosure to members and providers it utilization management process to authorize, modify or deny health care services under the benefit provided by the Plan. This includes the criteria/medical policies used to make determinations. It also includes Plan’s disclosure to members and providers the process to request its UM policy and procedure and criteria/medical policies used to make determinations. Health and Safety Code Section 1367.01 involves notifications of decisions to deny, delay or modify services requested by the providers, to enrollees verbally or in writing.
The bill requires the Plan to ensure that biomarker testing is provided in a manner that limits disruption in care, including the need for multiple biopsies or biospecimen samples. The bill also requires the Plan to ensure that restricted or denied use of biomarker testing for the purposes of diagnosis, treatment, or ongoing monitoring of any medical condition is subject to grievance and appeal processes.
PROCEDURE
1. SB 535 Biomarker for advanced cancer includes CPT code range of 81400-81408.
2. SB 496 Biomarker includes but is not limited to these CPT codes:
0062U – IgG and IgM analysis of 80 biomarkers of systemic lupus erythematosus in serum
0310U– Analysis of 3 biomarkers (NT-proBNP, C-reactive protein and T-uptake) for Kawaski disease in plasma specimen
3. Please refer to the Plan’s Utilization Management Policy & Procedure: Treatment Authorization Request Authorization Process and Timeline Standards to address compliance with Health and Safety Code Section 1363.5. The Plan’s Member and Provider Newsletters direct providers and members to the Plan’s website on how to access Plan’s criteria/ guidelines and policies.
Click Treatment Authorization Request: Authorization Process and Timeline Standards for further information
4. Please refer to the Plan’s Utilization Management Policy for Appeals to address compliance with Health and Safety Code Section 1367.667. The Plan’s Member and Provider Newsletters direct providers and members to the Plan’s website on how to access Plan’s criteria/guidelines and policies.
VCHCP’S GENETIC LABORATORIE S
Before referring your patients to an ancillary provider, or sending out a lab specimen, please make sure that the provider/facility is within the VCHCP network. Out of network claims will be denied unless previously authorized by the Plan.
As a reminder, all genetic lab tests require a prior authorization. When submitting a Treatment Authorization Request (TAR) to our UM Department Fax 805-658-4556 for review, please refer to one of the following contracted labs:
Esoterix (Genetics) Laboratory Services
Test Menu Available: specialtytesting.labcorp.com/test-menu/search 800-444-9111 (P)
Quest Diagnostics
Test Menu Available: testdirectory.questdiagnostics.com/test/home 866-GENE-INFO (866-436-3463) (P)
Natera, Inc.
natera.com
650-249-9090 (P), 650-730-2274 (F)
Ambry Genetics Corporation
Test Menu Available: ambrygen.com/providers 949-900-5500 (P), 949-900-5501 (F)
TOPA Diagnostics
Test Menu Available: topathology.com 805-373-8582 (P), Email: clientservice@topathology.com
LabCorp: Laboratory Corporations of America Holdings, Laboratory Corporation of America and Sequenom Center for Molecular Medicine for their NIPT
Test Menu Available: labcorp.com/test-menu/search Submit Provider Inquiries: labcorp.com/help/contactinfo-for-provider/provider-inquiry
➣ Please visit our website for access to our blank TAR form, more information on the process, and a list services that require prior authorization.
➣ If the above contracted genetic labs do not perform the test you need, you may submit a TAR to our UM department who will review for necessity and may issue a case agreement. Please indicate the type of test needed.
if you need
OptumHealth QUALITY PROGRAM
VENTURA
COUNTY HEALTH CARE PLAN contracts with OptumHealth Behavioral Solutions (Life Strategies) for Mental/Behavioral health and substance abuse services. OptumHealth has a Quality Improvement Program (QI) that is reviewed annually.
If you would like to obtain a summary of the progress OptumHealth has made in meeting program goals, please visit OptumHealth’s online newsletter at vchealthcareplan.org/members/docs/OptumHealthNEWSLETTER.pdf or call OptumHealth directly at (800) 851-7407 and ask for a paper copy of the QM program description.
• Identify local MAT and behavioral health treatment providers and provide targeted referrals for evidence-based care
• Educate members/families about substance use
• Assist in finding community support services
• Assign a care advocate to provide ongoing support for up to 6 months, when appropriate
Optum Behavioral Health Toolkit for Medical Providers
These are one-page documents that provide best practice information in support of Optum’s HEDIS® measures. These pages contain lots of information about treating behavioral health conditions in a primary care setting.
EXAMPLE OF MATERIALS AVAILABLE INCLUDES:
• Alcohol and Other Drug Dependence: Initiation and Engagement in Treatment
• Antidepressant Medication Management
• Best Practices for Children and Adolescents on Antipsychotic Medications
• Follow-Up Care for Children Prescribed ADHD Medications
• Metabolic Screening for Children and Adolescents on Antipsychotic
• Use of Multiple Concurrent Antipsychotic Medications in Children and Adolescents
RESOURCES ARE AVAILABLE VIA THIS LINK: providerexpress.com/content/ope-provexpr/us/en/clinical-resources/PCP-Tool-Kit.html
Accessing Services
for Behavioral Health
Contact OptumHealth Behavioral Solutions of California “Life Strategies” Program at (800) 851-7407 or visit the website at Liveandworkwell.com/content/en/public.html .
Further information may also be obtained by consulting your Ventura County Health Care Plan Commercial Members Combined Evidence of Coverage (EOC) Booklet and Disclosure Form.
Contact VCHCP Member Services at (805) 981-5050 to request an EOC copy or go to the Plan’s website at vchealthcareplan.org/members/programs/docs/countyemployees/EOCCountyAndClinicEmp2024.pdf.
Optum contact information can also be found at the back of member’s VCHCP health insurance card.
Information on authorization of Plan Mental Health and Substance abuse benefits is available by calling the Plan’s Behavioral Health Administrator (BHA) at (800) 851-7407. A Care Advocate is available twenty-four (24) hours a day, seven (7) days a week to assist you in accessing your behavioral healthcare needs. For non-emergency requests, either the member or their Primary Care Provider may contact Life Strategies for the required authorization of benefits prior to seeking mental health and substance abuse care.
Further information may also be obtained by consulting the Ventura County Health Care Plan Commercial Members Combined Evidence of Coverage (EOC) Booklet and Disclosure Form. Click HERE to view all activities for this series.
Integration of behavioral health services into the clinical primary care setting is often an overlooked component of population health management. The integration of these two specialties is an important care model needed to successfully manage population health and improve outcomes. This series will discuss best practices for the integration of behavioral care into a primary care setting.
PART 1
Mental Health Disorders and Follow-up after Higher Levels of Care
Presenter: Robin M. Reed, MD, MPH Activity Expiration Date: June 8, 2027
PART 2
Substance Use Disorders in Primary Care
Presenters: Steven Daviss, MD, DFAPA, FASAM and Brian P. Goldstein, MD, MBA, FACP Activity Expiration Date: October 31, 2024
PART 3
Behavioral Health Treatment for Children and Adolescents
Presenters: Robin K. Blitz, MD and Debra M. Katz, MD Activity Expiration Date: February 14, 2025
(805) 981-5050 if you need
or
2024 PROVIDER SATISFACTION with Behavioral Health Providers’ Timeliness of Communication
The 2024 Provider Satisfaction Survey was completed, and we would like to thank the 69 respondents!
We at VCHCP heard your feedback and we have been working closely with Optum Behavioral Health (BH) to improve Medical and Behavioral Health Providers’ communication and coordination of care.
In collaboration with Optum Behavioral Health, we have implemented actions to improve provider satisfaction on the timeliness of feedback/reports from behavioral health providers to the Plan’s Primary Care Physicians (PCPs). These actions include but are not limited to the following:
• Continued education of Behavioral Health Providers regarding coordination of care with primary care physicians to encourage members to complete the Release of Information (ROI) form. This will allow medical records to be shared with primary care physicians/medical providers.
• Shared members’ primary care physicians/medical providers contact information to high volume mental health providers to encourage communication.
• Provided Medical-BH Toolkit website to primary care
physicians/medical providers. This website contains BH screening tools and resources to help primary care physicians/medical providers identify tools that best fit their practice and patients.
• Encouraged members with mental health or substance abuse disorder diagnoses to follow up with their BH providers when discharged from the hospital or emergency room.
• Shared educational BH resources with primary care physicians/medical providers and behavioral care providers to encourage coordination of care:
• Optum Network Notes regarding the Important Information about Coordinating Care
• PCP/Pediatric Provider Questionnaire Surveys regarding Behavioral Health Treatment and Referrals Survey Results and Interventions (Optum BH shares PCP/Pediatric Providers Survey Results to BH/Mental Health Providers for Coordination of Care)
• Education on how to access behavioral health and substance abuse resources including Optum BH intake and referrals
• Member and Provider Newsletter articles on coordination of care
If you have any suggestions or comments to make this process better, please call our Medical Director at (805) 981-5060.
Our goal is to continue to improve communication and coordination between PCPs and Behavioral Health Providers. It is our hope that all these interventions will help to meet our goal. As a Health Plan, we are working diligently to improve PCP and BH communication for the satisfaction of providers and wellness of our members.
Antidepressant Medication Screening & Management
Behavioral Heath Referrals – Provider Types
Behavioral Health Referrals - Provider Types
Shorter Wait Times
We appreciate you taking an active role in screening your patients for depression
Therapist
Psychologist
Longer Wait Times
Psychiatrist
The American Psychiatric Association recommends patients complete the Patient Health Questionnaire (PHQ-9) screening tool
Use a screening tool
Master’s degree in mental health, social work, counseling or family therapy
• The PHQ-9 can aid in identifying the severity of depressive symptoms, especially before prescribing medication
Doctoral degree in Psychology (PhD, PsyD)
Licensure type includes:
• Licensed clinical social worker (LCSW)
• The PHQ-9 instruction manual recommends consideration of medication only for those patients who score in the moderate to severe range (scores above 15)
See page 2 for a PHQ-9 scoring guide
• Licensed mental health counselor (LMHC)
Can give mental health and psychological testing Can offer psychotherapeutic interventions
Resources
Cannot prescribe medications
• More tools and information about behavioral health issues are available on providerexpress.com > Clinical Resources > Behavioral Health Toolkit for Medical Providers
• Marriage and family therapists (LMFT)
• Licensed professional counselor (LPC)
• Patient education information is available on liveandworkwell.com > use access code “clinician”
Mental Health Nurse Practitioner
Prior to prescribing an antidepressant for patients assessed to have Mild to Moderate Depression:
Advanced Practice Registered Nurse with a Master's degree. Trained and licensed to practice in psychiatric care
• Encourage the use of self-help apps for depression. Apps are useful for symptom tracking, sleep and meditation, self-guided therapy, or other supports.
Psychiatric Mental Health Nurse Practitioner (PMHNP)
Medical Doctors who focus on the prevention, diagnosis and treatment of mental or behavioral illnesses
• Refer to supportive counseling as first treatment recommendation
Medical degree with specialized training in mental health (MD, DO)
For patients assessed to have Moderate to Severe Depression:
• Consider prescribing an antidepressant
Can provide diagnostic testing, medication management, and offer psychotherapy
• Encourage follow-up visits to discuss medication side effects, response to treatment, and adherence. Consider telephonic check in with patients between in person visits.
Can offer a range of services including diagnostic testing, psychotherapeutic interventions and medication management
Can prescribe medication
Refer to a Mental Health Professional
Can give some tests and offer psychotherapeutic interventions
You can request coordination of care and referrals for patients by calling the number on the back of the patient’s health plan ID card or searching liveandworkwell.com > use access code “clinician”
Cannot prescribe medications
Most are boardcertified in psychiatry and neurology
• Review tips to increase medication adherence with patients. Help patients move past stigma and see treatment for mental health and physical health equally.
Can prescribe medications
• Discuss barriers and identify solutions at the time of the prescription
• Encourage use of mail-order prescription fill. Remind your patients to sign up for refill reminders through their pharmacy, or utilize self-help apps for pill and refill reminders
Effectively coordinating care between treatment professionals can lead to improved health outcomes. Please be sure to have the member sign a release of information form.
You may use your own form or click here to access the Optum Confidential Exchange of Information form.
Sources: Kroenke, K., Spitzer, R.L., & Williams, J.B. (2001). The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine. 16(9):606-13. doi: 10.1046/j.1525-1497.2001.016009606.x. American Psychiatric Association (2022). https://www.psychiatry.org/psychiatrists/practice/dsm/educational-resources/assessmentmeasures
United Behavioral Health and United Behavioral Health of New York, I.P.A., Inc. operating under the brand Optum U.S. Behavioral Health Plan, California doing business as OptumHealth Behavioral Solutions of California
United Behavioral Health and United Behavioral Health of New York, I.P.A., Inc. operating under the brand Optum U. S. Behavioral Health Plan, California, doing business as OptumHealth Behavioral Solutions of California
children and adolescents on
Children and adolescents on antipsychotic medications
Antipsychotic medications may serve as an effective treatment for a narrowly defined set of psychiatric disorders. However, studies show that providers are increasingly prescribing these medications to pediatric patients with conditions, such as ADHD, depression, anxiety disorders, behavioral disorders, and even insomnia, where psychosocial interventions are recommended as first-line treatment.1
The American Academy of Pediatrics (AAP) advises providers to take great care and consideration before prescribing antipsychotic medications, given their adverse effects 2, which include:
• Metabolic Syndrome
• Increased Prolactin Concentrations
• Extrapyramidal Symptoms
• Cardiovascular Changes
Helpful tools and resources
•A HEDIS® Overview is posted on providerexpressˌcom (Schizophrenia/Antipsychotic Medications).
•liveandworkwellˌcom You may find relevant articles and resources for your patients (use access code “clinician”)
• Telemental Health Overview Telemental health information for providers
The AAP guidelines on metabolic monitoring for pediatric patients receiving antipsychotic medications include baseline and ongoing measurement 2 of:
• BMI
• Waist Circumference
• Fasting Blood Glucose
• Hemoglobin A1c
• Fasting Lipid Concentrations
HEDIS® specifications state these tests 3 should be done yearly for children and adolescents on antipsychotics:
• Blood Glucose or Hemoglobin A1c
• LDL-C or Cholesterol
1. Agency for Healthcare Research and Quality. Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP). Available at: http://www.ahrq.gov
2. Hua, L. L., & COMMITTEE ON ADOLESCENCE (2021). Collaborative Care in the Identification and Management of Psychosis in Adolescents and Young Adults. Pediatrics, 147(6), e2021051486. https://doi_org/10_1542/peds_2021-051486
3. National Committee for Quality Assurance 2021 Hedis® Specifications, see NQF-Endorsed Measures at www.ncqa.org
Nothing herein is intended to modify the Provider Agreement or otherwise dictate MH/SA services provided by a provider or otherwise diminish a provider’s obligation to provide services to members in accordance with the applicable standard of care. This information is provided by Optum Quality Management Department. If you would like to be removed from this distribution, please contact us at email: qmi_emailblast_mail@optum.com. Please include the email address you would like to have removed when contacting us.
United Behavioral Health and United Behavioral Health of New York, I.P.A., Inc. operating under the brand Optum U. S. Behavioral Health Plan, California, doing business as OptumHealth Behavioral Solutions of California
Follow -up Care for Children Prescribed ADHD Medications
The American Academy of Pediatrics (AAP) recommends children and adolescents newly prescribed on ADHD medication have follow-up care with the prescriber within 2 weeks.*
Using this time frame as a best practice guideline also meets the HEDIS ® measure for 30-day follow-up after initiation of ADHD medication.**
Follow -up Recommendations:
• Schedule a follow-up appointment with a provider who has prescribing authority within 30 days of writing the prescription
• Ensure at least two more follow-up appointments occur, with any practitioner, over the next nine months to monitor medication effectiveness and side effects and provide psychosocial treatment
Consider Telehealth visits for:
• Children on non-stimulant medication who do not require an in-person follow-up visit for a physical examination
• Children who cannot return for an in-person visit within 30 days from their initial appointment. Telehealth can be an efficient way to check in with patients between in-person visits
Schedule follow -up appointments before your patients leave the office
Telehealth visits are an effective way to provide care. Visit our provider website at the following link for more information: Telehealth Overview
Patient education information is available on liveandworkwell.com, use access code “clinician”
*American Academy of Pediatrics at AAP.org
More tools and information available on Providerexpress.com > Clinical Resources > Clinical and Quality Measures Toolkit for Behavioral Providers.
**National Committee for Quality Assurance HEDIS® Specifications; see HEDIS and Quality Measures at NCQA.org .
Documenting substance use disorder (SUD) remission
Treatment for individuals with substance use disorder
How you can help
• Encourage your patient to schedule routine follow-up visits.
• Reach out if they do not attend their appointment.
• Obtain release of information (ROI) to include the patient’s family, support system and other providers.
• A ssess and work with the patient’s existing motivation to change, and address co-occurring medical-behavioral conditions.
Treating co-occurring disorders
• Discuss with your patient how continued treatment helps prevent relapse.
• Refer for medications for opioid use disorder (MOUD) or medications for alcohol use disorder (MAUD).
• For patients with an active primary or secondary diagnosis of moderate to severe substance use disorder (SUD), Optum recommends professional services in combination with community-based recovery support services.
Treatment timeline
When newly diagnosing individuals with a SUD, please schedule follow-up treatment within 14 days of the diagnosis and 2 or more additional services within 34 days of the initial visit.
Treatment support for opioid use disorders
Medications for opioid use disorder (MOUD) help control withdrawal symptoms and cravings and help maintain long-term stability.
About MOUD and MAUD
MOUD is the standard of care for OUD and supports recovery. It pairs FDA-approved medication with support services to treat substance use disorders and prevent opioid overdose.
There are many forms of MOUD which can be used to treat MOUD, such as agonist and antagonist therapies, which may be provided in a variety of treatment settings, including virtually.
Discontinuation of MOUD may result in relapse, overdose and death. Individuals engaged in MOUD and psychosocial supports have better outcomes than medication alone.
Pharmacotherapy for opioid use disorder
The Pharmacotherapy for Opioid Use Disorder (POD) HEDIS® measure assesses members ages 16 and older with an OUD with a new OUD pharmacotherapy event and on the medication for at least 180 days.
With MOUD, the relapse rate for those with OUD decreases to 50% at one year.
Metabolic testing and monitoring
For adult patients with a diagnosis of schizophrenia and/or prescribed antipsychotics
Second-generation antipsychotics and metabolic monitoring
The prevalence of diabetes is 2- to 3-fold higher in people with severe mental illness than the general population.1
“Second-generation antipsychotics (SGAs) can generate a metabolic syndrome, with insulin resistance, weight gain and hypertension.”
SGAs include clozapine, olanzapine, ziprasidone, risperidone, olanzapine- fluoxetine (combination) and quetiapine.2
Patients who need testing
• Diagnosis of schizophrenia and/or prescribed antipsychotics
• Diagnosis of diabetes or cardiovascular disease and schizophrenia
Metabolic lab testing3
HbA1c and LDL-C
• Complete metabolic testing upon initial diagnosis or initial prescription of antipsychotic medication
• Complete annual testing for all patients prescribed antipsychotics
• Complete more frequent testing, as needed, based on patients’ results
Helpful tools and resources
Providerexpress.com
You may use this Confidential Exchange of Information Form, or your own release of information form, to facilitate timely exchange of knowledge and referrals to providers.
Liveandworkwell.com
Find relevant articles and resources for patients (guest access code: clinician).
1. Holt RIG. Association between antipsychotic medication use and diabetes Curr Diab Rep. 2019;19(10):96.
2. Tamminga C. Antipsychotic drugs Merck Manual. September 2022.
Metabolic testing and monitoring for those diagnosed with schizophrenia and/or prescribed antipsychotics
Second Generation Antipsychotics and Metabolic Monitoring:
The prevalence of diabetes is 2 to 3-fold higher in people with severe mental illness than the general population.1
“Second generation antipsychotics (SGAs) can generate a metabolic syndrome, with insulin resistance, weight gain, and hypertension.”
SGAs include Clozapine, Olanzapine, Ziprasidone, Risperidone, OlanzapineFluoxetine (combination), and Quetiapine.2
Resources:
• Tools and information about behavioral health issues are available on Providerexpress.com at Behavioral Health Toolkit for Medical Providers.
• Patient education is available on liveandworkwell.com use guest access code “clinician”.
Sources:
1.Holt RIG. Association between antipsychotic medication use and diabetes Curr Diab Rep. 2019;19(10):96.
2.Tamminga C. Antipsychotic drugs Merck Manual. September 2022.
3. 2024 HEDIS measure.
Important Reminder:
Individuals diagnosed with schizophrenia and/or prescribed antipsychotic medication are recommended to have metabolic/lipid testing. Complete testing after an initial diagnosis or a new prescription of antipsychotic medication, and then repeat annually. 3
Annual Testing Includes:
• HbA1c or blood glucose AND
• LDL-C or cholesterol
Refer to a Mental Health Professional:
• liveandworkwell.com - mental health provider information, use guest access code “clinician”.
• Call the provider phone number on the back of the patient’s health plan ID card.
Coordination of Care:
Remember to ask for contact information for other treating providers to coordinate care, you may use this Confidential Exchange of Information Form to facilitate.
Assembly Bill 2585 –Nonpharmacological pain management treatment requires Ventura County Health Care Plan (VCHCP) to encourage the use of evidence-based nonpharmacological therapies for pain management.
The overarching goal of chronic pain management is to relieve pain and improve function. The National Pain Strategy (NPS) report recommends that management be integrated, multimodal, interdisciplinary, evidence-based, and tailored to individual patient needs. In addition to addressing biological factors when known, it is thought that optimal management of chronic pain also addresses psychosocial contributors to pain, while considering individual susceptibility and treatment responses. Self-care is an important part of chronic pain management. At the same time, the NPS points to the "dual crises" of chronic pain and opioid dependence, overdose, and death as providing important context for consideration and implementation of chronic pain management strategies. A vast array of nonpharmacological treatments is available for management of chronic pain. VCHCP’s health plan benefits include nonpharmacologic services to treat pain. These interventions include and are not limited to the following:
‣ Physical Therapy/Occupational Therapy
‣ Osteopathic Manipulative Treatment
‣ Acupuncture and Chiropractic Treatments*
‣ Behavioral Health Treatments for example, cognitive behavioral therapy or mindfulness-based stress reduction (MBSR). For more information, please visit Optum Behavioral Health’s Live Work Well website: healthwise.net/liveandworkwell/Content/StdDocument.aspx?DOCHWID=cpain%20
References
*Chiropractic and acupuncture: When part of Plan coverage, chiropractic, and acupuncture treatments, arranged by Member, may be offset by reimbursement to the member of a portion of the practitioner’s fee incurred by the member in receiving such therapy. Reimbursements are limited to a maximum per visit and an aggregate maximum per plan year.
VCHCP encourages the use of evidence-based nonpharmacological therapies for pain management such as physical therapy/occupational therapy, osteopathic manipulative treatment, acupuncture/chiropractic treatment xand behavioral health treatments (as listed above). Providers and Members will be made aware of the above nonpharmacological interventions via the biannual newsletters.
Obtained from Optum’s live work well healthwise.net/liveandworkwell/Content/StdDocument.aspx?DOCHWID=cpain effectivehealthcare.ahrq.gov/products/nonpharma-treatment-pain/research-protocol
HOW TO REQUEST A STEP THERAPY EXCEPTION, FORMULARY EXCEPTION AND PRIOR AUTHORIZATION EXCEPTION
Submitting Exception Requests To The Preferred Drug List
Members can request individual exceptions to the preferred drug list through their primary care practitioner or directly to VCHCP by phone or through the VCHCP website.
To submit an exception request to VCHCP, complete the online request form available in the VCHCP member website Request for Pharmacy/Formulary Exception = Pharmacy Prior Authorization (vchealthcareplan.org) or by calling the Plan at (805) 981-5050.
VCHCP will review the exception request and will either contact the member or reach out to the doctor to get more clinical information.
A Prior Authorization (PA) request can be submitted by the practitioner on the member’s behalf to VCHCP for consideration. Practitioners themselves may also initiate a petition for consideration of coverage. Practitioners should include relevant clinical history, previous medications prescribed and tried, contraindications or allergies to medications and any other contributory information deemed useful. VCHCP will review the information according to the PA policy. Because the PA requests are reviewed by the Plan and not the PBM, if the medication does not meet criteria on initial review by the nurse reviewer, it is reviewed by a physician reviewer and special consideration is given to the exception request based on the information received. The physician reviewers are also available by phone to discuss an exception request with the practitioner.
Negative Formulary Update
To ensure that prescribing practitioners are notified of “negative” formulary updates, a list of affected members is sent to VCHCP medical management staff by Express Scripts. The list of affected members has information on prescribing practitioners’ name and contact information, excluded medications and preferred medication alternatives.
The VCHCP Medical Management staff notifies prescribing practitioners by phone or fax or CERNER messaging of the change to the formulary and offers the preferred medication alternatives.
If a prescribing practitioner indicates medical necessity for the member to continue the excluded/non-formulary medication, the practitioner is informed that the request would be handled through the Plan’s formulary exception request authorization process.
The most up-to-date ESI website formulary information is accessible to members and providers at express-scripts.com and through a link on the VCHCP website at vchealthcareplan.org . For any other inquiries, call Express Scripts at 800-753-2851.
Population Health Management Programs
Ventura County Health Care Plan provides ongoing support of its members to meet their healthcare needs. Our goal is to empower members to take control of their health. VCHCP wants to be sure you are aware of the many programs, services, and activities offered by us to support your patients in their health care goals. Please visit our website at vchealthcareplan.org/members/docs/VCHCPPopulationHealthManagement.pdf to see the list of programs/services offered, how members are eligible to participate, and how they decide to participate. If you need further information or have any questions regarding the programs or activities offered, please contact VCHCP UM Staff at (805) 981-5060 or toll-free (800) 600-8247.
SUBMITTING EXCEPTION REQUESTS TO THE PREFERRED DRUG LIST
Members can request individual exceptions to the preferred drug list through their primary care practitioner or directly to VCHCP by phone or through the VCHCP website. Practitioners can then submit a Prior Authorization (PA) Request on the member’s behalf to VCHCP for consideration. Practitioners themselves may also initiate a petition for consideration of coverage. Practitioners should include relevant clinical history, previous medications prescribed and tried, contraindications or allergies to medications and any other contributory information deemed useful. VCHCP will review the information according to the Prior Authorization (PA) policy. Because the PA requests are reviewed by the Plan and not the PBM, if the medication does not meet criteria on initial review by the nurse reviewer, it is reviewed by a physician reviewer and special consideration is given to the exception request based on the information received. The physician reviewers are also available by phone to discuss an exception request with the practitioner.
SUBMITTING AN EXTERNAL EXCEPTION REVIEW REQUESTS
for the Denial of Request for Step Therapy Exception, Formulary Exception, and Prior Authorization
An Enrollee, an enrollee’s designee, or a prescribing doctor can request that the original step therapy exception request, formulary exception request, prior authorization request and subsequent denial of such requests be reviewed by an independent review organization by following the steps below:
• Submit an exception via online request available in the VCHCP member website
vchealthcareplan.org/members/requestPharmacyExceptionForm.aspx or by calling the Plan at (805) 981-5050.
• Ask the Plan to make an exception to its coverage rules.
• There are several types of exceptions that can be requested such as:
- Cover a drug even if it is not on the Plan’s formulary.
- Waive coverage restrictions or limits on a drug. For example, the Plan limit the amount on certain drugs it covers. If the drug has a quantity limit, ask the Plan to waive the limit and cover more.
- Provide a higher level of coverage for a drug. For example, if the drug is in the Non-Preferred Drug tier, ask the Plan to cover it at the costsharing amount that applies to drugs on the Preferred Brand Drug tier 3 instead. This applies so long as there is a formulary drug that treats your condition on the Preferred Brand Drug tier 3. This would lower the amount paid for medications.
• Once the Plan receives the exception request via website or via phone call, the Plan’s Utilization Management will contact the doctor to process the External Exception Review Request.
• The Plan sends the external exception review request to an independent review organization called IMEDECS/Kepro.
• VCHCP will ensure a decision and notification within 72 hours in routine/standard circumstances or 24 hours in exigent circumstances.
• The Plan will make its determination on the external exception request review and notify the enrollee or the enrollee’s designee and the prescribing provider of its coverage determination no later than 24 hours following receipt of the request, if the original request was an expedited formulary/prior authorization/step therapy exception request or 72 hours following receipt of the request, if the original request was a standard request for nonformulary prescription drugs/ step therapy/prior authorization.
• If additional information is required to make a decision, the Plan in collaboration with IMEDECS/Kepro will send a letter via fax to your prescribing doctor advising that additional information is required.
• Exception request for step therapy/nonformulary/ prior authorization will be reviewed against the criteria in Section 1367.206(b) and, if the request is denied, the Plan will explain why the exception request for step therapy/nonformulary/ prior authorization drug did not meet any of the enumerated criteria in section 1367.206(b).
• The exception request review process does not affect or limit the enrollee’s eligibility for independent medical review or to file an internal appeal with VCHCP.
• The enrollee or enrollee’s designee or guardian may appeal a denial of an exception request for coverage of a nonformulary drug, prior authorization request, or step therapy exception request by filing a grievance under Section 1368.
• If the independent review organization reverses the denial of a prior authorization, formulary exception, or step therapy request, the decision is binding on the Plan.
• The decision of independent review organization to reverse a denial of a prior authorization, formulary exception, or step therapy request applies to the duration of the prescription including refills.
PHARMACY UPDATES & DELETIONS
Ventura County Health Care Plan updates the formulary with changes on a monthly basis and gets re-posted monthly on the VCHCP’s member and provider website. Here is the direct link of the electronic version of the formulary posted on the Ventura County Health Care Plan’s website vchealthcareplan.org/members/programs/docs/ProviderDrugList.pdf.
The Ventura County Health Care Plan's Pharmacy & Therapeutics Committee has recently approved a list of additions and deletions to the formulary. The list can also be accessed here: ProviderNotificationAddsAndDeletes.pdf (vchealthcareplan.org)
Additional information regarding the National Preferred Formulary is available through Express Scripts (ESI). Logging in is required.
Note: The Plan’s Drug Policies, updated Step Therapy and Drug Quantity Limits can also be accessed at: vchealthcareplan.org/providers/providerIndex.aspx
• Plan’s Drug Policies vchealthcareplan.org/providers/priorAuthDrugGuidelines.aspx
o vchealthcareplan.org/members/programs/docs/DQMAdvantage.pdf
o vchealthcareplan.org/members/programs/docs/DQMAdvantagePlus.pdf
o vchealthcareplan.org/members/programs/docs/DQMLimited.pdf
• Preferred Medications list vchealthcareplan.org/members/programs/docs/ProviderDrugList.pdf
A member or a member’s designee can request that the original step therapy exception request, formulary exception request, prior authorization request and subsequent denial of such requests be reviewed by an independent review organization, by submitting an exception via online request available in the VCHCP member website (vchealthcareplan.org/members/requestPharmacyExceptionForm.aspx) or by calling the Plan at (805) 981-5060. For more information about the Step Therapy, the policy can be found at the Plan’s website vchealthcareplan.org/providers/docs/padg/steptherapy/StepTherapyCheatSheet.pdf.
To access the policy and procedure for the Drug benefit Program of VCHCP, please click this link vchealthcareplan.org/members/programs/docs/PrescriptionMedicationBenefitProgramDescription.pdf.
2024 National Preferred Formulary Exclusions
Excluded medications are not covered by the National Preferred Formulary beginning January 1, 2024, unless otherwise noted. Please note that members filling prescriptions for one of these excluded drugs may pay the full retail price. Please discuss the alternative preferred medications with your patients and provide a new prescription for one that you feel is right for the patient.
To access the list of National Preferred Formulary Exclusions, please visit our website at vchealthcareplan.org/members/programs/docs/NationalPreferredFormularyExclusions.pdf.
FORMULARY WEB POSTING
Ventura County Health Care Plan updates the formulary with changes on a monthly basis and re-posted monthly in VCHCP’s member and provider website. The formulary includes information on covered pharmaceuticals and pharmaceutical management procedures including co-payments, prior authorization, drug limits, generic substitution, therapeutic interchange, and step-therapy.
Please refer to the Formulary Drug List posted in the VCHCP provider website by clicking this link: vchealthcareplan.org/members/programs/docs/ProviderDrugList.pdf
2024 PROVIDER SATISFACTION with Utilization Management
VCHCP performs a Provider Satisfaction with Utilization Management (UM) Survey annually. The 2024 survey was performed by Press Ganey (PG). VCHCP would like to thank the 69 providers who completed the survey, producing an overall response rate of 12.2%. Based on responses specifically related to provider experience with our Utilization Management (UM), the Plan is committed to improving provider experience and survey results. Below are the specific survey questions that pertain to provider satisfaction with our Utilization Management.
Question 10a:
Access to knowledgeable UM Staff
Question 10b:
Procedures for obtaining pre-certification/referral/authorization information
Question 10c:
Timeliness of obtaining pre-certification/ referral/ authorization information
Question 10d:
The health Plan’s facilitation/support of appropriate clinical care for patients
Question 10e:
Access to Case/Care Managers from this health plan
Question 10f:
Degree to which the Plan covers and encourages preventive care and wellness
There was an overall improvement in all areas of provider satisfaction with our Utilization Management. All categories met the internal benchmark of 75%. We will continue to implement actions to improve provider experience with our Utilization Management, such as but not limited to:
1. Collaborate with VCMC Ambulatory Clinics through the VCHCP Ops Triad Meeting to ensure timely receipt of requests from the clinics, streamlining of VCMC’s referral center process and continued expansion of the VCMC E-Consult.
2. Provide education to our members and providers through our newsletters regarding the importance of timeliness of receipt of treatment authorization requests by the Plan.
3. Educate members regarding the Plan’s prior authorization process and timelines of reviews.
4. Implement efficiencies in the Plan’s Utilization Management Department to reduce the 45-day denial for lack of information. Efficiencies include but not limited to:
‣ Calling or messaging providers to request the information needed on pended cases to complete timely prior authorization review.
‣ Medical Director reviews all pend and denial letters/determinations for appropriateness prior to sending to providers.
2024 Quality Improvement Program Evaluation
Each year, the Health Plan evaluates its success in accomplishing identified goals for the prior year, including, but not limited to, its ability to meet regulatory standards specified by the Department of Managed Health Care (DMHC). For 2023, the Plan is pleased to share that it succeeded in achieving multiple identified goals.
To view the summary of our Quality Improvement Program Evaluation, please click this link: vchealthcareplan.org/members/docs/AnnualQualityAssuranceProgramOverview.pdf
Referral & Prior Authorization Process & Services
Requiring Prior Authorization
Providers have the ability to review how and when to obtain referrals and authorization for specific services. Go to vchealthcareplan.org/providers/hsApprovalProcess.aspx. This area offers links for providers to obtain specific information on the Plan’s prior authorization process, what services require prior authorization, timelines, and direct referral information.
To ensure that requests for referral and prior authorizations are reviewed in a timely manner, Providers must submit TARs to the Plan’s UM department promptly.
QUESTIONS?
Call Member Services at (805) 981-5050
Standing Referrals
A standing referral allow members to see a specialist or obtain ancillary services, such as lab, without needing new referrals from their primary care physician for each visit. Members may request a standing referral for a chronic condition requiring stabilized care. The Primary Care Physician will decide if a standing referral is needed when the request meets the following guidelines:
A standing referral is limited to 6 months, but can be reviewed for medical necessity as needed, to cover the duration of the condition. If members change primary care physicians or clinics, member will need to discuss their standing referral with their new physician. Additional information regarding Standing Referrals is located on our website: vchealthcareplan.org/providers/docs/ medpolicies/StandingReferralsToSpecialists. pdf or by calling Member Services a (805) 981-5050 or (800) 600-8247.
A standing referral may be authorized for the following conditions when it is anticipated that the care will be ongoing:
• Chronic health condition (such as diabetes, COPD etc.)
• Life-threatening mental or physical condition
• Pregnancy beyond the first trimester
• Degenerative disease or disability
• Radiation treatment
• Chemotherapy
• Allergy injections
• Defibrillator checks
• Pacemaker checks
• Dialysis/end-stage renal disease
• Other serious conditions that require treatment by a specialist
Direct Specialty Referrals
A “Direct Specialty Referral” is a referral that the Primary Care Physician (PCP) can give to members so that members can be seen by a specialist physician or receive certain specialized services.
Direct Specialty Referrals do not need to be preauthorized by the Plan. All VCHCP contracted specialists can be directly referred by the PCPs using the direct referral form [EXCLUDING TERTIARY REFERRALS, (e.g. UCLA AND CHLA)]. Referrals to Physical Therapy and Occupational Therapy also use this form.
Note that this direct specialty referral does not apply to any tertiary care or non-contracted provider referrals. All tertiary care referrals and referrals to non-contracted providers continue to require approval by the Health Plan through the treatment authorization request (TAR) procedure.
Appointments to specialists when a member receives a direct referral from their PCP should be made either by the member or by the referring doctor. Make sure to communicate with the member about who is responsible for making the appointment.
Appointments are required to be offered within a specific time frame, unless the doctor has indicated on the referral form that a longer wait time would not have a detrimental impact on the member's health. Those timeframes are: Non-urgent within 15 business days, Urgent within 48-96 hours.
If you feel that your patient is not able to get an appointment within an acceptable timeframe, please contact the Plan’s Member Services Department at (805) 981-5050 or (800) 600-8247 so that we can make the appropriate arrangements for timeliness of care.
BREAST AND COLORECTAL
In an effort to increase awareness, VCHCP has sent postcards to all members who are due for their breast cancer or colorectal cancer screenings. The postcards were mailed in August and October. Our goal is to provide education to our members and encourage them to complete these important screenings. As a provider, you may receive telephone calls or have members bringing these postcards to their office visit. Please use this postcard as a tool to provide education and support.
Important information about coordination of care (coc)
Important Information about Coordination of Care (COC)
Optum requires contracted behavioral health practitioners and providers to communicate relevant treatment information and coordinate treatment with other behavioral health practitioners and providers, primary care physicians (PCPs), and other appropriate medical practitioners involved in a member’s care.
Resources for Coordinating Care
• Provider Express includes resources to support you in coordinating care. Select the “Clinical Resources” tab at the top of the main page, then select “Coordination of Care.”
COC between practitioners benefits your practice because it:
• Providing better management of treatment and follow-up for members
COC may be most effective:
• After the initial assessment
• At the start or change of medication
• Upon discharge
• Upon transfer to another provider/level of care
• When significant changes occur, such as (diagnosis, symptoms, compliance with treatment)
• Confidential Exchange of Information Form
•Use the Coordination of Care Checklist to document your efforts to coordinate care with your members’ other practitioners, including when your members decline further care.
Guidelines for Effective Communication
When scheduling appointments for new members, request they bring names and contact information for their other treating practitioners.
At the initial session, discuss what COC is, the importance and benefits for coordinating care with health care professions, and invite your patient to ask any questions they may have about the process.
Complete a COC form with the member within a week of your initial assessment and annually thereafter, documenting all actions in the patient chart, including if the patient declined to allow COC.
Exchange the following information with other treating practitioners:
• A summary of the member’s assessment and treatment plan recommendations
• Diagnoses (medical and behavioral)
• Medications prescribed (name, strength, dosage)
• Contact information (name, telephone, email, fax number, and the best time you may be reached by phone, if needed).
Primary Care Physicians and Specialists Medical
Coordination of Care
As a primary care physician (PCP), you are their main contact for your patients in maintaining good health, receiving medical care and organizing patient care activities, thus establishing a strong relationship with them is essential for their well-being.
As their doctor, you ensure they see appropriate specialists when necessary. One of your responsibilities is coordinating all of their medical activities to achieve a safer and more effective care. When referring a member to another specialist, please share the information with the PCP.
If your patient is receiving services from more than one practitioner or getting care from other specialists, it is important for all of the doctors to communicate
Post Hospital
valuable information with each other so you all can work together to help ensure your patient’s care is complete and effective.
Please talk to your patients about sharing their essential medical information with their PCPs and specialists by requesting them to sign a release of information.
Share your contact information with them so other providers involved in their care can request medical records when needed.
Reminder to VCMC practitioners to share your patients’ medical information with involved non-VCMC practitioners to improve coordination of care, as these non-VCMC practitioners do not have access to your EHR.
Discharge Continuity of Care
When members are discharged from an inpatient hospital stay, they should follow up with their PCP or specialist within 30 days of discharge, or sooner depending on their condition. This follow up appointment is important for continuity of care, patient safety, and to reduce preventable readmissions. VCHCP will send all members discharged from an inpatient stay a targeted letter instructing them to follow up with the specific time frame noted.
ER Room Visit Follow Up &Appropriate ER Use
A sudden trip to the Emergency Room (ER)
can be difficult and often times results in a change in medication or treatment for your patients. After a visit to the ER, it is very important that members make an appointment to see their Primary Care Provider (PCP) and/or specialist when applicable, as soon as possible, or within 30 days. This visit is to update the PCP on what occurred that required the member to seek emergency treatment, update their medication routine, and to be referred for additional care if needed. Establishing and keeping a good relationship between the PCP and patient is vital to their health and your ability to provide care to patients. If members find that making an appointment with their PCP or specialist after an ER visit is difficult and they can’t be seen within 30 days, or if their ER visit was due to the inability to be seen by their PCP, they are asked to notify the Ventura County Health Care Plan Member Services Department at (805) 981-5050. Members are mailed Postcard reminders regarding appropriate use of ER services and the importance of following up with their PCP after the ER visit for continuity of care. The members’ ability to access health care is important to us.
Follow-up c are after discharge
Help patients get care within 7 days after discharge
If any of your patients have recently been discharged from an emergency department or an inpatient hospital stay with a mental health (MH) or substance use disorder (SUD) diagnosis, you play an important role in ensuring that they receive appropriate follow-up care after discharge.*
Tips for success
•Discuss the importance of attending appointments with patients and suggest they set up a reminder in their phone/calendar.
•Send reminders to patients/caregivers ahead of the appointment.
•Ask patient, “Is there is a support person you would like to have at the first appointment with you?”
•Ask patient, “Do you have transportation or other reasons that would keep you from attending your appointment?”
• Suggest a virtual appointment, if applicable.
•Outreach to reschedule and discuss the need for additional support for patients who cancel or miss an appointment.
Helpful tools and resources
These resources can assist you and your patients with follow-up care after discharge:
providerexpress.com
Access resources for your patients on mental health, substance use and crisis support like educational materials, screening tools and assessments.
Recovery and Resiliency Toolkit
Determine personal strengths and facilitate recovery and wellness planning.
Medication for opioid or alcohol use disorder (MOUD or MAUD)
Learn more about MOUD and MAUD.
liveandworkwell.com
Access patient education materials and mental health and substance abuse provider information, use guest access code “clinician.”
* N ational Committee for Quality Assurance 2022 HEDIS Specifications. See NQF-Endorsed Measures at ncqa.org.
or feedback, please contact us at email: qmi_emailblast_mail@optum.com. P lease include the email address you would like to have removed when contacting us.
Case Management
Case Management is a process designed to coordinate services more efficiently, to provide a delivery methodology for targeted populations at risk, and to promote an interdisciplinary approach to meeting member needs throughout an episode of illness or continuum of care. It includes elements of behavioral change and self-management.
VCHCP licensed healthcare professionals collaborate with members, families, and providers to evaluate the appropriateness of care in the most cost-effective setting without compromise to quality care. The goal of VCHCP’s Case Management program is to help members regain health and functional capability.
Who Qualifies for Case Management/ Members Appropriate for Referral to Case Management?
Case Management is provided to eligible members with specific diagnosis or special health care needs. This includes members with complex acute and chronic diagnoses, or specialty care management needs. These members typically require extensive use of resources and need assistance in navigating the healthcare delivery system. Members appropriate for case management referral include those members with medical and psychosocial needs impacting their compliance with disease management and health improvement including increasing severity of condition, safety issues, decreasing functional status, new behavioral health issues, need for caregiver resources. Services are free and voluntary for eligible members. Members consent to being in the program but can opt out at any time. Being in the program does not affect benefits or eligibility.
How Does Case Management Benefit the Member?
Case management provides a consistent method for identifying, addressing, and documenting the health care and social needs of our members along the continuum of care. Once a member has been identified for case management, a nurse will work with the member to:
• Complete a comprehensive initial assessment.
• Determine benefits and resources available to the member.
• Develop and implement an individualized care plan in partnership with the member, his/her physician, and family or caregiver.
• Identify barriers to care.
• Monitor and follow-up on progress toward care plan goals.
How to Make a Referral to Case Management
If a provider identifies a VCHCP member needing case management, or has questions regarding the Case Management Program, the provider can make a direct referral by contacting VCHCP’s Case Management Department at (805) 981-5060, or (800) 600-8247. The VCHCP Case Manager can confirm if the member has an open case management case and works with physician/provider to coordinate the care plan. If a case is not open, the VCHCP Case Manager will confirm member demographics and clinical information to initiate referral through the QNXT module and assist the provider/Physician with care coordination, as appropriate. Members and caregivers can contact Member Services at (805) 981-5050 and request a referral for case management services. Members can also self-refer to a program online on the Member page at vchealthcareplan.org/members/ requestAssistanceForm.aspx
Hospital discharge planning staff may contact the VCHCP Concurrent Review Nurse or VCHCP Case Manager to initiate a case management referral by calling the VCHCP’s Case Management Department at (805) 981-5060. The VCHCP Concurrent Review Nurse/VCHCP Case Manager can confirm if the member has an open case management case and works with the Discharge Planner to coordinate care plan. If a case is not open, the Concurrent Review Nurse/ VCHCP Case Manager will confirm member demographics and clinical information to initiate referral through the Plan’s QNXT module and assist with care coordination, as appropriate.
Complex Case Management (CCM)
Case management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, facilitation and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality, cost-effective outcomes.
VCHCP’s CCM program is an opt-out program, and all eligible members have the right to participate or decline participation. Verbal consent is obtained prior to formally enrolling the member into the Complex Case Management Program. Members who are identified with the following situations include but are not limited to Transplants, ESRD, Traumatic Brain Injuries and High-Risk Diabetics. Referrals to CCM can be through VCHCP medical management staff, hospital discharge planners, members or caregivers, and practitioners.
For a detailed information regarding complex case management, please refer to the policy and procedure located in the provider website: vchealthcareplan.org/members/docs/VCHCPComplexCaseManagementPolicyAnd%20Procedure.pdf. Or you can call the VCHCP’s Case Management Department at (805)981-5060.
New Medical Technology
DID
YOU KNOW that VCHCP has a policy in place to evaluate any new technology or new applications of existing technology on a case by case basis? There are four categories we look at –medical procedures, behavioral health procedures, pharmaceuticals (medications) and medical devices. VCHCP’s Medical Director, or designee, evaluates new technology that has been approved by the appropriate regulatory body, such as the Food and Drug Administration (FDA) or the National Institutes of Health (NIH). Scientific evidence from many sources, specialists with expertise related to the technology and outside consultants when applicable are used for the evaluation. The technology must demonstrate improvement in health outcomes or health risks, the benefit must outweigh any potential harm and it must be as beneficial as any established alternative. The technology must
also be generally accepted as safe and effective by the medical community and not investigational.
For help with new medication evaluations, the Plan looks to our Pharmacy Benefit Manager, Express Scripts, for their expertise. For new behavioral health procedures, the Plan uses evaluations done by our Behavioral Health delegate, OptumHealth Behavioral Solutions of California (also known as Life Strategies). Once new technology is evaluated by the Plan, the appropriate VCHCP committee reviews and discusses the evaluation and makes a final decision on whether to approve or deny the new technology. This final decision may also determine if any new technology is appropriate for inclusion in the plan’s benefit package in the future. For any questions, please contact the VCHCP Utilization Management Department at (805) 981-5060.
In addition to VCHCP medical management staff, hospital discharge planners and practitioners; members and caregivers now have an opportunity to seek assistance for complex and or chronic medical needs such as asthma, diabetes, and coordination of challenging care online!
Case management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, facilitation and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality, costeffective outcomes.
VCHCP’s CCM program is an opt-out program, and all eligible members have the right to participate or decline participation. Verbal consent is obtained prior to formally enrolling the member into the Complex Case Management Program. Members who are identified with the following situations include but are not limited to Transplants, ESRD, Traumatic Brain Injuries and High-Risk Diabetics.
For a detailed information regarding complex case management, please refer to the policy and procedure on VCHCP’s website: vchealthcareplan.org/members/docs/VCHCPComplexCaseManagementPolicyAnd%20Procedure.pdf.
Members and caregivers can contact Member Services at (805) 981-5050 and request a referral for case management or disease management services. Members can also self-refer to a program online on the Member page at vchealthcareplan.org/members/requestAssistanceForm.aspx . You will be prompted to enter member specific information. You will then submit this form to a secure email. A nurse will evaluate your request and call you within 2 business days.
If you would like to speak directly with a nurse, please call (805) 981-5060 and ask for a Case Management Nurse.
EDUCATION MATERIALS
To access the Plan’s useful and current educational materials, please click on this link: VCHCP - Members - Health Education Information (vchealthcareplan.org)
CASE MANAGEMENT & DISEASE MANAGEMENT SERVICES
VCHCP has a Case
Management
Program
to help our members who have complex needs by ensuring that our members work closely with their doctors to plan their care. Case Management is a collaborative process of assessment, planning, facilitation, and advocacy. Determination is made for the best options and services to meet a member’s individual health needs through communication and utilization of available resources to promote quality care and cost-effective clinical outcomes. The goals of Case Management are to help members get to their best health possible in the right setting; coordinate and manage healthcare resources; support the treatment plan ordered by the doctor; and to take action to improve member overall quality of life and health outcomes. As a member in Case Management, members with complicated health care issues and their family have a truly coordinated plan of care.
VCHCP identifies members for Case Management through several referral sources, including health care provider referrals and member self-referrals. Members appropriate for case management referral include those
Your Healthcare plan for the future starts here!
members with medical and psychosocial needs impacting their compliance with disease management and health improvement including increasing severity of condition, safety issues, decreasing functional status, new behavioral health issues, need for caregiver resources. Some examples of eligible medical conditions or events include multiple hospital admissions or re-admissions, multiple chronic conditions, major organ transplant candidates, and major trauma. A member identified for Complex Case Management is considered a participant in the program unless the member decides to opt-out (not accept the services/coordination of care offered). Once a nurse Case Manager evaluates a member, the Case Manager creates a care plan with the member and healthcare team input. The care plan is shared with the member’s doctor for his/her input and review. The care plan is monitored by the Case Manager and coordinated with the member and doctor.
The VCHCP Disease Management Program
coordinates health care interventions and communication for members with conditions where VCHCP support of member self-care activities can improve their conditions. VCHCP has two Disease Management programs: Asthma and Diabetes. VCHCP has systematic processes in place to proactively identify members who may be appropriate for these disease management services. Diagnosis information on claims encounter data and pharmacy data prescription drug information are used to systematically identify members for disease management. Members and providers may also refer to the applicable Disease Management program. Once identified, the member is automatically enrolled in the program unless the member chooses to opt out. The Disease Management team works with doctors and licensed professionals to improve these chronic conditions, so members obtain the best possible quality of life and functioning. Included in the Disease Management Program are mailed educational materials, provider education on evidence-based clinical guidelines, member education over the phone (health coaching) and care coordination. VCHCP has a variety of member materials about diabetes and asthma available to help you better understand your condition and manage your chronic disease. Our goal is to improve the health of our members.
The VCHCP programs for Case Management and
Disease Management
are for members with severe illnesses and chronic diseases to help plan their care with their primary doctor and learn more about self-care. These programs have nurses who work with members over the phone to guide them towards the best possible health for their conditions.
Participation in these programs is free and voluntary for eligible members. Members can opt out at any time and being in these programs does not affect benefits or eligibility.
You may refer patients to VCHCP Case Management and Disease Management Programs by calling (805) 981-5060. For more information or to submit a referral for the Case Management and Disease Management Program, please call 805-981-5060. Members can also self-refer to a program online on the Member page at vchealthcareplan.org/ members/requestAssistanceForm.aspx.
Clinical Practice Guidelines
VCHCP encourages its providers to practice evidence-based medicine. VCHCP has links to clinical practice guidelines available to address conditions frequently seen in patients at your practice. All clinical practice guidelines included have been reviewed and approved by the VCHCP Quality Assurance Committee.
Recommended Clinical Practice Guidelines and links for providers:
• Clinical Practice Guidelines
• 2 Medical Conditions: Asthma & Diabetes
o Joslin Diabetic Center and Joslin Clinic
o American Diabetes Associates (ADA) at diabetes.org
o National Asthma Education and Prevention Program Expert Panel Report 3, Guidelines for the Diagnosis and Management of Asthma
• 1 Behavioral Health Conditions: Depression
o American Psychiatric Association
• Preventive Guidelines For All Age Groups
o Perinatal Care Guidelines
o U.S. Preventive Services Task Force (USPSTF)
o Advisory Committee on Immunization Practices (ACIP)
• Non-profit Professional Society, Standards of Care developed by the World Professional Association for Transgender Health (WPATH)
Link to be used: vchealthcareplan.org/providers/medicalPolicies.aspx
You may obtain hard copies of the above listed Clinical Practice Guidelines by calling VCHCP at (805) 981-5050.
(805) 981-5050 if you need
Disease Management & Case Management Programs
VCHCP makes a continuous effort to improve the quality of services that we deliver. One of the ways we strive to accomplish this is through our case management programs, into which members are enrolled free of charge. The Case Management (CM) Program is to help our members who have complex needs by ensuring that our members work closely with you, their doctors to plan their care. The goals of Case Management are to help members get to their best health possible in the right setting; coordinate and manage healthcare resources; support the treatment plan ordered by the doctor; and to take action to improve member overall quality of life and health outcomes. As a member in Case Management, members with complicated health care issues and their family have a truly coordinated plan of care.
We also offer a Disease Management (DM) Program to benefit members with diabetes and asthma. The Disease Management Program coordinates health care interventions and communications for members with conditions where member self-care can really improve their conditions. The Disease Management team works with doctors and licensed professionals to improve
these chronic conditions, so members obtain the best possible quality of life and functioning. Included in the Disease Management Program are mailed educational materials, provider education on evidence-based clinical guidelines, member education over the phone, and care coordination. VCHCP has a variety of materials about diabetes and asthma that they give to members to help members better understand their condition and manage their chronic diseases.
Both valuable programs are coordinated by highly skilled, compassionate registered nurses who personalize and tailor their services to benefit each individual person. Our nurses work in tandem with the physician to reinforce and strengthen the member’s understanding and management of their medical condition(s).
You may refer patients to VCHCP Case Management and Disease Management Programs by calling (805) 981-5060. Members may also self refer online by visiting our website at vchealthcareplan.org and clicking on “Request Case Management or Disease Management” link. If you would like to speak directly with a nurse, please call (805) 981-5060 and ask for a Case Management Nurse.
VCHCP continues to offer free, comprehensive disease management and case management programs for your patients.
VCHCP's 2023
HEDIS Results
FROM MEASUREMENT YEAR 2022 & INTERVENTIONS
VCHCP continues to maintain high standards in Healthcare Effectiveness Data Information Set (HEDIS) Measures.
Examples of some of the measures include preventive screening for breast cancer, colorectal cancer, and cervical cancer; appropriate childhood immunizations; as well as decreasing or preventing complications in diseases such as diabetes and asthma. When these measures are met by our members, disease and complications decrease.
2023 Accomplishments from MY 2022
• Of the 26 HEDIS measures with previous data, 18 measures improved with an improvement rate of 69.2%.
• VCHCP has a Diabetes Disease Management Program where our nurses perform health coaching calls when member risk is moderate and high. This means that your HgbA1c lab result is 8.0% and above. Our goal is to improve your health and it is important to call us back when our Health Coaching Nurse calls you because it is making a significant impact in your compliance with getting your HgbA1c testing done and decreasing your HgbA1c level and risk.
2024 Goals
• Breast cancer screening: All women aged 40 and above should receive a screening mammogram every two years (except for those with a history of mastectomy).
• Colorectal cancer screening: All adults aged 45 and above should receive colorectal cancer screening. The frequency of the screening depends on the type of screening performed. For example, a colonoscopy every 10 years, or a sigmoidoscopy every 5 years, or a Fecal Occult Blood Test (stool test) annually.
• Postpartum Care: A new mom should have a postpartum visit within 7-84 days of delivery.
• Controlling High Blood Pressure: All members who have been diagnosed with hypertension should strive to have their blood pressure remain below 140/90.
• Continue to improve Diabetes Care measures.
• Comprehensive Diabetes Care: Continuously improving diabetes care for better health management.
Most notably, the majority of the 2023 HEDIS Preventive Final Rates from Measurement Year (MY) 2022 showcased improvement, echoing the positive trend of more members seeking preventive care as services resumed in 2022. Here, we delve into key accomplishments, challenges, and our vision tailored to support our invaluable health plan providers.
2024 Areas for Improvement
• Childhood Immunizations Status
• Follow-up Children Prescribed ADHD Medication
• Antidepressant Medication Management
• Use of Imaging Studies for Low Back Pain
2024 Planned Interventions include but not limited to the following:
• Continue outreach to you and to your patients when they need preventive health screenings.
• Postcard reminder to members in need of breast cancer screenings twice a year.
• Postcard reminder to members in need of colon cancer screening annually.
• Health coaching calls to diabetics including mailed information and resources along with access to Health Coach Nurses.
• Follow up care letter reminder to all moms who delivered viable babies.
• Birthday Card with Care Gap information will be sent to you on your birthday month.
This is just a glance at the interventions continuously being performed by the VCHCP HEDIS team. When members fulfill these HEDIS measures, they are partnering with their Primary Care Physicians to improve their health or maintain good health.
If you have questions about HEDIS, please contact VCHCP at (805) 981-5060.
TIPS & INFORMATION HEDIS
Improving Quality of Care
HEDIS RATES ARE SCORED BASED ON ADMINISTRATIVE BILLING DATA.
USE THE BELOW TIPS TO HELP IMPROVE YOUR HEDIS PERFORMANCE SCORES:
• Ensure patients are accurately diagnosed and services are rendered appropriately based on medical necessity and clinical practice guidelines.
• Follow the American Academy of Pediatrics/ Bright Futures Periodicity Schedule and U.S. Preventive Services Task Force preventive and clinical practice guidelines for rendering health services to patients during wellness visits.
• Schedule appointments and review patient charts prior to patient visits to close care gaps.
• Ensure patients are accurately diagnosed with persistent asthma.
• Ensure that asthma medication, especially controller medication, is being dispensed to the patient in accordance with the proper medication schedule or need.
• Document date of mammogram along with proof of completion and develop standing orders along with automated referrals (if applicable) for patients ages 40–74, who need screening.
• The percentage of women 21-64 years of age who were screened for cervical cancer:
o For women ages 21–64 who were recommended for routine cervical cancer screening and had cervical cytology performed within the last 3 years.
o For women ages 30–64 who were recommended for routine cervical cancer screening and had a cervical high-risk human papillomavirus (hrHPV) testing within the last 5 years.
o For ages 30–64 who were recommended for routine cervical cancer screening and had a cervical cytology/cervical high-risk human papillomavirus cotesting within the last 5 years.
• Order a chlamydia screening and provide follow-up for patients who are pregnant, taking contraceptives or identified themselves as sexually active.
• Instruct staff to take a repeat reading if abnormal BP is obtained.
• Schedule appointments and complete services for patients ages 18–75 with diagnosis of diabetes on an annual basis to assist with health maintenance of the disease processes. The following services are required:
o Order at least one HbA1c screening annually. Repeat test if A1c is greater than 7.9%.
o Collect A1c data completed during inpatient visits or elsewhere in order to evaluate if a repeat test is required.
• Schedule patient’s postpartum care visit with an OB/GYN practitioner, midwife, family practitioner, or other PCP on or between 7–84 days after delivery.
• Ensure accurate action, follow-up, documentation, and billing of services.
• Submit claims correctly and in a timely manner.
• Correct encounters/claims with erroneous diagnoses.
We need to work together to improve and maintain higher quality of care. When our members are healthy, everyone benefits! The reminders above only provide a snapshot of some of the HEDIS measures. Please refer to the HEDIS Cheat Sheet you will receive in the mail. If you need additional information or assistance related to HEDIS, please call our HEDIS Program Administrator at (805) 981-5060
Overuse/Appropriateness
Helpful Documentation Tips for PCPs
of HEDIS Measures
URI ‐ Appropriate Treatment for Upper Respiratory Infection
HEDIS MEASURE DEFINITION: Members age 3 months and older with a diagnosis of upper respiratory infection (URI) and that did NOT result in an antibiotic dispensing event. What You Can Do: Do not prescribe antibiotics for URI treatment. Document and submit appropriate diagnosis on claims if more than one diagnosis is appropriate. A competing diagnosis of pharyngitis or other infection on the same date or 3 days after will exclude the member.
CWP ‐ Appropriate Testing for Pharyngitis
HEDIS MEASURE DEFINITION: Members age 3 months and older with a diagnosis of acute bronchitis/bronchiolitis that did not results in an antibiotic dispensing event.
This measure used to be for adults only and now includes everyone ages 3 months and older.
What You Can Do: Before prescribing an antibiotic for a diagnosis of pharyngitis, perform a group A strep test. Document and submit claims for all appropriate diagnoses established at the visit Submit claim for in‐office rapid strep test There are numerous comorbid conditions and competing diagnoses exclusions for this measure.
AAB ‐ Avoidance
of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis
HEDIS MEASURE DEFINITION: Members age 3 years and older where the member was diagnosed with pharyngitis,
dispense an antibiotic and received a group A strep test for the episode.
This measure used to be for children only and now includes everyone age 3 years and older.
What You Can Do: Treat acute bronchitis primarily with home treatments to relieve symptoms. Antibiotics don’t usually help (viral). Of course, some patients have comorbid conditions and require antibiotics. These patients would be excluded from this measure reporting. A diagnosis of pharyngitis on the same day or in the 3 days after also exclude this member. Educate patients about overuse of antibiotics and resistance.
LBP ‐ Use of Imaging Studies for Low Back Pain
HEDIS MEASURE DEFINITION: Adults age 18‐75 years old with a primary diagnosis of low back pain, who did not have an imaging study (plain x‐ray, MRI or CT scan) within 28 days of the diagnosis.
What You Can Do: Occasional uncomplicated low back pain in adults often resolves within the first 28 days. Imaging before the 28th day is usually unnecessary. Exclusions to this measure—a diagnosis of HIV, major organ transplant or cancer any‐ time in the patients history ‐Diagnosis of trauma during the 3 months prior to dx of back pain ‐ IV drug use, spinal infection or neurological impairment during the 12 months prior to the low back pain diagnosis. Above includes through 28 days after LBP DX 90 consecutive days of corticosteroid treatment any time 12 months prior to the dx of low back pain.
HEDIS Cheat Sheet &
Behavioral Health HEDIS Measures for Primary Care
In our ongoing effort to ensure compliance and provide the best possible care for our members, we continue to adhere to the rigorous standards set forth by our regulatory agency, the Department of Managed Health Care (DMHC). Each year, we evaluate our performance using the Health Effectiveness Data Information Set (HEDIS) rates.
VCHCP remains committed to collaborating closely with our valued members and providers to further enhance care and improve HEDIS scores. To assist you in understanding and navigating the evolving HEDIS requirements for this year, we've updated the HEDIS Cheat Sheet. This indispensable guide provides explanations of HEDIS measure descriptions, relevant codes, and handy tips.
For the latest updates, please review all sections of the HEDIS Cheat Sheet. You can conveniently access this guide at: vchealthcareplan.org/providers/docs/HEDISCheatSheet.pdf
Moreover, for HEDIS measures pertinent to behavioral health disorders frequently detected in primary care, we've ensured that these are available on our website. You can view them at: vchealthcareplan.org/providers/docs/HEDISMeasuresSummaryForPrimaryCare.pdf
Your feedback, queries, and suggestions are crucial to us. If you have any questions or require additional information, please get in touch with our health services department by calling (805) 981-5060 . We look forward to a productive year ahead and appreciate your continued partnership in delivering top-notch care to our members.
Empowering Healthcare Providers:
EVIDENCE-BASED APPROACHES
TO COMMON
AILMENTS
Dear Healthcare Providers,
At the heart of patient care lies the importance of accurate diagnosis and effective treatment. We aim to equip you with insights into four key areas of focus, all rooted in evidence-based practices.
1. Respiratory Care:
Acute Bronchitis/Bronchiolitis and Upper Respiratory Infections: The Centers for Disease Control and Prevention (CDC), the National Institute for Health and Care Excellence (NICE), and the World Health Organization (WHO) indicate that most of the acute bronchitis, bronchiolitis, and upper respiratory infections are viral in nature. The misuse of antibiotics for these conditions not only proves ineffective but also heightens antibiotic resistance risks. It is vital to prioritize supportive care such as rest, hydration, and symptom management and ensure that antibiotics are prescribed only when genuinely warranted.
2. Pharyngitis Management:
Pharyngitis, commonly known as sore throats, often have a viral origin. The American Academy of Family Physicians (AAFP) and CDC stress the importance of discerning between viral and bacterial causes. They advocate for the use of rapid strep tests to guide treatment decisions. This approach ensures that antibiotics are utilized only when they can be truly effective.
3. Upper Respiratory Infections:
It is paramount to differentiate between viral and bacterial upper respiratory infections. With most of these infections, including the common cold and flu, being viral, antibiotics often prove unnecessary. Healthcare providers should rely on evidence-based guidelines to direct treatments, focusing on supportive measures for viral cases.
4. Low Back Pain (LBP) and Imaging:
When treating low back pain, both the AAFP and the American College of Physicians (ACP) highlight that immediate imaging, such as X-rays, MRIs, or CT scans, often isn't required. A comprehensive evaluation, identifying red flag symptoms and considering non-invasive treatments, can lead to more accurate and cost-effective care. By sidestepping unneeded imaging, we can reduce costs, minimize radiation exposure, and eliminate the potential for unsuitable treatments.
In conclusion, we underscore the significance of adhering to evidence-based guidelines and appreciate your dedication.
THANK YOU FOR YOUR CONTINUED COMMITMENT TO EXCELLENCE.
REFERENCES:
*Centers for Disease Control and Prevention (CDC). (2023). Antibiotic Resistance Threats in the United States and Common Cold: Treatment.
*National Institute for Health and Care Excellence (NICE). (2022). Acute bronchitis: antimicrobial prescribing.
*World Health Organization (WHO). (2022). Antibiotic Resistance.
*American Academy of Family Physicians (AAFP). (2022). Sore Throat and Low Back Pain.
*The American College of Physicians (ACP). (2017). Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline.
STANDARDS FOR MEMBERS’ R ights & R esponsibilities
Ventura County Health Care Plan (VCHCP) is committed to maintaining a mutually respectful relationship with its Members that promotes effective health care. Standards for Members Rights and Responsibilities are as follows:
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Members have a right to receive information about VCHCP, its services, its Practitioners and Providers, and Members’ Rights and Responsibilities.
Members have a right to be treated with respect and recognition of their dignity and right to privacy.
Members have a right to participate with Practitioners and Providers in decision making regarding their health care.
Members have a right to a candid discussion of treatment alternatives with their Practitioner and Provider regardless of the cost or benefit coverage of the Ventura County Health Care Plan.
Members have a right to make recommendations regarding VCHCP’s Member Rights and Responsibility policy.
Members have a right to voice complaints or appeals about VCHCP or the care provided.
Members have a responsibility to provide, to the extent possible, information that VCHCP and its Practitioners and Providers need in order to care for them.
Members have a responsibility to follow the plans and instructions for care that they have agreed upon with their Practitioners and Providers.
Members have a responsibility to understand their health problems and participate in developing mutually agreed-upon treatment goals, to the degree possible.
For information regarding the Plan’s privacy practices, please see the “HIPAA Letter and Notice of Privacy Practices” available on our website at: vchealthcareplan.org/members/memberIndex.aspx . Or you may call the Member Services Department at (805) 981-5050 or toll free at (800) 600-8247 to have a printed copy of this notice mailed to you.
VCHCP NETWORK
NEW TO THE NETWORK
Amanda Chin, N.P., a Nurse Practitioner at Surfside Pediatrics in Ventura, has been added effective October 2024.
Andrew Clark, M.D., an Ophthalmologist at California Retina Consultants in Oxnard and Simi Valley, has been added effective September 2024.
Andrew Sou, D.O., an Infectious Disease specialist at Medicine Specialty Center West (VCMC) in Ventura, has been added effective September 2024.
Ashley Bowen, N.P., a Nurse Practitioner at Coastal Kids - Rolling Oaks Pediatrics in Thousand Oaks, has been added effective October 2024.
Brianna Guevara, N.P., a Nurse Practitioner at Pleasant Valley Pediatric Medical Group in Camarillo, has been added effective October 2024.
Caitlin Pirruccello, N.P., a Nurse Practitioner at Coastal Kids - Rolling Oaks Pediatrics in Thousand Oaks, has been added effective October 2024.
Christina Deal, F.N.P., a Nurse Practitioner at Ideal Womens Health Specialist in Ventura, has been added effective August 2024.
Christopher Tolcher, M.D., a Pediatrician at Coastal Kids - Los Robles Pediatric Medical Group in Thousand Oaks, has been added effective October 2024.
Elizabeth Armstrong, N.P., a Nurse Practitioner at Coastal Kids - Rolling Oaks Pediatrics in Thousand Oaks, has been added effective October 2024.
Erika Cardenas, R.D.N., a Registered Dietician Nutritionist at 360 Nutrition Consulting in Camarillo, has been added effective September 2024.
James Weintraub, M.D., a Dermatologist at Moorpark Family Care Center (VCMC), has been added effective August 2024.
John Nunh, M.D., a Family Medicine physician at Academic Family Medicine Center (VCMC) in Ventura, has been added effective July 2024.
For a full list of participating providers please see our website: vchealthcareplan.org/members/physicians.aspx or contact Member Services at (805) 981-5050 or (800) 600-8247.
Joseph Papador, D.O., a Family Medicine physician at Dignity Health Medical Group Ventura County in Oxnard, has been added effective September 2024.
Kaitlyn Danner, M.D., a Family Medicine physician at Moorpark Family Care Center (VCMC), has been added effective October 2024.
Kaitlyn Ike, M.D., a Family Medicine physician at West Ventura Medical Clinic (VCMC) in Ventura, has been added effective August 2024.
Kenneth Saul, M.D., a Pediatrician at Coastal Kids - Rolling Oaks Pediatrics in Thousand Oaks, has been added effective October 2024.
Logan Horejsi, P.A.-C., a Physician Assistant at Medicine Specialty Center West (VCMC) in Ventura, has been added effective June 2024.
Mahnaz Tabibian, M.D., a Pediatric Cardiologist at Obstetrix Medical Group of the Central Coast in Thousand Oaks and Ventura, has been added effective October 2024.
Matthew Hakimi, M.D., a Cardiac Electrophysiologist at Cardiology Associates Medical Group in Oxnard and Ventura, has been added effective October 2024.
Mee Na Song, M.D., an Internal Medicine physician at Clinicas Del Camino Real Inc., in Newbury Park and Santa Paula, has been added effective October 2024.
Mizin Kawasaki, M.D., a Pediatrician at Coastal Kids - Rolling Oaks Pediatrics in Thousand Oaks, has been added effective October 2024.
Natasha Narang, D.O., a Gastroenterologist at Moorpark Family Care Center (VCMC) and Magnolia Family Medical Center (VCMC) in Oxnard, has been added effective August 2024.
Oliver Wang, D.P.M., a Podiatrist at Foot and Ankle Concepts in Ventura, has been added effective October 2024.
Olumuyiwa Idowu, M.D., an Orthopedic Surgeon at Ventura Orthopedics Medical Group in Camarillo, Oxnard, Simi Valley, Thousand Oaks and Ventura, has been added effective September 2024.
Philina Yee, M.D., an Ophthalmologist at Miramar Eye Specialists in Camarillo, Oxnard and Santa Paula, has been added effective September 2024.
Raul Meza, M.D., a Family Medicine physician at Academic Family Medicine Center (VCMC) in Ventura, has been added effective July 2024.
Sarah Melzer, N.P., a Nurse Practitioner at Coastal Kids - Los Robles Pediatric Medical Group in Thousand Oaks, has been added effective October 2024.
Tammy Chi, M.D., a Pediatrician at Coastal Kids - Los Robles Pediatric Medical Group in Thousand Oaks, has been added effective October 2024.
Timothy Laurie, D.O., a Gastroenterologist at Medicine Specialty Center West (VCMC) in Ventura, has been added effective June 2024.
Zachary Koretz, M.D., an Ophthalmologist at California Retina Consultants in Oxnard, Simi Valley, and Westlake Village, has been added effective September 2024.
LEAVING THE NETWORK
Akinwunmi Oni-Orisan, M.D., a Neurological Surgeon at Robert A. Taylor, MD, Inc., in Santa Barbara, has left effective October 2024.
Alberto Odio M.D., a Family Medicine physician at Alta California Medical Group (Adventist Health Physicians Network) in Simi Valley, has left effective October 2024.
Alexis Kerl M.D., a Family Medicine physician at Alta California Medical Group (Adventist Health Physicians Network) in Simi Valley, has left effective October 2024.
Andria Terrazas, F.N.P., a Nurse Practitioner at Dignity Health Medical Group Ventura County located at 3901 Las Posas Rd., Ste. 10 in Camarillo, has left effective September 2024.
Ayhan Yoruk, M.D., a Cardiac Electrophysiologist at Cardiology Associates Medical Group in Oxnard and Ventura, has left effective June 2024.
Brittany Zeigler, F.N.P., a Nurse Practitioner at Alta California Medical Group (Adventist Health Physicians Network) in Simi Valley, has left effective October 2024.
Christine Weber, P.A.-C., a Physician Assistant at Main Street Obstetrics & Gynecology in Ventura, has left effective November 2024.
Dane Petersen, F.N.P., a Nurse Practitioner at Dignity Health Medical Group Ventura County in Oxnard, has left effective September 2024.
Daniel Lopez, M.D., an OB/GYN at Clinicas Del Camino Real Inc., in Oxnard, has left effective September 2024.
Emelia Perez M.D., a Family Medicine physician at Alta California Medical Group (Adventist Health Physicians Network) in Simi Valley, has left effective October 2024.
Jennifer Steen, M.D., an OB/GYN at Main Street Obstetrics & Gynecology in Ventura, has left effective November 2024.
John Ford, M.D., a Family Medicine physician at Rose Avenue Family Medical Group in Oxnard, has left effective September 2024.
Keith English, M.D., a Family Medicine physician in Oxnard, has left effective August 2024.
Kevin Seung Shin, D.O., a Family Medicine physician at Clinicas Del Camino Real Inc., La Colonia in Oxnard, has left effective July 2024.
Kevin Westbrook, M.D., a Family Medicine physician at Alta California Medical Group (Adventist Health Physicians Network) in Simi Valley, has left effective October 2024.
Laura Farhat, F.N.P., a Nurse Practitioner at Clinicas Del Camino Real Inc., Ojai Valley Community Health Center, has left effective August 2024.
Leslie Buchanan, P.A.-C., a Physician Assistant at Alta California Medical Group (Adventist Health Physicians Network) in Simi Valley, has left effective October 2024.
Mariela Varis, M.D., a Family Medicine physician at Rose Avenue Family Medical Group in Oxnard, will be leaving effective December 2024.
Masahiro Kushigemachi M.D., a Family Medicine physician at Alta California Medical Group (Adventist Health Physicians Network) in Simi Valley, has left effective October 2024.
Meaghan Pinheiro, M.D., an OB/GYN at Main Street Obstetrics & Gynecology in Ventura, has left effective November 2024.
Nancy Menges, P.A.-C., a Physician Assistant at Alta California Medical Group (Adventist Health Physicians Network) in Simi Valley, has left effective October 2024.
Nicole Abell, D.O., an OB/GYN at Main Street Obstetrics & Gynecology in Ventura, has left effective November 2024.
MILLIMAN CARE GUIDELINES
Pari Young, M.D., a Neurologist at Conejo Valley Family Medical Group (VCMC) in Thousand Oaks, has left effective August 2024.
Rebecca Richmond, F.N.P., a Nurse Practitioner at Alta California Medical Group (Adventist Health Physicians Network) in Simi Valley, has left effective October 2024.
Robert Taylor, M.D., a Neurologist at Robert A. Taylor, MD, Inc., in Santa Barbara, has left effective October 2024.
Steven Carter, M.D., an Ophthalmologist at Miramar Eye Specialists in Camarillo, Oxnard, Santa Paula Simi Valley, Thousand Oaks, Westlake Village and Ventura, has left effective September 2024.
Steven Chang, M.D., an Ophthalmologist in Ventura, will be leaving effective December 2024.
Tiffany Loh, M.D., a Dermatologist at Pacifica Center for Dermatology in Camarillo, has left effective August 2024.
CHANGES
Hanger Clinic, a Durable Medical Equipment supplier, in Ventura has moved to a new location in Ventura, effective July 2024.
Second Wave Physical Therapy will be adding a service location in Ventura, effective December 2024.
VCHCP Utilization Management uses Milliman Care Guidelines 28th Edition, VCHCP Medical Policies, Express Scripts (ESI) Prior Authorization Drug Guidelines and custom VCHCP Prior Authorization Drug Guidelines as criteria in performing medical necessity reviews. Due to proprietary reasons, we are unable to post the Milliman Care Guidelines on our website, but a hard copy of an individual guideline can be provided upon request. A complete listing of VCHCP medical policies and prescription drug policies can be found at: vchealthcareplan.org/providers/medicalPolicies.aspx .
To obtain printed copies of any of our VCHCP Medical/Drug Policies or Milliman Care Guidelines, please contact Member Services at: (805) 981-5050 or (800) 600-8247.
MEDICAL POLICY UPDATES
New and updated medical policies are posted on The Plan’s website at: vchealthcareplan.org/providers/medicalPolicies.aspx
To obtain printed copies of any of our VCHCP Medical/Drug Policies, please contact Member Services at:(805) 981-5050 or (800) 600-8247.
contact Member
at (805) 981-5050 if you need assistance or hard copies.
