VHP Provider Bulletin Fall and Winter 2023

PROVIDER BULLETIN FALL / WINTER 2023

AAAHC Accreditation

2

VHP Access Training Guides

3

Billing Guidelines for Non-Physician Medical Practitioners

4

Authorizations and Denials

7

Mental Health

8

Flu and COVID-19 Vaccines

10

Electronic Remittance Advice

10

Diabetes Care

11

VHP Open Enrollment

13

Santa Clara County Health Coverage Programs

14

MedAssist

14

VHP Connect Member Portal

15

AAAHC Accreditation

VALLEY HEALTH PLAN (VHP) AWARDED AAAHC ACCREDITATION! On August 9, 2023, Valley Health Plan (VHP) was awarded accreditation for three years by the Accreditation Association for Ambulatory Health Care (AAAHC). This is an important milestone in the continuing growth and success of the organization.

Pursuing accreditation demonstrates VHP’s commitment to delivering the highest levels of quality and service to VHP members and upholding excellence in business practices.

Achieving this accreditation ensures that VHP has met nationally recognized standards for the provision of quality health services set by AAAHC. VHP is proud to have met the challenge of accreditation and is determined to consistently offer quality, affordable health coverage plan s to individuals and families residing in Santa Clara, San Benito, and Monterey Counties.

If you have any questions regarding VHP or need assistance, please contact VHP Provider Relations at 408-885-2221 or providerrelations@vhp.sccgov.org. For more information on AAAHC, please visit www.aaahc.org.

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VHP Access Training Guides In March of 2023, Valley Health Plan launched VHP Access, the referral, authorization, and eligibility portal for providers and clinicians.

Through VHP Access, you can: ▶ Submit prior authorization requests. ▶ Verify health coverage and benefits information. ▶ View claims and explanations of payment.

TRAINING AND QUICK START GUIDES VHP Access quick start training guides for providers can be found on the VHP website here: VHP Access Provider Portal - Valley Health Plan -.

The quick start training guides can help you or your colleagues navigate VHP Access. Click on the links below to learn about various VHP Access topics.

Accessing a Patient Record with First Access Creating CRMs

▶ Receive status notifications regarding claims and authorizations.

Claim Disputes

▶ Review clinical documentation.

Inpatient Admission Referral Entry

▶ Submit claims payment disputes.

Guest Claims Lookup

▶ Submit referrals and view referral requests.

Guest Eligibility Lookup

If you do not have a VHP Access account yet, please contact VHP Provider Relations at providerrelations@vhp.sccgov.org.

If you already have a VHP Access user account, you can sign in at www.vhpaccess.org.

Site Administrator New User Request

Eligibility and Benefits Inquiry Report Enter and Review Referrals

Reviewing Coverage and Claim Information Site Administrator User Deactivation To access the full provider training, click here: Provider Training Lesson Plan.

QUESTIONS If you have any questions about VHP Access or obtaining a VHP Access account, please contact VHP Provider Relations at providerrelations@vhp.sccgov.org.

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Billing Guidelines for Non-Physician Medical Practitioners This is a reminder to all providers regarding the billing guidelines for the Non-Physician Medical Practitioners (e.g., mid-level providers) for both Medi-Cal and non-Medi-Cal providers. Services rendered by Non-Physician Medical Practitioners (NMPs) are covered by Medi-Cal under certain circumstances. See below for details: ▶

Physician Assistants (PA): Mid-level medical practitioner who works under licensed doctor (an MD) or osteopathic physician (a DO) supervision.

▶

Nurse Practitioners (NPs): Practitioner who is a licensed Registered Nurse (RN) legally entitled to use the title of NP.

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Certified Nurse Practitioners (CNPs): Practitioner who is certified and can render services as independent provider.

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Certified Nurse Midwives (CNMs): Advanced practice registered nurse who has specialized education and training in midwifery.

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Licensed Midwives (LMs): Practitioner who is certified and can render services as an independent provider.

▶

Certified Registered Nurse Anesthetists (CRNAs)

I. Medi-Cal Billing Guidelines for NMPs: a. Physician Assistants and Nurse Practitioners i. Services rendered by a PA or NP must be performed under the general supervision of a physician(s). The supervising physician need not be physically present, but the supervising physician must be available to the PA in person or through electronic means to provide supervision to the extent required by California professional licensing laws and as established in a practice agreement. ii. The supervising physician’s provider number must be entered as the rendering physician on each applicable claim line (e.g., Box 19 of the claim). iii. PAs, NPs must be enrolled with DHCS Provider Enrollment Division for Medi-Cal reimbursement. iv. Must be credentialed with VHP or VHP’s delegated entity for the scope of practice for which they are billing.

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b. Certified Nurse Practitioners, Certified Nurse Midwives and Licensed Midwives i. Physician supervision is not required for CNPs, CNMs or LMs. ii. CNPs, CNMs and LMs are authorized to become Medi-Cal providers and render services as independent practitioners. iii. CNMs must be enrolled with DHCS Provider Enrollment Division for MediCal reimbursement. iv. Be licensed as the registered provider by the California Board(s). v. Must be credentialed with VHP or VHP’s delegated entity for the scope of practice for which they are billing. c. Certified Registered Nurse Anesthetists (CRNAs) i. Physicians enter modifier QK on the claim with procedure code when billing for supervision of a CRNA. ii. CRNAs bill anesthesia services rendered with direct supervision of a physician with the appropriate five-digit CPT anesthesia code and modifier QX in conjunction with the appropriate modifier(s). iii. CRNAs bill anesthesia services rendered without direct supervision of a physician with the appropriate five-digit CPT anesthesia code and modifier QZ in conjunction with the appropriate service modifier(s). iv. There are no additional licensing and certification requirements for nurse anesthetists to participate in the Medi-Cal program. v. CRNAs may also bill for pain management and emergency services inside and outside the operating room. CRNA’s must use modifier AG when billing with these codes. vi. Must be credentialed with VHP or VHP’s delegated entity for the scope of practice for which they are billing.

II. Commercial Billing Guidelines for NMPs a. Physician Assistants i. Be licensed by the State to practice as a physician assistant. ii. Physician supervisor is required, but the physician supervisor (or physician designed) need not be physically present with the PA when a service is being rendered. iii. Must be credentialed with VHP or VHP’s delegated entity for the scope of practice for which they are billing.

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b. Nurse Practitioners i. Physician supervision is not required for NPs. ii. Be a registered professional nurse who is authorized by the State in which the services are furnished to practice as a nurse practitioner. iii. Must be credentialed with VHP or VHP’s delegated entity for the scope of practice for which they are billing. c. Certified Nurse Midwives i. CNMs can render services as independent practitioners. ii. Have active license to practice in the State as a registered professional nurse. iii. Must be credentialed with VHP or VHP’s delegated entity for the scope of practice for which they are billing. d. Certified Registered Nurse Anesthetists i. Physician supervision is not required for CRNAs. ii. Be licensed as a registered professional nurse by the State in which the nurse practices. iii. Must be credentialed with VHP or VHP’s delegated entity for scope of practice for which they are billing.

If you have any questions about how to direct bill for services provided by qualifying mid-level practitioners, please contact VHP Provider Operations at 408-885-2221 or providerrelations@vhp.sccgov.org

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Authorizations and Denials HOW TO RESOLVE DENIALS At VHP, we approve authorizations when possible, but at times we may need more information. Please review the list below, which shows you how to respond if you receive a denial from VHP.

WHAT TO DO IF YOU RECEIVE A… •

Pre-service or prior authorization denial for lack of information: Resubmit the request to Utilization Management on VHP Access at www.vhpaccess.org with the requested additional information.

•

Pre-service or prior authorization denial for lack of medical necessity, failure to meet criteria, or non-benefit: Appeal on behalf of the member by contacting the Valley Health Plan Member Services Department at 1-888-421-8444.

•

Post-service or retrospective authorization denial: Appeal on behalf of the member by contacting the Valley Health Plan Member Services Department at 1-888-421-8444.

•

Payment denial for any reason except for an unclean claim: Appeal your payment denial within 365 days by submitting a provider claim dispute through VHP Access at: www.vhpaccess.org. For instructions on how to submit your dispute in VHP Access visit: Quick Start Guide - Claim Disputes.

•

Non-payment for an unclean claim: Submit a clean claim within the noted timeframe and with the information that is requested in the remit message.

If you have any questions regarding authorizations or denials, please contact VHP Utilization Management at 408-885-4647.

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Mental Health

screened appropriately for any type of mental health conditions that may be occurring during both prenatal and post-partum care.

For more information on required screenings, click here: P-MaternalMentalHealthEN-080123.pdf (valleyhealthplan.org).

If you have patients who may benefit from the assistance of a case manager, please contact VHP Case Management at 669-220-5235 or vhpcasemgmt@vhp.sccgov.org.

MEDI-CAL MENTAL HEALTH SCREENINGS New Required Tools and Referral Pathways

MATERNAL MENTAL HEALTH SCREENING REQUIREMENTS VHP has created a Maternal Mental Health Program that supports practitioners who are providing prenatal and post-partum care to mothers and mothers-to-be.

This program offers clinical resources to support licensed practitioners’ compliance with California law (CA SB 1207), designed to address mental health issues during and after pregnancy, including post-partum depression. This law requires that patients are offered screenings or are

The Department of Health Care Services (DHCS) released a new mental health screening tool for your VHP Medi-Cal patients, effective January 1, 2023. The screening tool can be used by nonclinical and clinical staff and intends to identify whether a patient has mild to moderate or severe mental health needs. Separate adult and youth screenings are available.

Screenings VHP Medi-Cal patients can be directed to the Santa Clara County (SCC) Behavioral Health Call Center at 1-800-704-0900 for the screening.

Mild to Moderate Mental Health Needs VHP Medi-Cal patients determined to have mildmoderate mental health needs may contact Valley Health Plan Case Management at 1-669220-5235 for referrals.

Severe Mental Health Needs VHP Medi-Cal members assessed to have severe mental health needs will be treated within Santa Clara County’s Behavioral Health System.

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Substance Use Disorders VHP Medi-Cal members with substance use disorders (SUD) regardless of severity can access services by contacting the Santa Clara County Behavioral Health Call Center at 1-800-704-0900.

The DHCS mental health screening tool is not a full clinical assessment. Upon further clinical assessment, a patient may need to transition from mild-moderate to severe mental health services. Clinicians must complete and forward the Transition of Care Tool to SCC Behavioral Health Call Center to transition patients to SCC severe mental health services.

VHP case management is available to assist with coordination of care for its Medi-Cal patients. If you have questions or need assistance, please contact VHP case management at 1-669-220-5235.

For more information about the DHCS Mental Health Initiative, visit: DHCS APL 22-028 Adult and Youth Screening and Transition of Care Tools for Medi-Cal Mental Health Services(ca.gov) Adult Screening Tool for Medi-Cal Mental Health Services Youth Screening Tool for Medi-Cal Mental Health Services Transition of Care Tool for Medi-Cal Mental Health Services

COGNITIVE HEALTH ASSESSMENT FOR MEDI-CAL PATIENTS 65+ Get trained to be eligible for reimbursement!

Medi-Cal benefits now include an annual cognitive assessment for your Medi-Cal patients who are 65 years and older, if they are ineligible for a similar assessment as part of an annual wellness visit through the Medicare Program.

Medi-Cal providers must complete the Dementia Care Aware cognitive health assessment training (www.dementiacareaware.org), prior to conducting assessments, to be eligible for reimbursement.

For additional details, including training and billing requirements, see the Department of Health Care Services All Plan Letter, 22-025: APL 22-025 (ca.gov).

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Flu and COVID-19 Vaccines

get flu and COVID shots at any Valley Medical Center pharmacy by scheduling an appointment here: myHealth Online Schedule an Appointment (sccgov.org).

It is recommended that parents with children ages 6 months – 3 years old contact their pediatricians for vaccine information and appointments.

If your VHP patients have any questions about their health plan, they can contact VHP Member Services at 1-888-421-8444 or email memberservices@vhp.sccgov.org.

Electronic Remittance Advice (ERA) ENROLLMENT PROCESS Now that cold and flu season is here, it is more important than ever to recommend flu and COVID-19 vaccines to your patients at every encounter.

It is recommended that everyone ages 5 years and older receive 1 dose of the updated (2023–2024 Formula) mRNA COVID-19 vaccine. The number of doses for children ages 6 months to 4 years will depend on their prior COVID vaccination status.

VHP members can get free flu and COVID shots through their primary care providers, if available, or at Walgreens, Safeway, Costco, or CVS pharmacies.

They will need to schedule a time in advance over the phone or online, and bring their VHP ID cards. VHP’s Santa Clara County-based members can also

The Electronic Remittance Advice (ERA), or 835, is the electronic transaction that provides claim payment information. These files are used by providers, practices, facilities, and billing companies to auto-post claim payments into their systems.

You can receive your Electronic Remittance Advice or 835 files through your clearinghouse, direct connection, or download them on VHP Access by logging into www.vhpaccess.org.

Through our partnership with Utah Health Information Network (UHIN), VHP is pleased to continue to offer a simpler and more efficient 835/ERA solution to all providers.

835/ERA is your solution to save time on manual posting, eliminate having to call VHP to request missing remittance advices, and reduce posting payment errors.

If you have not enrolled for 835/ERA, we highly encourage you to enroll.

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I.

How to Enroll for 835 Electronic Remittance Advice 1. Contact your contracted/preferred clearinghouse to request direct delivery of your Valley Health Plan 835 files.

2. Your contracted clearinghouse will send 835/ERA enrollment requests to UHIN at enrollment@uhin.org.

3. Once UHIN receives your 835/ERA enrollment request, UHIN will work with VHP to verify that you are fully registered with VHP and complete the 835/ERA set up.

4. Once verification and 835/ERA set up is complete, UHIN will notify your clearinghouse of the 835/ERA approval.

If you do not have a clearinghouse, you may choose to work with UHIN. UHIN is happy to contract directly with individual providers. If you would like to contract directly with UHIN, please email your request to customersuccess@uhin.org.

If you have questions or need assistance, please contact VHP Provider Relations at 408-885-2221, option 7 or providerrelations@vhp.sccgov.org.

Diabetes Care

5. Providers will work directly with their preferred clearinghouse to download 835/ERA files for processing and posting of remittance data.

II. During 835 Enrollment: For questions related to the 835/ ERA enrollment, please contact your preferred clearinghouse for the following: •

Questions regarding ERA enrollment forms, such as how to fill out a specific section or field on a form.

•

To check the status of ERA enrollment, such as if the form been processed.

III. After 835 Enrollment: For questions related to missing 835/ ERA, please contact your preferred clearinghouse with the following required information: •

Tax ID

•

Payer Name/Payer ID

•

Check number/EFT Payment Number/Warrant number

•

Payment Date

•

Payment Amount

IMPROVING CULTURAL COMPETENCY IN DIABETES CARE FOR PRIMARY CARE PROVIDERS As rates of type 2 diabetes continue to rise in the United States, the role of primary care providers (PCPs) becomes more crucial. Furthermore, diabetes prevalence and related mortality disproportionally affects non-White individuals. The U.S. Hispanic/Latino population is one group who is affected by the diabetes epidemic. PCPs and other health care professionals can learn to connect and communicate effectively with patients of different cultures and backgrounds.

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Importance of Cultural Competency in Diabetes Care There is a notable difference between the average A1C levels of minority populations compared to White populations, with minority populations having higher levels and a higher incidence of diabetes-related complications. To help effectively manage chronic conditions like diabetes, it is important for practitioners to have cultural competence, which can help them identify and address any barriers that may prevent individuals from accessing treatment.

This can also help to reduce disparities and promote equal access to diabetes care. The American Diabetes Association predicts that by 2050, over 50% of the U.S. population will come from different cultural backgrounds. There is growing evidence on the connection between culture and health, highlighting the importance of understanding and applying cultural constructs in diabetes care and education.

For example, to understand how cultural food practices affect diabetes among ethnic and racial groups, it is essential to first develop cultural competence.

Ensuring the Provision of Culturally Competent Diabetes Care Practicing culturally competent care means recognizing and respecting cultural differences among patients. It is not a set of skills to be learned or mastered, but a practice of awareness.

As leaders of healthcare teams, PCPs can use assessments for cultural and linguistic literacy to self-evaluate their clinics. Another approach to gain cultural competency skills is to understand how the disease process is conceptualized within a culture and how that influenced a patient’s own theory about their disease etiology, prognosis, and outcome. On a

more personal level, healthcare providers can expand their education on different cultural beliefs surrounding health and illness, diet, and Western medicine. Cultural competency emphasizes the need for health care systems and providers to be aware of, and responsive to, patients’ cultural perspectives, backgrounds, preferences, values, cultural traditions, language, and socioeconomic conditions. The concepts of cultural competence and patient-centered care intersect in meaningful ways.

Culturally Competent Lifestyle Change Recommendations A large part of managing diabetes involves helping patients adopt therapeutic lifestyle changes. On a community level, connecting with local resources such as diabetes education classes and nutritionists can significantly increase efficacy and continuity of care. When discussing diet and nutritional goals, PCPs should be careful not to advise patients to cut out entire food groups, especially if these foods are a staple in patients’ cultural community. Food is a big part of maintaining cultural identity, wellbeing, and overall health. One way for PCPs to connect is to recognize and acknowledge a person’s heritage diet, which requires Page 12

understanding the traditional foods of different cultures. Cultural competency training is another strategy to reduce health disparities and ensure that racial/ethnic populations receive “equitable, effective, and culturally appropriate clinical care.”

Resources •

National Culturally and Linguistically Appropriate Services (CLAS)

•

Tools to Promote CLAS and Related Training Resources

VHP Open Enrollment DO YOU HAVE PATIENTS WHO NEED HEALTH INSURANCE? Occasionally life or job circumstances for your patients may change, and you may end up seeing patients who either do not currently have health insurance or need to switch health insurance plans. Covered California’s Open Enrollment is taking place from November 1, 2023, through January 31, 2024. If any of your patients would like a quote for health insurance, VHP would be happy to answer questions and assist them.

For 2024, Valley Health Plan (VHP) is the carrier with the lowest cost bronze and silver plans in Santa Clara County, San Benito County, and Monterey County. This means your patients can save money and ensure their health care is covered at the same time.

Be sure that your patients do not wait until after they are sick or have an emergency to try to get health insurance – only certain exceptions allow California residents to obtain coverage outside of the Open Enrollment period.

VHP has been offering quality health plans for nearly 40 years, and we now offer health coverage to even more individuals and families living in Monterey, San Benito, and Santa Clara Counties. Over 200,000 regional residents have selected VHP as their health plan, and we are committed to serving more of our neighbors with quality service, comprehensive health benefits, and competitively priced premiums.

VHP’s large provider network throughout all three counties allows your patients access to preferred doctors, specialists, hospitals, pharmacies, and clinics. In addition to primary and specialty care services throughout our region, VHP covers emergency care worldwide, and telehealth services by phone or video are available to members from any location.

If your patients have questions regarding our health coverage or options, they can contact the VHP Sales Team at 408-885-3560 or at sales@vhp.sccgov.org.

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Santa Clara County Health Coverage Programs

adults who live in Santa Clara County, are uninsured, and have low to medium income.

To qualify, individuals must: •

Be ages 19 or older and live in Santa Clara County

•

Have a household income of 650% of the federal poverty level or less

•

Be ineligible for or unable to attain coverage through an employer insurance, Medicare, Medi-Cal, or Covered California, nor be enrolled in any health insurance plan

For assistance or to apply, Santa Clara County residents can call 1-888-363-3394 or visit a Community Clinic in person. For more information about PCAP, refer patients to: https://vhpn.sccgov.org/pcap.

PRIMARY CARE ACCESS PROGRAM (PCAP) EXTENSION

MedAssist

Do you have patients who are ineligible for health insurance and need health coverage?

If you have patients who are ineligible for employer health insurance or Medi-Cal, they may qualify for the Primary Care Access Program (PCAP).

During 2023, the Santa Clara County Board of Supervisors expanded eligibility for the Primary Care Access Program to include those who earn 0-650% of the federal poverty level. This means even those who earn an income that is too high for other programs may be eligible.

PCAP provides health coverage for primary care, preventive care, pharmacy, mental health, and some diagnostic services for

Do your patients have asthma, diabetes, or allergies?

If so, they may qualify for up to $600 in quarterly grant funds deposited directly Page 14

to them. If your patients or their children have a prescription for asthma inhalers, insulin, EpiPens, or any diabetic medication, and they live in Santa Clara County, then they may qualify.

VHP Connect

Even if your patients did not pay out-ofpocket for prescriptions and they have health insurance, they may apply. The income limit is 949% of the federal poverty level, so even middle to high income residents may be eligible.

An Online Portal for VHP Members!

The MedAssist program is sponsored by the County of Santa Clara and the Santa Clara Valley Medical Center (SCVMC). The program provides cash grants to eligible adults or parents of children with valid prescriptions for asthma inhalers, insulin, or EpiPens.

Your VHP patients can go online to view their VHP member ID cards and health insurance details, pay their premiums, and communicate with VHP Member Services.

They can also view medical bills and out-ofpocket expenses through the portal.

To apply or for more information, patients can visit www.getmedassist.com. For questions or assistance with the application, patients can call 408-970-2001.

Members can access VHP Connect at www.vhpconnect.org or by scanning the QR code. They also get VHP Connect on their phones and tablets by downloading the MyChart app for free on the App Store or Google Play and then selecting Valley Health Plan from the drop-down menu.

Did you know that your VHP patients can now easily access all of their health information in one place through VHP Connect, the online member portal?

If your patients have any questions regarding VHP Connect, they can contact VHP Member Services at 408-885-2221 or email memberservices@vhp.sccgov.org.

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